Cuomo's Corona Panic by Larry C Johnson [UPDATED 8:40 PM]

For the past week it appeared that NY Governor Cuomo realized it was more important to be an adult and eschew partisan politics. That was then. He is now in full partisan panic pandemonium. He is now accusing the Feds of dragging their feet in getting NYC 30,000 ventilators. Here is the quote:

"What are you doing sending 400 when I need 30,000 ventilators," Cuomo said. "You're missing the magnitude of the problem."

No Cuomo, you do not understand. For starters, you do not have 10,000 patients on a ventilator now. The number of patients who test positive does not mean that all will require a ventilator. The numbers available so far indicate most who test positive for corona virus are not being hospitalized. That means the numbers for ventilators are not going to skyrocket and immediately outstrip the existing capability.

But Cuomo is missing a more important point. Shame on him. He has a duty to help educate his constituency. Let us start with the production reality--you cannot magically produce ventilators overnight. The existing manufacturers have limited, not UNLIMITED, capabilities to expand production. Bringing other companies, like GM on line, will require about a month to retool and repurpose machinery and quality control techs.

Producing the machines is the easy part. It is the human infrastructure that is the problem. If there are 30,000 ventilators up and running then you need an additional 45,000 ICU qualified nurses and an additional 22,500 Respiratory Therapy Technicians. (I am assuming one ICU nurse can handle two patients per shift. There are three eight hour shifts per day. I am assuming that one Respiratory Therapy Tech can handle 8 ventilators per shift and there are three eight hour shifts per day). 

Along with the ventilators and the nurses and the respiratory techs you will also need oxygen, vacuum and forced air lines for each ventilator station. The nurses and techs also will have to put on new personal protection gear and respirators for each patient encounter (normally, a nurse assigned to a patient can last about three hours in a PPE (Personal Protection Equipment) suit and mask). There is another major complication to consider--every time the nurse goes in and out of the patient room then the nurse (or tech) must put on and then take off the personal protection gear. This can be time consuming if done properly.

I have some background for opining on this topic. I worked my way through college as a Respiratory Therapy Tech and handled patients on ventilators. The ventilators require regular changes of the tubing that connects the patient to the machine. And there are also medications sometimes administered via the ventilator as an aerosol. Getting a trained, certified Respiratory Therapy Tech requires about two years of school/training. Even with that basic training the new Tech is not ready to handle ventilators. That requires additional training.

Getting a qualified ICU nurse is more daunting and more concerning. Ideally the nurse has a four year degree. But there are very sound ICU nurses now on the job with only two years of post-high school education. But to become qualified to work effectively in an ICU a nurse will have to have a minimum of one month of training. (That means the nurse has basic orientation to the policies and procedures for providing intensive or critical care to very sick patients). Ideally the nurse would have six months of training under her or his belt. (Note--my wife was the Nurse Manager for a very prestigious, internationally renowned critical care unit and I have interviewed her).

Someone needs to tackle Governor Cuomo and hit him with a tranquilizer. He needs to calm down and take some time to understand how complex this problem is. Providing a ventilator without having the nurses and technicians required to operate and maintain the ventilator is meaningless and futile.

UPDATE--There are 62 hospitals listed in NYC (see here). According to this data there are 23,762 beds. The vast majority of these are not, repeat NOT, Intensive or Critical Care beds. The number of ICU beds, which means they have the ability to use and maintain a ventilator, is probably about 1500 total. 

As of Tuesday morning, New York State had 25,665 cases.  Here is what we do not know:

1. What percent of people who are tested positive for Corona are admitted to a hospital?
2. What percent of those admitted to a hospital are then placed in a Critical Care or Intensive Care unit?

If all who test positive for Corona are admitted to the hospital then you can see how the existing hospital capacity can be quickly overwhelmed.

According to the New York Times (as of Tuesday), 12% of those who tested positive for Corona in the State of New York were hospitalized. That number is manageable at present. 23% (750) of those hospitalized in the State of New York were put into an ICU (or CCU). We do not know how many of those are in NYC hospitals.

Here is what we know with certainty:

• There are not enough ICU or CCU beds to handle more than 1500 patients in NYC right now.
• There are not enough ICU qualified nurses and Respiratory Therapists to handle more than 1500 critical care patients in respiratory distress from Corona.
• The real problem is not the lack of ventilators. It is the lack of personnel to set up and operate those ventilators.

