I have a mixed opinion on this. In particular, I don't think we really need to create more skilled medical professionals, we just need to change the way they work.
Most of doctors have exposure to the basics of intubating and ventilation through medical school. Those without direct critical care experience would likely be absolutely terrible at it. However, they all still have the baseline knowledge. They're able to assess patients, read charts, and report on vitals.
I just asked my wife (a psychiatry resident) if she could intubate/ventilate a patient. Here response was, "If I were the last person alive, I could intubate. You wouldn't want me to do it, but I could do it. I don't know how to run a vent, but I'm sure I could figure it out if I consulted with a doctor/therapist that does". I think most non-critical care doctors would express the same opinion.
What I'm getting at is we have a large amount of doctors that can act as multipliers for intensivists, hospitalist, ER docs, and pulmonologists. They are able to do much of the time consuming work while relying on specialists to guide overall care plan and intervene the on most challenging cases.
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Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.
Right now, the death rate still isn't higher than a flu epidemic but just the number of known infections promises a lot worse and the potential doublings after that are terrifying.
It seems like there's an endless dialogue of:
A: How would you accomplish X? B: I wouldn't, X is not what I do.
But we need to give the final answer: A: I didn't ask whether you can do X. I'm telling you, "do X or many people die, you are all we have at this point. Think outside the box".
Indeed. I was organizing some people to make face shields and was looking for a big room. When I talked to the city about using a school gym, one of the criteria was that everyone needed to have background checks. Because it would be in a school!
The millions of people who would die in a worst-case scenario are mainly demographics that society is already used to neglecting: the elderly, the terminally ill, those with lifelong chronic illnesses where any infection could be a killer, etc.
Therefore, I would expect this to continue to be considered more of a peacetime inconvenience than a real war. A frequent response to this is, "But they could overwhelm the healthcare system so you or me couldn't be treated for our needs!" Well, if the bulk of the population is left inconvenienced and unemployed for too long, I can imagine some ugly scenarios where the population demands, broadly speaking, that those demographics simply be triaged out of treatment so that they don't overwhelm the healthcare system for everyone else. This is said to be already happening in Italy to a degree.
People imagining such triaging seem to think that a willingness to be appalling brutal means such brutality could be achieved with limited costs.
Italy's situation is far from the worst-case scenario. It's death rate is not that much higher than a seasonal flu, it's just the death-process that is far more messy.
Which is to say, let the infection rate get high enough and you'll have hospitals crowded with the young and healthy even if carry the old directly to the morgue.
Moreover, authorities shouting "all clear" in the midst of this dreck isn't going just summon a phalanx of consumers ready to go to restaurants, death chance or not.
In short, just because you're evil doesn't mean you aren't stupid too.
https://ourworldindata.org/coronavirus#case-fatality-rate-of...
If you read my parent post in context, I hope it's clear that I mean currently in Italy, people are not dying at a rate higher than the seasonal flu BUT this has a big potential change if the infection rate were to shoot up (we know this is prevented by extreme quarantine measures, enforced by the army).
The flu is a well-enough study disease that they're able to, relatively accurately, model population statistics based on a sub-set of tested patients.
We have spent decades holding people systemically dis-incentivizing people from doing positive things in bad situations by assigning responsibility in this perverse "who was the last one to touch it" manner. Society has made its bed and now it gets to lay in it. Nobody is gonna be the one that bucks the trend and reduces and sort of real or perceived safety standard in order to increase volume of care until the situation becomes so obviously bad that not doing so is indefensible.
There are news reports right now on HN on how the real death rate on countries that are not falsifying reports might be up to 4 times the assumed rate.
The hypothesis is supported by the increase in total deaths compared with the baseline, and after subtracting deaths linked to covid19.
This being true, we might be looking into 2 to 4% of the population.
Link to the HN thread:
You need the experience and you need the detailed instruction. That's why there are certification programs around the operating of complex healthcare machinery. Just like you don't want a front-ender doing back-end or systems work you don't want your psychiatry residents to operate an ICU.
This is not the argument I'm making though. That implies the front dev has no oversight.
I'm making the argument that a frontend development can successfully complete features with the guidance/oversight of a backend dev. The results might not be ideal, but it can provide an acceptable outcome.
