Coronavirus (COVID19) Update: Fairly Rationing ICU Care 

The analysis of the worst case scenario for ventilator supply does not include discussion of the ethics of the CDC not recommending the use of 3D printed, but unapproved, ventilators and pseudo-N95 masks. There are large groups of 3D printing enthusiasts who are presently stymied by the CDC and FDA not deploying a standardized approved design. When is the use of an unapproved ventilator or mask device appropriate within the context of a worst case supply case?

It makes sense to consider all of these very real clinical judgements. It was expected in light of all the factors at play here.

The title alone is sobering ... even after all the images and videos of ICUs worldwide being overwhelmed with patients.

Forgive me, but the first ones to be deprived of resources should be those politicians who dismantled public health readiness, delayed response, refused to provide adequate testing, equipment and PPE, and put the financial greed of themselves and their cronies before the needs of the people they supposedly serve. There’s a special hot place waiting for them,

Shouldn't the goal be to reduce the mortality rate? Allocating a ventilator to a younger person, who may well survive w/o it while condemning to death the elderly, seems counter intuitive.

Thank you.

Some very difficult discussions and choices that may have to be made here in the US. If the goal is to save as many patients as possible and these difficult decisions are being made I don’t see how how it would be ethical to allow family members to be exposed to these conditions. That’s a recipe for even greater disaster.

My viewpoint on the related topic of the standard for ethics of euthanasia is that it’s more ethical to weigh salvageable viability on the patient’s current and projected quality of life rather than the patient’s current or projected ability to contribute to society. Thus it’s morally irksome that in the hypothetical case discussed that medical personnel would get privileged treatment. I’m a retired Catholic zuegmatographer so my opinion means little and I’m apologetic for the harsh terms I used. Absolutely a wonderful topic of discussion. As a former UPMC Magee employee thank you. I also worked at NIH so hats off to Dr White and Dr Fauci.

I feel that in any hospital that is overwhelmed and needing to make these challenging decisions, there is no place for family members. When we cannot waste resources due to value decisions, we can also not waste time and resources to allow such visitations. The ultimate goal is to save as many lives as possible, while protecting the healthcare workers to the maximum we can achieve. Visitors do not fit in to that. I will have a talk with my family members that should any of us require hospitalization, we would understand that other members of the family cannot be present while that treatment is being administered, including right up to any terminal conclusion. It is just safer for all, including healthcare staff. It is a sad reality of a devastating crisis that we must all be able to accept.

Very interesting and trying decision making processes. Good luck and God bless.

Im a nurse at a hospital north of NYC. Governor Cuomo announced that they'll shift ill people from NYC to hospitals in the state. These urban presumably young vital people will likely change the ethical ecology and the outcome for rural people like me. Thanks for the great discussion.

Can you add closed captioning please.

