TM Lutas

Cytokine storms

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Covid-19, as a virus, generally does not directly kill. Instead, it fools our own immune system into killing us via the mechanism of a cytokine storm.

It is not the only disease that can provoke cytokine storms. We don’t know how to reliably stop cytokine storms. If we did, we wouldn’t have to shut down the economy. We could just treat those who are starting to get sick so they wouldn’t develop into a cytokine storm, pay the bills, however, and we would all come out trillions of dollars ahead with a death toll of no national or international significance as the only people who would succumb would be those already on death’s door.

If nobody else will say it, I will. We don’t need to close down the majority of our economy just to change what’s written on a death certificate that was coming out anyway.

Diseases will continue to emerge. Any disease that provokes cytokine storms while not killing many itself will be just as scary as Covid-19 and we’ll be back to the question of whether we have another economic shutdown.

Cytokine storms are not just associated with infectious diseases. The first mention of the term in the literature was about graft vs host disease in a 1993 article. They entered into the general public’s imagination 15 years ago with the H5N1 flu. We don’t really understand why they happen and how to reliably stop them from taking a life. This is a public health issue deeper than how we pay for healthcare. It threatens us all and will continue to do so at irregular intervals as new diseases emerge that cause cytokine storms.

So as we move past our currently unsustainable shutdown due to Covid-19, we all have to decide whether we’re going to let cytokine storms go until the next time some disease breaks out and kills significant numbers of people via this mechanism or whether we’re going to treat this seriously so that the next time we’ll be ready. It’s our choice.

Will we learn not to trust the government with unsexy maintenance tasks for vital public needs?

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Pro-Publica lays out the facts decently but fails to draw the right conclusions in its dissection of New York City’s failure to stockpile for a pandemic. An endowment to finance storage and maintenance of an adequate stockpile would not have been subject to cost-cutting mandates and a move to just-in-time inventory systems. It would not be subject to political moves to take away its budget. It would just go on, year in, year out, assisting medical providers with emergency supplies stock rotation and providing a backup reserve for their on-site emergency supplies.

So who is going to propose to create such an endowment, whether local, statewide, or nationally?

Covid-19 moment of truth for our healthcare systems

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The University of Washington’s Institute for Health Metrics and Evaluation (IHME) has crucial data on Covid-19 for planning and it comes with a moment of truth for all Americans. The tide of good times has run out and those states that have built up a Potemkin health care system are now exposed in an undeniable way, in insufficient total hospital beds per million, insufficient total ICU beds per million, and insufficient ventilators available.

The IHME data is available for download here. You can get to the pretty data projection visualizations here. The link takes you to the national visualization. Click on “United States of America” and you will see a state listing dropdown. They are doing the District of Columbia separately but the territories are missing.

The state differences are sometimes stark and the worst state in the nation is not Alabama. More to come in further posts.

Dueling Doctors

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In the blue corner, we have the joint statement on multiple patients on ventilators by the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), American Association of Critical”Care Nurses (AACN), and American College of Chest Physicians (CHEST) which recommends letting people die when spare ventilator reserves run out. And in the red corner, we have the VESper by Prisma Health fresh off of its recent victory to get regulatory approval under emergency use rules to allow ventilators to be used by up to four patients.

It is triage with its ugly logic of letting patients die vs hope and technical advancement to save everyone, live in the United States at Covid-19 virus hot spots across the nation. This may affect you personally so it is important that you know whether or not the hospital you might depend on to save your life has picked one side or the other in a thoughtful way.

Everybody could ask the question but it would be better if our press did ask and broadcast the answers. At the time of writing, they’ve had two days to do so. Are you informed on the issue? Are your neighbors? Is your hospital?

This lack of discussion is the death of journalism. This time ignorance can have deadly consequences for us all.

Ventilator manifold can quadruple number of people on ventilation

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A paper published in 2014 documents the invention of a ventilator manifold which can lead to up to 4 people sharing a ventilator.

Ventilator manifold for disaster surge usage

You can find the paper here and an article describing the invention here.

Does anyone know the regulation that is stopping us from printing these manifolds and reducing the death toll from a local overwhelmed medical system? A lot of people are rightly worried about our ventilator situation. Something that quadruples system capacity would be a godsend.

Update: This is deemed a method of desperation with numerous problems that can lead to worse patient outcomes in this joint statement by six US medical associations. They really don’t like it.

This is not stopping innovators like Prisma Health from developing ways to have multi-user ventilators.

Update 2: New York has approved ventilator splitting as they purchase 7,000 more ventilators. Federal ventilators are also starting to arrive, all 400 of them.