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> You need the experience and you need the detailed instruction. That's why there are certification programs around the operating of complex healthcare machinery.
These programs are focused on developing individuals who can robustly and independently manage this complex machinery.
Should we also discredit airline pilots because laypeople have landed planes in emergencies? Or discredit sports professionals because many can kick a ball?
Life is not a movie, some stuff is just hard and requires a long time of training before we'll let you go 'solo'. One mistake and someone ends up dead, there are no do-overs, there is no undo button.
The last thing ICU's need right now is on top of all the stress already going on there to be overrun by eager rookies that are trying to help.
The best we can do - and this is happening in some places - is to move up the training schedule and to graduate ICU nurses early. This is need for several reasons: to man the extra ICU capacity that is coming online and to take the place of those who have died or can't take it anymore due to psychological stress.
I think this sort of language is why a lot of non-professionals are sort-of balking. Life currently is like a movie. A zombie or some similar disaster movie, a situation where things are changing fast, where the normal plans are expected to fail.
...and requires a long time of training before we'll let you go 'solo'. One mistake and someone ends up dead, there are no do-overs, there is no undo button.
We are talking about a situation, coming up in X many days, when it won't be a matter of the authorities "letting" people try but a matter of the entire health system being overwhelmed. What are the other, workable plans you have for people dying in the parking lots of the emergency room? And yeah, this is a different world, one where we expect people to end up dead and we're asking how to decrease that are much as possible.
This horrible movie is the consensus of most projections. The question is not "could we deal with this? Can we play doctor, please!" but rather "how should we best deal with an ongoing disaster where we're assured, the doctors will be gone. Surely there's something one could beside 'die in place'?".
The last thing ICU's need right now is on top of all the stress already going on there to be overrun by eager rookies that are trying to help.
If the ICUs have a different, workable plan for when they are overrun with a massive number of patients, I'll be tremendously happy. The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
No, because after a movie you get to go home, no matter how terrible it was. And in real life you don't get to go home. So you will have to trust in the people that have spent their lives preparing for stuff like this while we, the software smartasses were 'changing the world' with our SaaS toys.
Right now the best programmer is worth less than a mediocre ICU nurse, and that will remain so for a while. Afterwards we can all go back to pretending they don't matter but right now this is how it is.
> We are talking about a situation, coming up in X many days, when it won't be a matter of the authorities "letting" people try but a matter of the entire health system being overwhelmed.
That's a past station in some places.
> What are the other, workable plans you have for people dying in the parking lots of the emergency room?
I don't have any plans. They will die. Because we were too stupid to listen to those sounding the alarm when it mattered.
> And yeah, this is a different world, one where we expect people to end up dead and we're asking how to decrease that are much as possible.
We can decrease it as much as possible by stopping to move around so much. And yet, that seems to be too much to ask. Just now in another thread some religious guy claiming an exception just because the risk was low. I sincerely hope they'll all be fine, I also hope that if they are not that they'll trust their god rather than to hog precious ICU capacity needed by people who were careful and who did not seek this out on purpose.
> If the ICUs have a different, workable plan for when they are overrun with a massive number of patients, I'll be tremendously happy. The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
The ICU staff is working double shifts and around the clock in plenty of places. They too get ill, plenty of them have already died. It's a bit late to stick your oar in now and make it your mission, I totally sympathize with the intentions but this isn't your fight other than to stay put, tell other people to stay put and accept that this story will not have a Hollywood ending for many people.
Let's first all stay the fuck home, then ensure good personal hygiene and if and when infected self isolate as much as possible and leave the rest to the HCWs who are risking their lives in the most literal way possible.
All this well intentioned backseat driving isn't going to move the needle, not even a little bit.
This is a good point. Preventative medicine is the best medicine. That's true in general, but is especially true during this type of crisis.
We should also be more strict about isolation measures and lockdown, both individually and as a matter of policy and enforcement. That would keep our hospitals from flooding, to a much greater degree than an army of respiration therapists and ventilators would.
> All this well intentioned backseat driving isn't going to move the needle, not even a little bit.
