Conoravirus ...

[Chris Chesley]

We got some experts here on Scantlings. This morning's article by Karl Denninger. Can you refute it?


https://www.market-ticker.org/akcs-www?post=238752

Chris,

I'll skip any comment (but this one) about what an arrogant ass this author sounds like.

There is almost a complete lack (unless I missed something) of sources for some very outlandish claims. A quick review of claims about the survival rates of patients who have been intubated etc... shows that as written this is a massive compilation of opinions, not facts. My high school science teacher would give this paper an "F" immediately. I think my grandpa's saying applies: "Opinions are a lot like belly buttons, everyone has one and they are all useless." No citations = grade of "F".

His claim that 85% of seriously ill people is really the foundation of his argument. There is not one shred of evidence that this is true, other than this author's opinion. I can tell you that within the UCSF system, which has treated hundreds of patients, this is not true. I can't use my source here, because it was told to me in confidence. But at the very least this guy should back up his claims with sources. Otherwise... it's just a belly button (or some other part of your anatomy which my grandpa used in private).

Beau, by itself the article does not have the data you (correctly) would want to see. However, over the past month, he has documented much of it. Yes, he's an ass and strongly opinionated. What I've seen of his data and previous work however, has caused me to not just throw him out because of his 'tude. He documents China's self reported 95% failure rate of vents. Also that US experience in non-covid usage is only 50% survival and 30% after one year. Heck, my neighbor (a recently retired anesthesiologist) confirmed to me that any time on a vent longer than 5-7 days had extreme risk and low success. Anecdotally, one of our employees had a relative who has seemingly just been able to be taken off a ventilator (for COVID19) but she's severely compromised currently. This just came in yesterday so we'll see how the recovery works out.

Ultimately, we are in a war alright. OrangeManBad is correct about that. There will be casualties. Personally, while life is precious, I believe we've chosen short term pain relief over the big picture. Neither choice is palatable. But only trying to avoid the pain we see today will turn out to be a tragic, costly mistake to far more people. That belief coupled with a couple bucks may get you a drip coffee at Starbucks.

Obviously, it's not in my hands to decide but I have a sinking feeling in the pit of my stomach...

Hey, the good news is that we made payroll this week. Two weeks from now....?

[BeauV]

snipp...
The question, which is not addressed in the product insert, but will most likely be published later (I couldn't find it with a quick google search) is the actual rate of false-negative and false-positive diagnosis. I can tell you that all medical devices and diagnostic procedures have FDA specifications for how these are measured and those numbers are reviewed by statisticians who are WAY beyond my math skills..

I think this is the bigger issue at the moment. These numbers have been looked for, but they don't seem to be available. Without this data, the overall accuracy of the test is in question by people who need to make recommendations to people who make decisions. Maybe it's in acceptable limits, maybe it's good enough, maybe it's absolute garbage. At this point, it's hard to tell.

Well, I never expect to get the numbers until a product is extremely mature. Public posting always lags by a long way. I do believe that the UCSF folks have seen the accuracy data on this device, but I'm not certain. I just emailed a guy who could know the exact data. Of course, all of this is emerging in real-time and being pushed really hard. The technical experts aren't particularly concerned with educating the public on the arcane numbers, which the vast majority won't understand anyway.

[SemiSalt]

If anyone is interested in how projections like the one above are made, here is a video that might be of interest. (Trigger alert: differential equations are mentioned, though not solved on-screen.)

https://youtu.be/k6nLfCbAzgo

This is an unrealistically simple example. A first step in elaboration might be to divide the susceptible group into three: the very susceptible (e.g. say healthcare workers), medium (e.g. grocery store workers), and less (those isolated at home).

[BeauV]

We got some experts here on Scantlings. This morning's article by Karl Denninger. Can you refute it?


https://www.market-ticker.org/akcs-www?post=238752

Chris,

I'll skip any comment (but this one) about what an arrogant ass this author sounds like.

There is almost a complete lack (unless I missed something) of sources for some very outlandish claims. A quick review of claims about the survival rates of patients who have been intubated etc... shows that as written this is a massive compilation of opinions, not facts. My high school science teacher would give this paper an "F" immediately. I think my grandpa's saying applies: "Opinions are a lot like belly buttons, everyone has one and they are all useless." No citations = grade of "F".

