Monday, March 23, 2020

Week Two Of Taking It Seriously

     And, of course, since I set ground rules for comments, commenters are testing the limits.

     They're pretty strict.  If you have ideas, feelings, thoughts that you simply must get off your chest, and they are not supportive of your fellow humans trying to get through this thing, please get your own blog (they're often free!).  I'm not going to publish them.  I will try to answer them.

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     For the RN, irked at the government's response and the limited supplies, I don't have much comfort.  I'm slightly less qualified to explain supply-chain logistics than a non-surgical nurse is to explain the subtler details of brain surgery: I sometimes see it happening and occasionally I help it along, but....

     Still, I'll give it a try.  In normal times, the usage of PPE is essentially constant. The factories know their market and produce about what they need; this probably doesn't get warehoused in any great quantity (the miracle of just-in-time manufacturing processes!).  Instead, it goes on train cars to a wholesaler, and on trucks from from the wholesaler to retailers and bulk purchasers.  Figure the whole process takes somewhere between one and six weeks.

     Ramping that up -- first, you need raw materials.  Assume them, and if the factory was running one shift, it can run three, if it can find the workers.  Congratulations, you have tripled the supply; a week to train them, and a week, minimum to get to get the PPE to the end users, if they have ordered them; better add another week to sort that out.  Meanwhile, hospitals and testing in the hardest-hit areas is burning through these supplies five or six times as quickly as normal.  And changing from a supply-and-demand model to a command model won;t make it any faster or ensure the supplies get to where they are most needed.

     Federalism plays into this as well.  Public health in this country is a good example of federalism; it's bottom-up, as FEMA and CDC keep trying to explain: locally run, state managed, Federally supported.  FEMA does not have any super-deep infinite stockpiles; they have some supplies, suitable to support a state's response to an ordinary disaster, to get them through the first few weeks while the supply chain reacts.  The scale of this problem is ten to a hundred times as great.  FEMA's stockpiles, your state's stockpiles -- they're like spitting on a bonfire. 

     I'm sorry the Feds and state-level agencies lack the power of precognition, but that's the case.  Complaining about it now won't help.  Chewing them out just wastes time better spent on doing what we can, while we can.  Take notes and write a searing analysis after we're through this.   Do what FEMA appears to have done after Katrina: take a good hard took at the mission and how to manage it, and try to figure out how we can avoid this kind of problem in our next response.

     Testing is a PPE problem.  I will keep explaining this: the only way to keep the testers from risking passing the virus from the infected to the merely worried is for them to discard their PPE -- gloves, at the very least -- every time they take a sample.  If you're low on PPE, you restrict testing.  You need that PPE for the caregivers treating the people who are already ill.

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     Another commenter asked if I really believed that flattening the curve won't reduce the death rate.

     The answer is that it's probably not going to make a huge difference in the direct death rate.  Probably the overall deaths will be lower, though by how much is impossible to say.  People are saved by having equipment available to save them,m and the flatter we make the curve, the better that looks.  The virus puts the same proportion of the people it makes ill in mortal danger. 

     It is very likely someone you know is going to die of this, especially if you live in a large city.  And I'm damned sorry about that.


JayNola said...

The real widespread supply issues are going to occur when the gap in the box ships comes. China stopped a lot of boats from every leaving at the height of their lockdown so there's a bunch of ships missing from the usual conveyor belt of supplies coming into the country. Not just ppe but everything from toasters to TV's.

RandyGC said...

As a former Emergency Management type all I have to say is "yep". Thanks for working at keeping the keel even Roberta.

Anonymous said...

Thank you for commenting on my previous comment (And I don't expect you to publish this one.)

I guess it depends on the definition of "death rate." Further, I don't know what you mean by "direct death rate." I was defining death rate as the percentage of people who contract the virus die. We are on the same page that the way to save people is to get them the best care, and not overloading the system by flattening the curve does that.

Well reasoned opinion (which I won't bother to link, since this will not be published) is that we eventually get out of this by:
- Herd immunization: Not really a plan, although to the extent that it is occurring anyway is a good thing.
- Finding drugs to effectively treat it: Difficult with a virus, but maybe possible, and time to do the work helps.
- Developing a vaccine: Hopefully very possible, but as Wernher Von Braun famously said "Nine women can't have a baby in a month." It will take some time.
- Mother Nature throws us a favor by the virus being seasonal: This would at least by us some time for ramping up the systems, finding drugs to treat, or developing a vaccine.

Flattening the curve does two things. It helps get people the best treatment by reducing the peak load, and it buys us time. I've already discussed what we can (hopefully) do with the time, if (again hopefully) it buys us enough time.

The real issue is will flattening the curve, combined with brains and luck, reduce the area (total deaths) under the curve. hell, if flattening the curve doesn't reduce the area under the curve, all it does is lower the load on funeral homes and make the optics better (the optics probably affecting election results.) If we cannot substantially reduce the total deaths, we'd probably be better off to take the hit and get it over with. That's essentially throwing in the towel, and I'm not ready to do that.

Wishing you, Tam, family and friends the best, and I sincerely mean that. Keep writing reasonable stuff.

Roberta X said...

"Flattening the curve" only helps those people who would die without medical intervention and who do not get that intervention because demand exceeds supply. If it's gonna kill you anyway, that's different. --And that's probably sloppy language on my part. We can ensure fewer people die if we flatten the curve; it will not reduce the total number of people who contact the virus and get sick, only ensure that it happens spread over a longer period of time and the number ill on any given day is less.

The total fatality rate can be reduced by a lot by having enough equipment available when it is needed. And the only practical way to do that is for fewer people to be sick at the same time. We can't build respirators (and train nurses!) quickly enough to cope with the worst- and second-worst-case scenarios.

Cincinnatus said...

Unfortunately most people do not understand that we do not keep an excess of ICU beds. For various reasons including explicit gov't regulations, "normal" means 80-90% utilisation of those beds. And as you say, they do not expand easily.

Anonymous said...

Thank you for the reply.

I too, am guilty of sloppy language, mostly by "creating" a curve and discussing it.

Number of known active cases vs. time:
I believe this is the curve most talk about. I agree with you, I don't see the area under this curve being markedly reduced unless we find drugs to quickly treat it, or a vaccine. And one or both would need to come online before the curve drops for other reasons. (Otherwise, they cannot markedly affect the area under the curve.) We will be fortunate indeed should one of those come online in time. Absent those, and as you have noted, perhaps we can flatten this curve, and hopefully save lives. (That said, should it prove seasonal the curve will have some expected seasonal bumps.)

There is also a curve of total currently infected people vs. time, but we don't have those numbers and never will unless we solve ALL the issues around and then elect to institute frequent, widespread testing. I'm sure the experts could do great things with those numbers, but getting them is far from a priority right now.

But in my last paragraph I got sloppy and "created" a curve:
Number of deaths in a given interval vs. time: The area under this curve is total deaths, and I'm truly hoping flattening the other curve markedly flattens and reduces the area under this one.

One encouraging thing is that if you listen to the daily briefings it is clear that the experts are looking at this with a very fine grid, at least county to county if not finer. Dr. Brix said as much in the briefing today 3/23/20, and noted that each "hot spot" was on its own timeline. The hope implied in the post you didn't publish (no judgement, it's your blog) is that we can hopefully prevent the entire country from going the way of our hot spots. If we can do that, then we will have the capability to bring more resources to bear on the hot spots. It is sort of like the rest of Europe being in a position to help Italy, but sadly they are not.

I'm 66, My wife is 65. We're hoping for the best.
Kindest regards.