But how else shall we spend our weekends locked indoors without pointless arguments on the internet? ;)
This language of addressing each posters as if they personally had this intention is pretty bizarre. It's very much the language of "proper authorities are taking care of that." I don't personally have any intention of jumping but I'm part of a community and part of a situation where the proper authorities aren't taking care things.
Oh, so it's just posturing. Forgive me then for taking you serious.
I find it doubly frustrating because the majority of these are asserted as fact, typically based on flawed reasoning, when what they really are, are estimations/predictions.
If this lack of concern (if not outright disdain) for correctness becomes too prevalent within a society, I worry that it may affect the quality of our decision making.
Regardless, is this somehow related to my comment above?
It has in a simulator.
The US did a disaster prep simulation for virulent flu, that involved a shortage of ventilator scenarios. They took people with something approximating medical backgrounds, including nurses, other kinds of docs and vetinarians, and gave them training in how to use a ventilator. After two days they were given a test and the vets had the best score.
Here's an /r/medicine discussion of it.
https://www.reddit.com/r/medicine/comments/fr0x3m/how_do_you...
Another thing to consider is this is a rapidly changing/progressing disease and there are no standards. The opinion of a recently graduated fellow has different biases than an experienced attending. They can both be correct while disagreeing on the specifics.
USA has 5 million medical professionals, almost as much medics per capita as Cuba.
There is a shortage of doctors that actually treat sick people.
> what would be a ballpark estimate to get a reasonably intelligent person with no medical experience up to a "functional" level?
It really depends and I'm speaking out of my comfort zone here.
Becoming a doctor takes a really long time because it includes a LOT of background and general medicine knowledge. Doctors know a lot about medicine outside their speciality.
Med school is 4 years (2 years of bookwork focus and 2 years of clinical focus) and builds on undergrad significantly. Residency is 3+ years. I'd say the majority of people with STEM backgrounds could have function acceptably as a general doctor with 2 to 5 years of postgrad training. Surgeons are built much more on experience so that's very hard to fast track.
In my opinion, the real measure is the ability to handle edge cases/unusual cases. Specialized/limited scope workers, especially those with the direct support of an experienced individual, could pick up tasks much, much more easily as long as an expert is there to take over the challenging cases.
I'm willing to consider that it isn't possible, but if that is the case, I'd be keen to know the particulars of why. If there happened to be a documentary on respirators that covered some of the complexity involved, I would be on my couch watching it.
Some medical students also could be utilised, if there is acute shortage, perhaps.
This has already been happening in Lombardy according to an account I read about two weeks ago.
Given how American medicine works, I see challenges with this approach.
Your assumption doesn't hold.
Triage is just to deal with limited resources, essentially it divides the applicants into 'walking', 'dead' and 'care', and the fewer resources you have the more people will get sorted into the 'dead' category even if they still have a pulse when you see them. The 'care' category will still get unique personalized care otherwise you might as well sort them into the 'dead' category on the spot.
How much training does someone need before they become a clear net positive for the patient?
The ICU staff would not even allow the doctors to mess with their setup because it is critical and it is their responsibility until some either dies or is discharged from the ICU and allowed to move back to a normal ward.
Think 'airline pilot' not 'assembly line worker'.
If I had to choose between an uncontrolled emergency landing, and an emergency landing done by a volunteer who did two days of training, I'd choose the volunteer every time. I understand that the volunteer does not have the training to fly or land safely and that becoming an airline pilot takes a lot of training, but that doesn't matter if there's no pilot available.
If 20% of patients die with trained ICU staff, 90% die with no ICU staff, and 70% die with a trained volunteer, and you have no more ICU staff, then the volunteer is a net positive and the volunteer has left a lot of dead people. The question is not whether the volunteer is even anywhere close to a trained professional in effectiveness, it's whether the volunteer is better than sticking a red or black tag on someone's bed and leaving them to die.
But when you're dealing with a pandemic, you can do without. Do you really think that your typical doctor spent all that much time in med school or residency learning how to operate a particular kind of machinery? If we have the ventilators, we'll be able to find people to operate them.
No, it's because medicine has a very low fault tolerance, and requires a large body of technical knowledge to even understand what needs to happen for your patient.