His claim that 85% of seriously ill people is really the foundation of his argument. There is not one shred of evidence that this is true, other than this author's opinion. I can tell you that within the UCSF system, which has treated hundreds of patients, this is not true. I can't use my source here, because it was told to me in confidence. But at the very least this guy should back up his claims with sources. Otherwise... it's just a belly button (or some other part of your anatomy which my grandpa used in private).

Beau, by itself the article does not have the data you (correctly) would want to see. However, over the past month, he has documented much of it. Yes, he's an ass and strongly opinionated. What I've seen of his data and previous work however, has caused me to not just throw him out because of his 'tude. He documents China's self reported 95% failure rate of vents. Also that US experience in non-covid usage is only 50% survival and 30% after one year. Heck, my neighbor (a recently retired anesthesiologist) confirmed to me that any time on a vent longer than 5-7 days had extreme risk and low success. Anecdotally, one of our employees had a relative who has seemingly just been able to be taken off a ventilator (for COVID19) but she's severely compromised currently. This just came in yesterday so we'll see how the recovery works out.

Ultimately, we are in a war alright. OrangeManBad is correct about that. There will be casualties. Personally, while life is precious, I believe we've chosen short term pain relief over the big picture. Neither choice is palatable. But only trying to avoid the pain we see today will turn out to be a tragic, costly mistake to far more people. That belief coupled with a couple bucks may get you a drip coffee at Starbucks.

Obviously, it's not in my hands to decide but I have a sinking feeling in the pit of my stomach...

Hey, the good news is that we made payroll this week. Two weeks from now....?

You're far more tolerant than I am if you put up with this ass for months on end. If he's going to be an ass, he should document the fact that he's an accurate ass, at the least. You haveing to defend his undocumented claims is a perfect example of... well, an Ass.

Unlike when we're in a real war, where we are dealing with a sentient enemy, this virus is simply RNA. It doesn't have a strategy, it doesn't have the ability to misinform or misdirect, it doesn't have an emotional weakness, it doesn't understand momentum, bluntly it is not alive. The "War" metaphor is a blatant plea by this Idiot In Chief to try and get himself into the position of a "War Time President". It is entirely transparent and entirely self-serving. There is very very very little in common between dealing with a disease and dealing with a human enemy and we're making a massive mistake if we conflate the two.

To be blunt, what you're saying is that there is a point at which our economic health is more important than people dying. Let's call a spade a spade.

Yes, an argument can be made that the destruction of our economy might kill more people than this disease. But that case has not been made by this Ass or by you. First, there is quite literally no evidence of long term destruction of our economy, despite people mistakenly believing that their 401k is never going to recover. Will there be some damage, sure. But it is nowhere near the overly alarmist TOTAL DESTRUCTION which is being kicked around as if it was a fact.

Is it worth killing 250,000 people to get GDP to recover in six months? One year? Two Years? If the answer is "yes" to any of those, please describe who we kill and how we choose. Networth? religion? political party? I haven't heard anyone answer any of these questions. All I hear is lots of rationalizing without any clear statement of the choice being made and who dies. Let's keep in mind that only 230,000 US soldiers died in battle in World War 2. That's the magnitude of the choice some folks are talking about without being willing to face the blame for those consequences.

I know that sounds harsh but that's what this discussion really is all about once you strip away all the pseudoscience.

It is certainly fine to worry about sacrifice, even financial sacrifice for a failing medical strategy. But for anyone to make that argument they'd better have their facts straight and be ready to withstand a significant examination. Something I've not seen anywhere, let alone from the Ass you linked us to.

[LarryHoward]

Chris,

Anecdotal data from New Orleans ER docs is between 10 and 20% of CV19 patients put on vents survive. Average patient is on a vent for about 10 days and gets on the vent at roughly 10 days after showing symptoms. They are too much in to crisis mode to hazard a 90 day or 6 month survival rate. Basically, reported deaths (as reported cases are simply not trustworthy statistics due to lack of testing of non hospitalized cases) lag infection by around 4 weeks so if the estimated peak of deaths is less than 4 weeks ago, its an assumption that actual new cases are already going down. Letting it run its course quickly and suffering the consequences will increase the death rate as those who would survive with supplemental O2 and other supportive inpatient treatments won't get it. Social distancing has the effect of reducing R0 but isn't expected to bring it below 1.0 so a bunch of folks will continue to get infected.

