Anecdata: I distinctly remember spending a lot of time lying on my stomach in hospital beds during several stints of double pneumonia I experienced as a child, some 30 years ago. It's hard to imagine that front line doctors didn't know about proning a month ago.
Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators?
Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs
> Is this a technique that went out of vogue since my childhood
I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it.
Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.
This is a perplexing article. Prone ventilation has been known to reduce mortality in severe ARDS from randomized, controlled trials for almost a decade[1].
Proning is great! It keeps people alive. We are doing a lot of it. It's not new.
I agree it was a weird focus of the article based on the title.
There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week.
I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
> “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.
I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal.
But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.
Using extreme scenarios to plan for normal life has long been the recipe for bad policy.
This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning.
The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff.
Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses.
I’d be wary to practically apply this beyond the next viral epidemic.
>> In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower.
And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.
After watching this video [i] it seems like there's an opportunity here to completely rethink/redesign of the related equipment. I.e. instead of a normal bed, one that allows for a device to temporarily enclose the patient (like a tanning bed) inflate like a blood pressure cuff, rotate/turn the patient, then deflate and be removed for use on the next bed (i.e. the bed and rotating machines are co-operative, but separate).
Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation.
Since January leaks from Chinese health care warned about all of this. Was there internet ban in US I was unaware of? Or a widespread belief in exceptionalism?
edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment
(3) Prone Position Ventilation
Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position.
Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance.
Coworker of mine who happens to be Chinese bought portable oxygen for use in this situation. She bought it in February, after looking at videos about what was going on in Wuhan. We all thought she was kind of crazy. Doesn’t look so crazy now.
This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well.
We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
I'd love to know where you got those statistics. I couldn't find anything on country mortality rates for COVID-19 ICU patients. However, since the US obesity rate is way higher than Sweden, it is surprising that the COVID-19 death rate in the US is around five percent, while it is around ten percent for Sweden. Of course, Sweden has decided not to impose a lockdown, so I have no idea how much that might be overwhelming their hosipitals.
Sweden has reported 1,511 deaths and 13,822 cases. Does that mean 7,555 of the 13,822 cases have passed through the ICU or a significant number of people have died without entering the ICU?
> This was rebuilding the engine on a car going 100 miles per hour.
It isn't ideal, but this environment may make it much easier to rejig care standards.
The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally.
It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.
If patients are in shape to be on the phone why do they feel the need to put in a breathing tube?? I have measured my O2 saturation being in the 80s and my reaction was "so that's the effect of being this high up"--and I continued to head up the mountain. I had been there before, I knew I wasn't getting into too much. (I forgot to check on the summit itself. I don't expect to be there this year but I'm going to check again next year.)
This was the single scariest piece I've read in a while. The video is even worse. Especially Dr. Hardin from Massachusetts General Hospital at 5m:37sec in the video:
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.
[+] [-] elric|5 years ago|reply
Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators?
Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs
[+] [-] kbenson|5 years ago|reply
I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it.
Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.
[+] [-] the_mitsuhiko|5 years ago|reply
Where do you get the idea they didn’t?
[+] [-] andrewtbham|5 years ago|reply
[+] [-] Scoundreller|5 years ago|reply
I think in this situation, it’s letting these patients be managed without sedation or intubation.
[+] [-] carbocation|5 years ago|reply
Proning is great! It keeps people alive. We are doing a lot of it. It's not new.
1 = https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
[+] [-] epmaybe|5 years ago|reply
There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week.
I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
[+] [-] andrewtbham|5 years ago|reply
[+] [-] SilasX|5 years ago|reply
[+] [-] dmurray|5 years ago|reply
I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal.
But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.
[+] [-] dmix|5 years ago|reply
This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning.
The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff.
Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses.
I’d be wary to practically apply this beyond the next viral epidemic.
[+] [-] dchichkov|5 years ago|reply
And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.
[+] [-] canada_dry|5 years ago|reply
Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation.
[i] https://youtu.be/E_6jT9R7WJs?t=65
[+] [-] inamberclad|5 years ago|reply
[+] [-] casefields|5 years ago|reply
[+] [-] huhtenberg|5 years ago|reply
[+] [-] rasz|5 years ago|reply
[+] [-] shalmanese|5 years ago|reply
"(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended.
When human resources allow, prone ventilation should be carried out for 12 hours or more every day. "
https://www.chinalawtranslate.com/coronavirus-treatment-plan...
There's simply a shocking degree of arrogance from the West to refuse to learn even the most basic things from Asia about this.
For example, people are finally grudgingly admitting that CT scans could play a useful role in diagnostics after months of CDC & ACR denialism: https://www.statnews.com/2020/04/16/ct-scans-alternative-to-...
edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment
(3) Prone Position Ventilation Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position.
Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance.
https://www.alibabacloud.com/universal-service/pdf_reader?cd...
[+] [-] Raphaellll|5 years ago|reply
Starting at 1min https://youtu.be/rfkbv_WQtn0
[+] [-] antocv|5 years ago|reply
I thought it was just official health care, public institutions talking thru public media?
[+] [-] killIdeas|5 years ago|reply
Reduce hospital load, reduce healthcare costs, get rid of the need to flatten the curve.
(Waiting for a my job to begin, waiting for my son to get his surgery)
[+] [-] e40|5 years ago|reply
[+] [-] misja111|5 years ago|reply
This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well.
We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
[+] [-] maxerickson|5 years ago|reply
[deleted]
[+] [-] jordanbeiber|5 years ago|reply
Are we perhaps using less mechanical breathing devices here i Sweden?
Edit: this didn’t come out right... couldn’t find total icu death rate but have read stories about high mortality in NY.
[+] [-] watwut|5 years ago|reply
If there was dishonest statistical comparison, this is the one.
[+] [-] ytNumbers|5 years ago|reply
https://bnonews.com/index.php/2020/04/the-latest-coronavirus...
[+] [-] garmaine|5 years ago|reply
[+] [-] shalmanese|5 years ago|reply
[+] [-] amiga_500|5 years ago|reply
[+] [-] roenxi|5 years ago|reply
It isn't ideal, but this environment may make it much easier to rejig care standards.
The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally.
It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.
[+] [-] neonate|5 years ago|reply
[+] [-] okasaki|5 years ago|reply
[deleted]
[+] [-] downerending|5 years ago|reply
[+] [-] goldenkey|5 years ago|reply
[+] [-] js4ever|5 years ago|reply
[deleted]
[+] [-] chki|5 years ago|reply
[+] [-] elisharobinson|5 years ago|reply
[deleted]
[+] [-] azranoman|5 years ago|reply
[deleted]
[+] [-] yters|5 years ago|reply
[+] [-] andrewtbham|5 years ago|reply
https://twitter.com/cameronks/status/1251233871137574913
[+] [-] andrewtbham|5 years ago|reply
[deleted]
[+] [-] LorenPechtel|5 years ago|reply
[+] [-] vvanders|5 years ago|reply
[+] [-] oldgradstudent|5 years ago|reply
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.
[+] [-] nickthemagicman|5 years ago|reply