Having a team of incompetent clinicians perform complicated medical procedures "good" as a layperson still results in disproportionate people dying, that would have survived under a competent practitioner.
Bringing us back to the topic of this thread, a potential lack of competent practitioners if the pandemic worsens, and what the best solution to address this would be, such as a COVID-specific ventilator training.
The army knows how to train people to basic competency very fast, and they know a thing or two about drafting volunteers ;)
Not everyone need be coming in completely untrained. And job shadowing is the obvious thing most people are over looking. Nobody is going to dump a bucket of scrubs with 30-days classroom training all over the ER floor. Groups of trainees would be shadowing trained professionals 15 hours a day.
Medical professionals learn how to do their entire job in a similar time frame. Ventilator operation is surely a small part of that. I'd be astonished if it would take someone more than a week or two to learn the basic mechanics of how to use a ventilator. None of the theory or nuances, but a course that says "hook it up like this, do X, Y and Z and come get me if this or that happens".
Regarding whether doctors would want undertrained help - that's immaterial. If current healthcare workers have the capacity to handle the pending wave of sick people, then that's great and we shouldn't get in their way. If they have another, better solution, then let's do that. If the alternative to having minimally trained people operate ventilators is letting people die without any intervention - I'd want to see some explanation or evidence as to why letting people die is better.
Getting nurses, doctors from other specialties, or even medical students through an intensive training is one thing, and I suspect it's actually a good idea. These are people who have (or, in the case of students, are at least likely to have) the knowledge required not just to learn how to operate a piece of machinery, but also to understand when they're in over their heads, when to ask for help, and to understand the magnitude of what they're doing.
But IMHO -- also based on my experience in other potentially dangerous fields -- putting people with zero medical education except for a thirty-day training in charge of observing people in a life-or-death situation is a really bad idea. Under-educated, even if well-trained assistance has a very high potential of making things worse, not better -- worse than doing nothing at all, that is.
Running a ventilator as in pushing the right buttons is something you can learn to do just by reading the manual. I can obviously operate every medical device I've worked on. I've obviously had more than 30 days of exposure to them. And nonetheless, I think the chances of getting someone killed by operating them are extremely high. I am also 100% convinced that they are much higher than the chances of someone who's had some medical education doing the same thing, even if they've never seen that machine and have never read the manual. What doctors and nurses do with the things I've built is way above my level of understanding.
I can't speak for medical students but I can guarantee that, if you let 30 final-year engineering students walk around a power plant without constant supervision, one of them will get themselves killed by the end of the day. And that's after three years of education. 30 days shouldn't even get you past the lobby.
I'm reading that hospitals may be overwhelmed. I understand that to mean there will be more people requiring intensive care than capacity to give intensive care. If the choice is between the hospital sending people who need ventilators off to die and sending them to someone with thirty days of training and good intentions... Well, my intuition is that you'd have better outcomes with the latter.
The point is not "can we do this without killing people." Nope. More people will die with amateur ventilator-operators than professionals. What I'm suggesting is that more people will die without amateur ventilator-operators in the event hospitals are overwhelmed.
If we think hospitals are going to be overwhelmed in thirty days then the time to start training amateur ventilator-operators is now.
It takes an inordinate amount of time just to teach people what they can and can't touch and when and how, how to wash their hands properly, how to put on and take off their masks/gloves, and where to stand so as not to be in the way of people. All this in the context of a pretty contagious disease. I am pretty sure that, within 20 days, most of the volunteers would be infected themselves, and end up putting even more strain on the system.
I've been in an OR as part of my job, and I'd definitely think twice before enrolling in a program like this one (and definitely not just for my own safety, although yeah, that would be a big factor, too).
Given that we likely have more spare doctor cycles now than we will in the future, we should utilize them now. We can also do things like hire doctors from countries not as badly stressed to come teach the classes.
And of course there are many levels to addressing bottlenecks. For example, operators wouldn’t have to be amateurs at first, they could be any of the non-essential medical professionals who are not able operate business as usual due to the virus. Could a podiatrist or urologist operate a ventilator given enough training?