I do understand that financial ruin from a loss of employment or the extended market crash has it's own serious downside as does depression and anxiety on everything from domestic violence to suicide.

As to company finances? The CARES act has some help for Small Businesses. We are looking at the paycheck loan and its forgivable loans if you can maintain headcount. Has some real potential.

[Jamie]

The SBA 7(a) loan program is pretty good - up to $5MM, capped interest...etc..

[Olaf Hart]

There are a number of unspoken issues with the management of severe forms of this condition.

The first is low survival rates from ventilation, which raise the question of are we ventilating the wrong patients?

At the moment, there is no triage, we ventilate the sickest people. As pressure builds on ventilation resources we will have to move to ventilating the people with the best chance of recovery.

The second is looking at long term survival from SARS, which is the lung condition we are ventilating people for. We have good data on this, and it’s not pretty.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5757654/

Personally, I am not interested in being intubated and ventilated. The chance of survival is not great, and the long term result is just misery and an early death.

This is the reality of any disaster management scenario, at some stage we have to ration limited resources to the people with the best chance of long term survival.

[Olaf Hart]

On a more positive note, the PCP in me is very interested in why some people fight this thing in their alveolae, while others fight it in their upper airways.

Maybe COVID cases with SARS are mouth breathers?

[BeauV]

OH, can you direct me to any credible concrete information on survival rates for intubated patients with COVID-19? I'm having trouble turning up sources I trust. I'm also dubious about analogies with SARS1.

[Chris Chesley]

Larry, yes we're 'on it' for the Paycheck Protection program. Not yet available, my sources tell me Friday at the earliest.

[Chris Chesley]

On a more positive note, the PCP in me is very interested in why some people fight this thing in their alveolae, while others fight it in their upper airways.

Maybe COVID cases with SARS are mouth breathers?

Ouch, that'd be me....

[LarryHoward]

Larry, yes we're 'on it' for the Paycheck Protection program. Not yet available, my sources tell me Friday at the earliest.

Correct. Applications can be lodged starting 3 April (Friday). We are well down the path to make a decision.

[Olaf Hart]

OH, can you direct me to any credible concrete information on survival rates for intubated patients with COVID-19? I'm having trouble turning up sources I trust. I'm also dubious about analogies with SARS1.

At 2:55 There is a summary of recent early data from Wuhan, with a 7% survival rate for acute respiratory syndrome patients.

I regard this as a credible source, it quotes the author of the paper, you might be able to find it.

The survival and long term morbidity rates are consistent with other forms of acute respiratory syndrome.

There is probably some variation institution to institution, but this gives some idea of survival rates in an overwhelmed health system.

https://youtu.be/vPtH42Lnt_Y

[Benno von Humpback]

OH, can you direct me to any credible concrete information on survival rates for intubated patients with COVID-19? I'm having trouble turning up sources I trust. I'm also dubious about analogies with SARS1.

There’s a series in the NEJM from Seattle with about a 50% survival rate, and including some patients still intubated at the end of the study. Ugly!

https://www.nejm.org/doi/full/10.1056/NEJMoa2004500

[Olaf Hart]

OH, can you direct me to any credible concrete information on survival rates for intubated patients with COVID-19? I'm having trouble turning up sources I trust. I'm also dubious about analogies with SARS1.

The previous SARS outbreak was similar to this, a Coronavirus that caused Sudden Acute Respiratory Syndrome, although IIRC the rate was higher than this one.

https://www.who.int/ith/diseases/sars/en/

[Ajax]

Well, the fabulous lobster dinner that I prepared for my Ranger was a huge success.

...and now, I'm quarantined to my boat, alone.