It would be very helpful if Federal and State officials would provide concrete numbers on the percent of Corona patients requiring hospitalization and critical care intervention. 

Comments

[Keith Harbaugh]

Re Andrew Cuomo, let me again point out this article:
https://theconservativetreehouse.com/2020/03/22/the-chosen-one-rises/

[Amanda]

The central bankers (owners of the Federal Reserve who have had the power to create money out of thin air for 100+ years) want to use this virus psyop to bring in a new digital financial system:

https://www.forbes.com/sites/jasonbrett/2020/03/23/new-coronavirus-stimulus-bill-introduces-digital-dollar-and-digital-dollar-wallets/#6bb272394bea

Along with Agenda ID2020:

The Coronavirus COVID-19 Pandemic: The Real Danger is “Agenda ID2020” -Peter Koenig (former World Bank economist)
What is the infamous ID2020? It is an alliance of public-private partners, including UN agencies and civil society. It’s an electronic ID program that uses generalized vaccination as a platform for digital identity.

https://www.globalresearch.ca/coronavirus-causes-effects-real-danger-agenda-id2020/5706153 (please read entire article)

[Deap]

Bravo Zulu.

[JJackson]

I agree with everything that Larry said regarding the inability to magically install ventilators. Ramping up production is a medium term goal but staffing these machines is going to be the real bottleneck. Cuomo is basing his need on the number of patients he is projected to have by the time they are up and running. There is a national stockpile but NY is not going to get what it wants or Chicago, Miami etc. will have to go without. If NY got all it wants it is going to be tricky reclaiming them if they are in use but desperately needed elsewhere. China might be able to pull that off but I can not see it working in the west.

[ked]

Larry, are you aware of the pre-COVID19 occupancy rate of the nation’s existing ventilators?

[JerseyJeffersonian]

Somewhat OT. I am a resident of Southern New Jersey. I just returned from a trip to the pharmacy to pick up some refills for my wife, and I observed a fair number of businesses that technically were not in compliance with Gov. Murphy's restrictions on commerce in These Plague Times. For instance, a couple of garden centers/nurseries were up and running, as well as a tobacconist shop. Seems as if some folks are flipping the Gov off, likely owner-operated businesses. On the other hand, the Ace Hardware was closed, but I suspect that this was on advice of the legal department of Ace as prophylaxis against lawsuits.

BTW, is Mr. Danan any relation to Elora Danan? Heh.

[Eric Newhill]

Ked,
NY is typical of major cities across the US. ICU/vent room run at 80% "occupancy" in normal years.

IMO, Larry is correct in all he says. Most important being that Cuomo, like the insane media, WHO and CDC, is whooping up the public by equating testing positive with needing a vent. In fact, only a small proportion of those testing positive will even stay in a hospital let alone be on a vent.

Then you need to understand that many of those who will require a vent because of covid-19 would have required a vent anyhow - meaning absent covid-19 - because they are old and very sick with other conditions. So that lowers the number of extra vents needed as well. Caveat being that most covid ICU admissions may have ended up in the ICU on a vent anyhow, but it would have been spread out over a longer time frame; maybe a year. It's hard to say because of all the bad reporting coming out of places like Italy where if you had 8 serious comorbidities and you test positive for corona virus and you die, you are counted as a victim of the new plague (probably if you test positive and get hit by a bus and die, you're still counted as a covid-19 victim).

In reality very sick people have compromised immune systems and are far more likely to contract all manner of awful diseases. Until a month or so ago, this was a well established medical fact. It seems forgotten now that it might lessen the panic.

Does Cuomo have a crystal ball? Magic tea leaves? Perhaps he has developed remote viewing skills that he has had a terrible, yet certain, vision of ICU demand?

How many nurses, techs and physicians with the right training are in the states' National Guard units? Maybe they could be mobilized to NYC should Cuomo turn out to be the Oracle at Delphi and get his vents on top of that. How about the regular military?

[JohninMK]

I know that Cuomo and others are spitting blood at the lack of 'stuff' provided by the Feds, but is there a responsibility or capability at State level to procure it as well?

[Eric Newhill]

Larry,
There is something that you must have missed. Cuomo, being a little dictator, has recently issued a number of laws, overnight, that he thinks will allow him to staff the vents. For example, he can, as of yesterday, commandeer any equipment or medical staff from anywhere in the state to serve any covid-19 related issue. So he thinks he can rob hospital staff and equipment and supplies from Upstate and Western NY to serve NYC's needs. Western NY has several very republican counties. I guess taking their medical staff and equipment serves two purposes for Cuomo. It won't hurt him, at least, because he is despised in those counties anyhow.