In general we are brainstorming proactive measures. I think, at least in the US, we continue to have a reactive as opposed to a proactive strategy because of our decentralized government structure as well as the delicate balance between effective mitigation and maintaining social order. While we should be leveraging the current shelter in place strategy to build as much healthcare infrastructure as possible (both physical and technical, as per the thread) to handle slowly returning society to normal operations, we probably are not moving fast enough. In several weeks, as the unemployment and anxiety builds, so too will unrest. And I guess then it will really be a test of a nation’s people.
To my exceptionally limited understanding - and I would love to be corrected if I'm wrong - operating a ventilator correctly is not a matter of standing in front of a machine and watching a few numbers for problematic readings. That can be done by machines and computers. What requires training is everything else around it, which requires an understanding of medical protocols, anatomy, the ability to respond usefully to emergencies without being in the way, and so on.
Which is to say that this is not something that highly specialized and narrow technicians can be usefully trained for in a very short time at this particular moment.
That's not to say your idea is bad! It's definitely good and worth exploring in the future. There will be time to explore how to have smarter tools that can be used with a less general skillset can be developed. There will also be time to explore how to develop specialized and narrow curricula for such things - itself not a trivial task.
This thread isn’t about automating medical professionals responsibilities one task at a time, or attempting to step on their egos. I’m as proud of their title, their coat, and their debt as they are.
If a pandemic respiratory virus is not the time to “consider exploring” this idea, when is? When people are left to die in their homes because the ambulances stop taking calls...?
We are, of course, just shooting out ideas of grandeur. A reactive strategy will be maintained, people will die, and everyone will throw their hands up in the sky and say “nothing else could have been done. March simply was not the time to think about COVID-specific medical operation efficiencies. There will, however, be a time to explore...”
Please accept my deepest apologies if I have in any way seemed to imply that the current reactive strategy is an ideal long-term solution. I do not in any way think this.
Don't hesitate to ask if there's anything else I can clarify for you - I frequently fail to express myself as well as I'd like.
This will happen soon or not at all. The AMA and its equivalents worldwide have a very consistent attitude to anyone, anywhere being allowed to do anything a doctor can do. It should not be allowed. Psychologists should not be allowed prescribe; nurse practitioners should not be allowed practice independently under any circumstances, etc.
Indeed, doctors did more harm than good until the early 1900s at the earliest, and we can only be sure that they were on net leading to lower rather than higher mortality with the introduction of antibiotics.
Or rather, this should be common sense, but the over-inflated egos on HN don't understand that it takes more than knowing which button does what to operate a ventilator. Being able to hold a paint brush is a very different skill level than painting a portrait.
Painful given some past threads on this subject.
Other than that: spot on.
If there is relevance to this conversation in the 10,000 or so words that you have spent on this thread then I fail to see it, so I really don't know what this particular comment is trying to achieve other than that it has me considering whether I shouldn't just plain give up on HN.
Don Hopkins has it right, sealioning is the perfect term to describe what you are doing and it is a destructive thing on something as fragile as this forum because it narrowly fits the guidelines and yet makes it impossible to have a normal conversation. It's the online version of passive aggressive belligerence with a veneer of sincerity on top.
His arguments are incoherent, rambling, and and focused on nothing but derailing the conversation and wasting everyone's time. He perfectly fits the definition of "sealioning". He even admits he knows what it is and is familiar with the web comic that coined the term, then in the same post, he continues to behave as if he's working directly off the wikipedia definition, acting out its every point and symptom, as if it were his playbook.
When confronted with arguments that directly address his points, he complains and runs away and refuses to respond to them. His "concern" for the topic and interest in having a conversation is totally insincere. His only goal is to waste time. Only when he can waste time and divert the conversation away from the point, does he bother to reply. But once there is no way out but to confront the glaring contradictions in what he wrote, his suddenly disappears and has no more to say.
It's supremely ironic and proves he's a troll with absolutely no sense of self-awareness, when he says things like "I'm not seeing much relevance to this conversation", after spending so much time and energy trying to derail the conversation with irrelevant bullshit. That should serve as a warning and warning sign to anyone tempted to engage him in conversation, or take anything he says seriously.
https://knowyourmeme.com/memes/sea-lioning
Another tactic you can see him practicing, which we're all familiar with coming out of the White House, is psychological projection. Trolls like misterman are fully aware they're sealioning, know all the terminology because they study and emulate it, and they love to throw around and misuse terms like that themselves, to attack other sincere people for doing what they're actually maliciously doing themselves, to make it seem like it's just "both sides", which it's not.