While eating dinner, my co-workers blew up my phone because my OFFICE MATE has been told to stay home for 14 days while another co-worker is tested. My office mate and I barely have 6 feet of separation. Now there's research showing that this thing can travel for 27 feet. Now, the CDC says "Gee, maybe masks should be required for everyone after all?"

The co-worker "under testing" is suspected of having bronchitis but they're testing them to be sure.
My office mate is supposed to stay home (with pay) until negative test results, or 14 days if the results are positive. Given that I have been sitting with this guy all week, I'm not sure why they think it's ok for ME to come to work.

I've emailed my manager to let him know that I'm staying out of the office until I talk to him about this.

I had my wife throw a bunch of shit at me in the front yard like flannel PJ's, my tablet, some peanut butter cookies and clean underwear and now I'm down on the dock.

[LarryHoward]

Well, the fabulous lobster dinner that I prepared for my Ranger was a huge success.

...and now, I'm quarantined to my boat, alone.

While eating dinner, my co-workers blew up my phone because my OFFICE MATE has been told to stay home for 14 days while another co-worker is tested. My office mate and I barely have 6 feet of separation. Now there's research showing that this thing can travel for 27 feet. Now, the CDC says "Gee, maybe masks should be required for everyone after all?"

The co-worker "under testing" is suspected of having bronchitis but they're testing them to be sure.
My office mate is supposed to stay home (with pay) until negative test results, or 14 days if the results are positive. Given that I have been sitting with this guy all week, I'm not sure why they think it's ok for ME to come to work.

I've emailed my manager to let him know that I'm staying out of the office until I talk to him about this.

I had my wife throw a bunch of shit at me in the front yard like flannel PJ's, my tablet, some peanut butter cookies and clean underwear and now I'm down on the dock.

Rich

Tough situation. General guidance has been direct contacts should quarantine. Indirect (contact of a contact) don’t need to. Of course, that came out before it was commonly understood that you can be infectious for several days before showing symptoms.

Fed guidance for the 2 week sick leave is fairly restrictive and based on direct contact, infection, or unusual risk (I have an employee with a compromised immune system. He qualifies based on a doctor recommendation. Fortunately he is teleworking so can save that sick leave for a bit.

DOL has the criteria on their site. Email me if you want the link before you talk to your boss.

[Steele]

This was already noted by Rich, but part of the benefit of lowering the peak for covid 19 is freeing up resources for the non covid 19 patients. People are still having heart attacks, appendicitis, and being diagnosed with cancer. These conditions have very good good survival rates with comprensive health care, which will not be available if we are overrun with a peak of respiratory patients. We were barely able to keep up before all this happened. So many docs have volunteered for our covid 19 clinic that I am back seeing "regular" patients. Yesterday I saw a young woman with a breast mass, and a very healthy retired guy with a lung lesion. Both will need lots of tests, biopsies, and probably surgery. I am not sure I can get all this done, perhaps for months.

I also have a large population of patients with chronic illnesses not getting care. Lots of data has shown intense care of these patients reduces a multitude of sins, kidney failure in diabetes, deadly arrythmias in heart failure, the list goes on. I am afraid these will be the silent victims of the epidemic.

Keep in mind 30 plus organizations are working on a vaccine, multiple drug trials are underway. We do not know if or when they will be successfull, but the longer we stall this illness, the more likely these interverntions can get up to speed and make a real difference. As an example, in the last 3 months we have gone from no available tests, to tests with a high error rate that took a week, to better testing now pushing a 15 min window for results that patients can administer themselves sitting in their car with no direct contact with health providers. With some more time widespread rapid testing should allow us to start IDing and squasing community outbreaks. It is too late now for Seattle or New York, but will be very important for other communities and also once we start to open up restrictions.

Enough for now.

[Benno von Humpback]

Well, the fabulous lobster dinner that I prepared for my Ranger was a huge success.

...and now, I'm quarantined to my boat, alone.

While eating dinner, my co-workers blew up my phone because my OFFICE MATE has been told to stay home for 14 days while another co-worker is tested. My office mate and I barely have 6 feet of separation. Now there's research showing that this thing can travel for 27 feet. Now, the CDC says "Gee, maybe masks should be required for everyone after all?"