[upstater]

I do not like Andrew Cuomo. He is corrupt hack, that should have been set to jail based on the "Buffalo Billion" grifter scheme (along with his top aide Todd Howe, the SUNY-Tech president and Cuomo's benefactors).

Having said that, COVID-19 in NYC is doubling every 3 days. Of those who test positive, 15-20% will need hospitalization (half below age 50) and a smaller fraction on ventilators. There were 25,000+ infections this morning statewide, 15,000 in the city and much of the non-city state total is in NYC suburbs (my county, Onondaga, has 60 cases this evening). Of course the hospitals are not overwhelmed... yet.

But do the Math, Larry. If infections continue at the same rate, there are a million in 2 weeks. Even if social distancing and the partial economic shut down slows transmission, there will still be hundreds of thousands positives and hospital admissions. And it won't die out until there is "herd immunity".

It bothers me that you can post yesterday about individual deaths being tragedies. Surely they are -- I have an elderly mom and in-laws, all very vulnerable.

But it isn't it a Stalinist mentality the "One death is a tragedy but a million deaths are a statistic". Isn't it?

COVID isn't a political problem, it is a public health problem. Unfortunately there isn't a dime's bit of difference between the two parties in politicizing this very serious matter. The US will prove to the world that it is utterly incapable of managing this pandemic. We're #1! USA!USA!

[noel s. cowling]

Maybe it's time to return to Hill-Burton and eliminate medical- care for-profit institutions.

[jjc]

upstater is correct on the math. The CDC failed back in February and allowed infected persons to continue daily life in a dense metropolis. Cuomo has been briefed on very unsettling contingencies in the near future, as has Newsom in California.

[Terence Gore]

"The authors of the smaller study also found that 30 (81%) of 37 patients requiring mechanical ventilation had died by 28 days."

http://www.cidrap.umn.edu/news-perspective/2020/02/study-72000-covid-19-patients-finds-23-death-rate

"Talking with one of the nurse practitioners in our hospital’s new Covid-19 I.C.U. one recent night, I asked what worried her most. “Patients dying alone,” she replied quickly.

A doctor next to her nodded in sad agreement. On a recent shift, he had intubated an elderly husband and wife, both of whom had severe respiratory failure from coronavirus. Their daughter asked if she could come in to see them. Though we will make exceptions for many end-of-life visits, in this case, he had to say no..."

https://dnyuz.com/2020/03/24/when-you-die-of-the-coronavirus-you-die-alone/

https://www.theamericanconservative.com/dreher/coronavirus-what-it-feels-like-to-be-on-a-ventilator/

[BillWade]

Not sure if most people know this, when you mobilize the Guard, you have next to zero increase in the numbers of nurses, doctors, medical technicians - these are their civilian jobs as well. And, they can only do one at a time.

[Deap]

Sweden chooses to keep things open, business as usual. But does expect people to act responsibly. Imagine that. So far it is working. From the Daily Wire: https://www.dailywire.com/news/while-europe-locks-down-sweden-keeps-schools-restaurants-open

[Bill H]

Upstater, where are you getting that 15%-20% needing hospitalization? I have not seen that number or any other number anywhere. People without symptoms are not tested, and are therefor not included in counts of infected persons. Most epidemiologists admit we have no idea how many actual cases there are, and I have not seen one citation anywhere of percentages requiring hospitalization. I would very much like to know your source.

Ratios of infections to hospitalizations and need for ventilation are numbers I have been searching for since this thing began, and I have been shocked by the total lack of that information.