It's not just an internet thing. Here's an example of how racists sealion and project in real life:
https://medium.com/@codeGrit/a-story-about-sealions-gamergat...
Sealioning is related to the Gish Gallop, to which there are some countermeasures that work (beyond systematically flagging his post every time he does it, which is the least we all can do to protect the community).
The approach that worked for me, and shut him up cold in his steps and made him suddenly retreat, is to be very calm and structured about your replies, and not let him derail you, which is something that we can all cooperate together on, and support each other by doing together as a tag team.
Carefully chose and enumerate your questions, and repeat them when he doesn't answer them, but don't get distracted by his off-topic diversions, or his passive aggressive belligerence with a veneer of sincerity on top. His pseudo-intellectualism and pretend-open-mindedness and saccharine-sincerity is all just an act, and you don't owe him the level of courtesy that he is pretending to extend to you and mocking you with. I can practically see him laughing to himself (and his Gamergate veteran buddies) behind the keyboard every time he thinks he's fooled anyone into taking him seriously, because he certainly doesn't believe what he says.
Just calmly point out every time he ignores one of your questions or somebody else's questions, or tries to derail the conversation. Keep relentlessly pushing him back onto the topic, and never let him derail you. When I did that, he was mortified and childishly complained that I was not the boss of him, and that I could not tell him what to do, or force him to answer my questions, then he immediately lost interest and fled without another word, because the last thing he actually wanted to to was to stay on topic and answer the questions I would not stop asking.
https://en.wikipedia.org/wiki/Gish_gallop
Technique and counter measures
During a Gish gallop, a debater confronts an opponent with a rapid series of many specious arguments, half-truths, and misrepresentations in a short space of time, which makes it impossible for the opponent to refute all of them within the format of a formal debate.[3][4] In practice, each point raised by the "Gish galloper" takes considerably more time to refute or fact-check than it did to state in the first place.[5] The technique wastes an opponent's time and may cast doubt on the opponent's debating ability for an audience unfamiliar with the technique, especially if no independent fact-checking is involved[6] or if the audience has limited knowledge of the topics.
Generally, it is more difficult to use the Gish gallop in a structured debate than in a free-form one.[7] If a debater is familiar with an opponent who is known to use the Gish gallop, the technique may be countered by pre-empting and refuting the opponent's commonly used arguments first, before the opponent has an opportunity to launch into a Gish gallop.[8]
Common sense does not determine how difficult something is, how difficult it is determines that. Reality, for the most part, flows into the brain from the outside world, not the other way around.
> An emergency doesn't change the hard technical requirement of administering ventilation.
Neither does common sense. The "the hard technical requirement of administering ventilation" is precisely as hard as it is. So, how hard is that? You represent (in poker parlance) that you know the answers to such things, but you seem reluctant to provide evidence.
> Or rather, this should be common sense, but the over-inflated egos on HN don't understand that it takes more than knowing which button does what to operate a ventilator.
This seems a bit ironic, because no one other than you has made that specific claim.
> Being able to hold a paint brush is a very different skill level than painting a portrait.
Now this statement is actually correct, but unfortunately I don't think it has much relevance to the topic at hand.
https://news.ycombinator.com/newsguidelines.html
Edit: it looks like you've been using HN mostly for political and ideological battle. We ban accounts that do that. Please stop doing that.
For starters, sincere apologies. You asked me nicely to stop this behavior in the past, I didn't, and you subsequently rate-limited me. After some time, once I had gone through some "personal work" as they say, I asked for this to be removed, you kindly accommodated me while repeating your earlier warning, and I promised to comply.
I think it is more than fair to say that I have clearly violated your trust - although, I would also say, only in a sense. I will describe the details of my thinking on that (the method to my madness so to speak), in a reply to your last email when I can find the time (next few days or so). Not that you care I imagine, just an fyi.
Just as a preview of that email, I won't be arguing for a removal of my rate-limiting. You have your hands full on HN maintaining some reasonable level of decorum (herding cats) in discussions, in a world that seems to have almost gone mad. This is no small task, and I fully appreciate why you must resort to this. No disagreement from me on this particular decision.