*** NEEDS TO BE RESEARCHED *** The most direct goal of treatment should be to "treatably prevent" or greatly reduce the interactions between the Type 2 Neumocytes and the viral load. Another goal is to mechanically prevent attachment of the S-Spike Protein to ACE-2. So, how can we: 1 - Attack the virus directly while in the lungs? 2 - Interfere with the attachment? The normal way by which the human body interferes with things that want to harm the lung is to create mucus. That's the role of the mucous membranes. They create an immunological fluid which collects particles [ eg viruses interacting with the cilia of the respiratory cells ] and move them away from the cells that they may be "digested" by the body - OR - cast out by the organism with a hacking cough. So, how do we cause the patient to create more than a normal amount of mucous in such a way that the effect is reversible? Also, the effect of the virus upon the alveoli is basically to create a form of pulmonary edema. The alveoli drown in fluid. So, how do we: 1 - Attack the virus directly while in the lungs? 2 - Cause the body to create more mucous than is normal for the organism? 3 - Create a situation where the fluid around the alveoli [ basically pulmonary edema ] is mitigated? The inhalation of 91% isopropyl alcohol - aerosolized - eg inhaling from a half full, shaken bottle of 91% alcohol - accomplishes all three goals in a very treatable way. 1 - We know that 70% alcohol is enough to destroy the protein envelope around SARS-COV-2. Inhaling 91% which has been aerosolized will actually be the inhalation of a concentration less than 91% due to the presence of some water vapor in the patient's normal room air. However, a lot of the aerosol should be over the 70% concentration level. When that alcohol comes into contact with the virus - the virus will be destroyed. That is a chemical necessity. This will destroy viral load that has been inhaled - as well as new viral load budded off from the Neumocytes. 2 - Inhaling the alcohol will cause the mucous membranes to activate. This will turn the "dry cough" into a "wet cough. That wetness is an immune system material created to protect the cells from damage. That material will - in small amounts - coat the surfaces of Type 2 Neumocytes and block their interaction with the S-Spike proteins. Further, those viruses that are not directly destroyed by the alcohol - will be captured by the mucous for discharge or digestion. [Hot peppers contain Capsaicin which activates the mucousal membranes. Also, the flush that occurs when one eats a hot pepper can interrupt the transmission vector of this virus.] 3 - Alcohol [ Ethanol ] Inhalation has been used successfully to treat Pulmonary Edema. Here, one would be using Isopropyl alcohol instead of Ethanol because it is more common for patients to have access to it - without overloading the healthcare system - and because it causes the production of fluid rather than fully discharging it. To discharge the fluid, treatment plans could include a second phase where the patient switches to ethanol - OR - the patient could take a decongestant such as Mucinex Day and Night. The goal is to break up the mucous - with the destroyed viral load within - and discharge it. So, to me, it appears that an Alcohol Inhaler offers the most direct possibility of treatment for this disease. Also, watch for the sore throat. It seems that there comes a point where the adenoids [especially] and the lingual and palatine tonsils get very sensitive and painful. [ squeeze a bunch of grapes - feeling is like point just before they pop and it lasts a couple days ] I offer that to be the point where a patient should stop with the inhaler and spend a few days on the Mucinex. And do not be surprised with the weird sound the voice makes as it seems the mucous? coagulates? in the larynx. [ I do not understand that. ] Also, after inhaling the alcohol for a couple weeks the sinus cavities will fill with snot. Blow this out normally. It will happen for a few days. I think the development of the "chunky mucous" aka snot - is useful for the body as an immune function as it collects and binds the viral load more efficiently than fluid can. Fluid mucous in the lung is good. Chunky mucous in the sinus is good there. The "wet cough" and presence of phlegm should be encouraged as long as deep breathing is maintained. The goal with this is to keep the intra-lung environment inhospitable to the virus without endangering the patient. I can live with uncomfortable. [ There are indications that one can be reinfected - a "wet cough" may reduce that opportunity.] I know this treatment plan works because I have just completed doing it. [Former Paramedic, Combat Medic, EFMB etc US ARMY] My wife, an RN with both BSN and MSN is doing so too. We live in San Antonio, Texas. The only side effects either of us have had is a slight light headedness. We have never practiced "deep breathing" and are getting a lot of air with every breath we take. I am seeing videos where others are beginning to describe their symptoms and they are all consistent with what I felt - except the fever. I started with the alcohol on 1 March due to cough, fatigue etc as a "preventative." Around the 14th I had a few hot flashes and quickly inhaled the alcohol. The hot flashes went away with no development of a fever. Thank you and I hope it helps - if it is considered. James Anthony Wright Thank you for your reply. I used this treatment as a preventative. I started when my wife and I began having a dry cough. This was a couple of days after the patients who were quarantined here in San Antonio Texas were told to go to a hotel. One of them went shopping at a large local mall instead. My wife is an RN who specializes in high risk OB. She, and I, began to feel fatigued, coughing etc and wanted to try to do something pre-fever onset. This virus has some HIV-like functions and other issues that appear to be attacking the immune system even harder after it begins to respond to the virus. I suggest the 91% isopropyl alcohol as an inhaler. I explained why in my original post. I have no idea what any other substance would do, except, do not use bleach as WW1 gas attacks proved that to be a very bad option. [A bottle of 91% isopropyl alcohol costs about $5 at the local HEB. Assuming patients can find it on the shelf - it should be available.] As for the autopsy, I have not seen it. It is hard to speculate because vaping, smoking, living in urban air pollution etc all have an effect on the lung. Mucous is a natural self defense mechanism of the body. I am not surprised that it would be present. The issue is having enough in the lung to prevent viral development - early enough - without creating so much that it becomes harmful. Dosing is a primary issue that I feel doctors need to research. Remember, alcohol inhalation has been used to successfully treat pulmonary edema. Also, the volume of aerosolized alcohol inhaled should be low. I only took 2 or 3 deep breaths with each nostril each session. Sessions occurred after coughs, heat flashes, etc. The goal is not to get intoxicated, but, to interfere with this virus. One thing I failed to mention in my original post was that the mucous can be generated by eating hot peppers. Capsaicin causes the mucosal system to flush. [ jalapeño = teary eyes ] That action interferes with the transmission vector of this virus. Hot Peppers - interrupt transmission - create mucous Alcohol Inhaler - perhaps put alcohol onto virus envelope - interfere with linkage in lung - treat the edema Mucinex - assist with the removal of excess mucous when it develops as outlined in my original post Of course, again, all of this should be researched and verified by doctors.

I agree. Survival years, quality of life, QALY's, regional framing, the patient's will, and religious&theologic&metaphysic&ethic aspects (general, and the patients') have to be considered by a triage team. Nullius in verba. sg

Why don't we create US Pandemic Service. Draft (Quarantine) all who test positive to empty hotels (minor care facility). Crash course covid 19 specific minor, care giver. Free up RN, LVN Nurses for more intensive tasks in hospitals. If you tested positive you don't need protective gear if quarantined with others.

Hello, it would be helpful if you discussed ways of optimizing PPE effectiveness. I'm a counsel for drug & device companies & while there have been no public statements re: the many HCPs being infected, I want everyone to know that PPE manufacturers & suppliers care deeply about this. When tested, the equipment has all met quality standards. No batches have been recalled by any major US supplier. This indicates infections are due to community spread, insufficient PPE supply &/or ineffective PPE use. Scientists & engineers familiar with PPE who've studied SARS-Cov2 believe certain qualities of this virus, including its "stickiness" for lack of a better term, result in infections due to minor user errors that are inconsequential with other infectious agents. For example, PPE should NOT slide over the skin, jewelry should be removed, nails cut & filed & users should avoid contact with any other sharp edges that can compromise PPE, etc. Some ER HCPs even use antibacterial moisturizers like Neosporin to prevent masks from moving on skin. It would be interesting to hear a discussion on these methods & if they help

Thank you, so it poisons you then you fight and you get it and you fight it again and then intensity can still poison you again until it is gone. I wish you all the best.

Great contents gents.

What bodies are responsible for conferring critical worker status? Who anoints them? Are democrat government decision makers, governors, etc, going to be found likely to save more lives in conservative healthcare settings administered by members of the republican base?

I agree with these guidelines except that I would add a lifetime contribution rather than simply years. Mothers and grandmothers keep our world turning. This is a very important discussion- thank you!

This should never have to happen in America because of a pandemic I could see this if we were attacked by nuclear weapons.

Well, no surprises here. No families present in this crisis, in order to advocate for the patients.

Douglas be white