[JJackson]

The numbers still seem to be causing some problems in these threads. How many infected with SARS-2 go on to develop COVID symptoms is not known but will become clear once the serology testing results start being published. Of those who become symptomatic 80% develop mild to moderate disease (including pneumonia) but should still be able to recover without any outside medical help. 20% will require hospitalization and some treatment or they are likely to get worse and may well develop to a life threatening stage. Of the 20% a quarter will still get worse and will require critical care without which they have little chance of survival. The most in demand ICU equipment is invasive mechanical ventilation and the staff to run it - which is what Larry has been writing about.
The problem that lies ahead is due to the fact testing and contact tracing capacity dropped below demand for a while leading to lots of undiagnosed community spread. The infections caused by this have not yet developed to the point they are needing ICU beds, which may be a month after initial infection. For which it can be seen that current ICU demand is based on the infection rate about 3 or 4 weeks ago when the US was reporting 20 cases a day not 10,000 (which is still an undercount). All this hidden transmission needs to work its way through the disease progression timeline so it is the 5% of 10,000 who will want ICU next month Cuomo is worrying about (or, if undercounting as bad as it was, 2500 times more case than today). 500 a day for the whole US may not seem too bad but as each new ventilator patient may be on it for a month that becomes, 15,000 or if you assume 80% occupancy by non COVID patients, 75,000 ICU beds. The 10,000 a day will keep rising exponentially until the isolation measures begin to slow new infections (about a week) but will not begin to show reduced ICU demand for a month after that.

[English Outsider]

Upstater - hope you're not right. I've just sent a comment to an English web site saying I wish we in the UK could show half the drive they're showing in the States! Grass greener the other side of the fence?

But might I put a question to Eric Newhill? Eric - you're familiar with health systems. Given the wildly different health services in the various Western countries, is there anything one is doing better than the others?

[EnvMT]

To add to upstarters comment, people that are presenting symptoms now were most likely infected 1 - 14 days ago. That means that the rate of infection will not be flattening out immediately.. with 15 to 20% of the cases requiring hospitalization and taken into account that other needs for hospital beds are still there (all ICU beds and ventilators are not laying there unused), the projected scenarios are probably whats panicking some people. Still, if anything, public servants are elected to maintain cool heads, specially under a crisis situation. Panicking doesn't help anypne, but nor does minimizing the situation (which other elected officials seem to be doing)

[Keith Harbaugh]

Soon enough, our Navy ships will be having to return to port to avoid the spread of the virus.
What this situation reminds me of is the H.G. Wells novel The War of the World's
https://en.wikipedia.org/wiki/The_War_of_the_Worlds_(1938_radio_drama)

[Fred]

Keith,

What a brilliant idea, lets bring everyone into port, let them go home, then see what happens! The risk profile is a whole lot different than amongst passengers on that the cruise ship in Japan and even they did not experience 100% infection nor a 4% fatality rate. But thanks to the fine career professionals of our federal bureaucracy they got sent home early over Trumps objections. Congrats to the "resistance" for scoring another victory against the Trump.

[Eric Newhill]

BillWade,
The national guard units from states that are not impacted can be sent to states/cities that are impacted.

There are also agencies with substantial numbers of traveling nurses that can send staff.

[Eric Newhill]

JJackson,
I think you are just wrong about the disease in every aspect of it.

It is causing ICU hospitalizations and deaths among a very few who are elderly and already quite sick with other conditions. It is not causing morbidity in the young and healthy. The analysis I've ben waiting for out of Italy confirms what I'm saying.

https://swprs.org/a-swiss-doctor-on-covid-19/

"Less than 1% of the deceased were healthy persons, i.e. persons without pre-existing chronic diseases.
Only about 30% of the deceased are women.

The Italian Institute of Health moreover distinguishes between those who died from the coronavirus and those who died with the coronavirus. In many cases it is not yet clear whether the persons died from the virus or from their
pre-existing chronic diseases or from a combination of both"

Many of these people were already going to be in the hospital, in ICU on vents,dying, etc.

You're double counting, something that the panic mongers have been doing all along.

If you're concerned about morbidity and mortality among the infirm elderly, then there are ways to isolate them without interfering with life as usual for the rest of us. It's relatively easy to do.

[Eric Newhill]

EO,
They should be making data based decisions, not freaking out.

Isolate the elderly and infirm.

The US has 34 critical care units per 100,000 population. You guys have 6.6 (Italy 12).

The costs twice as much and delivers worse care argument is about to become destroyed once and for all in ways that even socialists can understand.

The outcomes in the US will be the best because we invest way more in our system.

Sorry, friend. I call 'em like I see 'em

[BillWade]

Eric, yes but not sure if state governors are going to be too keen on the moving of their troops to other states short of them being federalized. I can't remember where but I saw a chart this morning that showed of the elderly deaths in Italy, roughly 1/3 had 3 underlying condition, 1/3 had two underlying conditions, 1/3 had one underlying condition.