The co-worker "under testing" is suspected of having bronchitis but they're testing them to be sure.
My office mate is supposed to stay home (with pay) until negative test results, or 14 days if the results are positive. Given that I have been sitting with this guy all week, I'm not sure why they think it's ok for ME to come to work.

I've emailed my manager to let him know that I'm staying out of the office until I talk to him about this.

I had my wife throw a bunch of shit at me in the front yard like flannel PJ's, my tablet, some peanut butter cookies and clean underwear and now I'm down on the dock.

Rich

Tough situation. General guidance has been direct contacts should quarantine. Indirect (contact of a contact) don’t need to. Of course, that came out before it was commonly understood that you can be infectious for several days before showing symptoms.

Fed guidance for the 2 week sick leave is fairly restrictive and based on direct contact, infection, or unusual risk (I have an employee with a compromised immune system. He qualifies based on a doctor recommendation. Fortunately he is teleworking so can save that sick leave for a bit.

DOL has the criteria on their site. Email me if you want the link before you talk to your boss.

No problem with erring on the side of caution, but yeah, as Larry points out, that's not a situation where the authorities would recommend isolation.

[Ajax]

I would LOVE to be told that I'm being melodramatic and to go sleep in my own bed.

[Jamie]

I would LOVE to be told that I'm being melodramatic and to go sleep in my own bed.

Stop being melodramatic and sleep in your own bed.

That sucks. I'm very jealous of the lobster. Now please quarantine yourself until you know better. You have internet service?

[BeauV]

I would LOVE to be told that I'm being melodramatic and to go sleep in my own bed.

Ajax, suck it up and sleep on the boat. You'll be fine (I hope). But, if you're not fine, the last thing you want to do is infect your beloved!

Be sure to call her and tell her how miserable you are being away from her!

[Benno von Humpback]

I would LOVE to be told that I'm being melodramatic and to go sleep in my own bed.

I don't traffic in that sort of invidious characterization.

[Ajax]

No wi-fi, just cell.

[Charlie]

No wi-fi, just cell.

Maybe it’s me, but sleeping on a boat (even alone) in a relatively warm mid-Atlantic location sounds pretty nice. We all spend a lot of time think and writing about boat stuff. Far more than we actually experience it. So if there’s any consolation, revel in the fact that you’re on a boat while millions of other people don’t have that luxury.

[Olaf Hart]

Good information from the frontline in Italy..

https://youtu.be/3dmIzW3icRs

[BeauV]

One of our most cherished MAYAN crewmembers just called. With his permission, I'm allowed to talk about his case of COVID-19. He was tested and he's got it. He is 2 weeks in and can talk, a little. He says it has been tough. The fever broke three days ago and the coughing is much reduced. Kim, you know him, it's Lance.

His wife is an ER nurse and she's been taking care of him at home. So far, it hasn't been bad enough to hospitalize him and he feels like he's on the mend. While Lance is about 60, he is in great shape. He had a few stents put into his coronary arteries about 4 years ago, so we're worried. But, so far so good. He said his heart rate was quite elevated at the worst of the fever.

He has no idea exactly where he caught it, but it was some time on a ski trip through Jackson Hole, Alta, and then the drive home which went through Vegas and LA because Highway 80 was closed. His guess is Vegas, but he doesn't know. He doesn't remember seeing anyone who was symptomatic.

This is getting pretty close to home.... sign.

[LarryHoward]

One thing to keep in mind. This virus is moving to “Community Spread” in pretty much any area where there are more than a few isolated cases, even in “little St Mary’s County” with 110K residents and 23 cases, we declared that it is now community spread yesterday afternoon. Probably doesn’t help that probably 2/3 of the working adults are in essential businesses. Even with max telework and a stay home order, there are a lot of people out and about. You don’t need to have direct contact to catch it. People (and businesses) need to pay lots of attention to cleaning and other precautions.

[kdh]

Be sure to call her and tell her how miserable you are being away from her!

Great idea, Beau. Will have to remember that one.

[TheOffice]

Rich,

Stay warm! If you have any trouble breathing call 911! Apparently Covid causes a unique strain of pnemonia that requires agressive intervention.

You can always camp in the 5 ton if you need more cabin space.

Joel