COVID and Hospitals — Why Flattening the Curve is So Important
We’re all feeling the pinch right now. If it’s not in our wallets, it’s in our stress levels. (Hopefully the stimulus bill will help, I haven’t read it yet, obviously).
And a lot of people, including apparently our President, don’t seem to understand what we’re aiming for here. So let’s go through it.
There is no Vaccine or Specific Treatment for COVID-19
There is no tested vaccine. There is no drug we can give COVID-19 patients to cure them. Both of these things will change, although in the short term we may be down to an old technique called convalescent plasma, which means making a serum from the plasma of recovered patients and giving it to sick people or front line workers. This is an important fact to bear in mind as we go through the explanation.
How does Flattening the Curve Work?
So, and I’m going to over-simplify this, there’s a reason why flattening the curve works.
I’m over-simplifying the numbers to make it easier to understand.
Your hospital has 5 ER doctors and 10 available beds for admitting patients.
Each ER doctor takes about 30 minutes per patient. They are working an 8 hour shift. So your ER doctors can see 16 patients per shift each, meaning a total of 80 patients per shift.
You typically get 70 patients through the door. Each of those patients can be seen, with more serious patients being seen faster, and less serious ones having to wait.
Of those 70 patients, 7 have to be admitted at least overnight. You have three beds left at the end of the shift.
Now, you have another shift. 100 patients come through the door.
Now, only 80 of them can be seen by a doctor during that shift. So, you can do two things:
- Make people wait until the next shift.
- Decide that some people aren’t going to see a doctor.
Generally, both of these things will happen. Some people will have to wait. Other people will be assessed by a triage nurse, who will determine that they do not, in fact, need to see a doctor. Their issue can be taken care of by a “physician extender,” that is to say a nurse or physician assistant.
10 of them have to be admitted. You are now out of beds, but that’s not a big deal.
Shift three, 200 patients come through the door.
You still can only see 80 of them. At this point, 1 and 2 aren’t going to cut it. What can you do?
You can start sending people to another hospital. One way systems do this is publicly posting the current ER wait times to encourage people to go to the least overburdened hospital.
You can temporarily call in some on-call doctors (add resources).
Then 20 of these people need a bed. You only have 10. You have to send 10 of them to another hospital or you have to find more beds somewhere. You can do this by putting people in the hall until a bed is available or discharging people slightly early.
Somebody ends up in the hall in a chair with an IV.
Now, next shift, 400 patients come through the door…
You can still only see 80 of them, and 40 of them need beds…not only is somebody going to end up in the hall, but somebody is going to end up not being treated.
Ah, but you can send them to another hospital.
Nope. You can’t do that any more, because every hospital has had 400 patients come through the door.
During a typical mass casualty event, that isn’t the case. People may be sent to hospitals a distance away, but they will eventually find somewhere to put them.
During a pandemic, all the hospitals are overloaded.
So, What Can You Do?
So, you’re at this point. Every day you’re getting in more patients than you have beds. What can you do?
There’s only two things you can do:
- Increase your resources. Have doctors and nurses work longer shifts. Find or make more beds.
- Not treat some patients.
When 1 is exhausted, you have no choice but to move to 2.
And this is what’s happening in Italy.
When 2 comes up, we call it emergency triage. Normal triage is when you walk into an emergency room (or if you’re lucky don’t walk in) and a nurse looks at you and decides whether you need to see a doctor right away, whether you have to wait, whether it’s just a bandage that a nurse can do, etc.
But this kind of triage is worse.
This is doctors having to decide who gets treated. At this level, patients are split into three groups (hence tri).
- People who will get better without any intervention.
- People who will get better only with intervention.
- People who will not get better.
In a normal hospital situation, 3 is basically your DOAs. The people you know you can’t save. You might do a hail mary.
But once you get into this situation, you have to expand 3 until it overlaps 2.
You have to start letting patients you could treat die. You have to start saying “Patient X is 80, patient Y is 60, we treat patient Y.”
And that has literally been happening in Italy.
All of the annoying social distancing measures are designed to keep this from happening.
How Does Flattening the Curve Work?
There are two things flattening the curve achieves:
- It spreads the patients out. Remember our 400 patients in one shift? If we spread them out over four shifts, our hypothetical ER can just about cope. If we spread the out over five, you have a semblance of normality. Even if the same number of people get sick we can now treat most to all of them.
- It buys medical research time. It takes time to work out how to treat a new disease. A vaccine can take over a year, but a reliable treatment can be much faster if an existing, tested drug ends up working. At that point, while the number of infections stays high, the number of people needing those precious beds shrinks dramatically. Even if all a treatment does is cut a typical hospital stay from 10 days to 8, that’s a remarkable difference.
But What About the Economy?
That is a big question. The people suffering the worst are the most vulnerable; people who live paycheck to paycheck and who’s landlords aren’t giving them a break on the rent. It is also a concern because it’s adding to everyone’s stress, which is bad for your immune system.
However, two things:
- The economy can be fixed. Again, I haven’t seen the stimulus package, but I know it will help. Some states are also providing disaster relief. I admit to being concerned for restaurants, for organizations that have expensive maintenance or animal care (please support your local zoo if you can) and others. But we can pay businesses to stay closed, we can cover payroll, we can make sure nobody ends up homeless. Harass your politicians if they aren’t doing enough.
- Millions of deaths would also tank the economy.
We have to stay the course, and not go to the beach or throw flower viewing parties. Otherwise it might be your relative you find out was allowed to die in an emergency room corridor because there simply were not the resources to treat them.