Rather, in the email I will attempt to explain the reasoning behind my (deliberately) anomalous conversation style (this entire comment, for example). Whether you will agree with my thinking, or even have the time to give it any serious thought, is of course up to you. As I said, you are a busy guy with a thankless job, and if you decide that you can afford little time to spare on entertaining the out-of-the-box theories of some random crackpot (who also exhibits numerous signs of classic schizophrenia) on the internet - no disagreement from me on the decision. You have been more than fair and patient with me under the circumstances as you understand them (and yes, I am aware of the ~"implied condescension" in that statement - I believe noting such things can be useful to minimize misunderstandings regarding beliefs &/or intent).
I've anticipated the day your hammer would come down on me, as did some of the folks I was in conversation with - it seemed quite inevitable. The only ways that quickly come to my mind for how this eventuality could have been avoided are:
- I personally decide to "knock it off" (rather unlikely, to say the least)
- Multiple people happening to notice a pattern in behavior, and realizing "what it is I'm up to", or "what I am trying to draw people's attention towards". To my mind, "what I am up to" is so blatantly obvious that it boggles my mind that not one single person, in a community of thousands of the planet's best and most logical minds, has noticed the method. One person I can think of noted it somewhat, but I got no sense that they noticed the systematic and intentional pattern, but rather were merely thanking me for "pointing out" when we were straying from evidence-based discussion in his particular sub-thread. One thing I speculate people may be overlooking in this situation, or "the point I am trying to make", is that there is a "pattern in behavior" that can be observed not only on my behalf (this one is easy to see), but also in the behavior of my counterparts, in essentially every conversation I've participated in recently.
Wrapping up, I'll just say: no hard feelings on my end. On the contrary, I am sincerely grateful for your patience with me. You've got a job to do here, you did it with amazing restraint under the conditions, but at the end of the day, sometimes pragmatic justice must be dispensed to maintain overall order.
https://news.ycombinator.com/newsguidelines.html
Edit: it looks like you've been posting other flamewar comments to HN too. We ban accounts that do that, so please don't do that.
It's quite interesting to hear the opinion of someone who has both education and hands on experience directly in the field, and then compare that opinion to the opinions of those who have neither.
Younger doctors without 4 years onsite experience are still probably extremely capable and I’m sure you’re right, they can learn how to do a subset of their eventual job very short amount of time and do it well if given the chance.
It sounds like there is some fundamental idealogical opposition to this.
I have a friend who is going through her residency now, she has to deal with a lot of very unhealthy psychological and physical treatment (ridiculously long hours) to get through it. Sounds more like a hazing than a professional introduction.
Now in war, you have to throw bodies at a problem, and if the bodies end up 6 ft under, that's war. But generally bad pilots only kill themselves, they don't kill patient after patient through malpractice.
https://www.vettimes.co.uk/news/veterinary-sector-primed-to-...
Of course, it flies in the face of a common sense view that someone careful, able to follow orders, just hold things or press button etc would provide some use in a world where the doctors are fundamentally limited.
It seems like a world where the medical industry has piled goldstandard-or-nothing upon goldstandard-or-nothing approaches, to the point yeah, doctors really don't know how to produce useful people without those fricken' eight years or twelve years. Well friend, you should start thinking "outside the box" about how to make other people useful or many, many people will dies.
FYI: The US produces field medic with 16 week training period after basic training. That might who you want attending to you but things are going to be resembling a war zone really soon.
And, yeah, maybe I know little of what exactly ICU processes are but it seems indeed implausible that there are no intermediate levels of skills that are the slightest bit helpful, just about physical task can aided by a "third hand" etc.
But my SO runs, (COO), a system of hospitals. Including some teaching hospitals. And part of their plan definitely includes sequestering final year med students and all residents at their respective homes. Apparently the idea is that as hospital staff go down, this pool of residents and med students can be drawn on.
I know she stays up nights worried sick that residents might go to a party, or invite their boyfriend over, or engage in some other risky behavior instead of stay home alone and safeguard their health. So I get the idea that they really don't have a backup to that plan. I suspect med students and residents are a pretty critical part of the plan for surge operations across the nation.
Just pointing that out because I think hospital administrators and medical directors are starting to plan on doing things they wouldn't normally do. Like pressing 4th year med students into service, or taking 68 year old women off of ventilators if a 33 year old woman presents with a need for it. It's not so much a question of what doctors want to do, as it is a question of doing what has to be done to get through this with the maximum number of recoveries.
I don’t know what the fatality rates were for those healthcare workers at those facilities, but it would be good to know for future reference.
The person was asking a question, not proposing a plan of only training people for thirty days.
This thread is a like a giant version of that telephone game that we used to play in school, except in that game you didn't have the advantage of reading the exact words that the person said, as we can in this thread.
Medicine has traditionally had a problem with a large number of very clever people who are sufficiently insulated from other communities that they are a bit behind the times. A good humourous example is the 1994 paper where a doctor will rediscover calculus.
Why do people on HN consistently presume that they somehow know better than the experts? It’s distressing to me that anybody can say something like this with a straight face.
But seriously, the amount of people on here trivializing modern medicine isn't helping matters.
Granted, neither is business-as-usual, but a 30-day "ventilator boot camp" for untrained professionals is going to kill far more people than it helps. And a poor allocation of resources during a time of scarcity.
It's absolutely incredible. But that's exactly the kind of attitude that 'move fast and break things' fosters.
Everything you've written here is inconsistent and contradictory, and you desperately try to derail the conversation and change the subject whenever anyone points that out, then you run away when you realize you've painted yourself into a corner and are getting called on it.
Just look at how many downvotes and flags you're getting, and how many of your postings are light colored, dead, and hidden. You're well on your way to a shadow ban. I wonder how long it will take you to figure it out that the only people replying to you have "showdead" set to true, because they love to see you floundering.
If somebody's paying you by the hour for trolling, then they certainly are not getting their money's worth, because the moderation system is working, as the text in your posts becomes lighter and lighter until your posts are hidden and nobody sees them, thankfully.
Go back to Gamergate where you came from, mistermann.
Perhaps you think our capacity won't be overwhelmed. Then it would make perfect sense not to bother training amateur operators. If you think an amateur operator is worse than no operator, I'd like to see your evidence. If all you have is your intuition then my intuition is that you're wrong.
Going from zero to medical professional - not a doctor, just someone who can perform invasive medical procedures without killing a large number of people - isn't 30 days of work. Ignoring that reality will recklessly endanger people's lives.
If we're talking veterinarians, dentists, nurses, residents, MDs in unrelated specialties - then sure! They actually have the requisite knowlege and manual dexterity to cross-train. But going from, say SWE to ventilator operator, is not a 30 day crash course.
> If you think an amateur operator is worse than no operator, I'd like to see your evidence. If all you have is your intuition then my intuition is that you're wrong.
Because then you end up wasting a life and keeping a ventilator occupied, when there are much more efficient ways to kill patients that don't involve misusing a ventilator.
Former scientist, including (lab side) FDA trials. Medicine is complicated. Even sterile technique, to make sure you don't inadvertently give your patient a life-threatening infection in the process of "helping" them, can take years to get right. This is true of the most routine aspects of any kind of medical work.
But, do tell: since my "intuition" is so obviously wrong, I want to hear all about your empirical research. Or let's just start with your credentials, medical or otherwise.
This pretty much dissolves your only real objection, that we'd be keeping a ventilator occupied that would otherwise be in use. Nope. The solution to a deficit of ventilators is producing more - not letting people die without them.
Generally, you are trying to invent reasons and restrictions to make trying to train ventilator-operators seem like a bad idea rather than understanding or advancing how the idea might be viable. An example of this is how you acknowledge that training other medical adjacent professionals (e.g. vetrenarians) would likely work. Great, you agree the idea could work. If you expect that our capacity will be overwhelmed then presumably you think we should training additional operators. Instead of reaching that conclusion you imagine reasons to object to the idea though.
A SWE would likely be worse than a vet after a bootcamp. That's a good reason to have some entry requirements to the bootcamp and those requirements could be relaxed or strengthened depending on where we expect demand to be in 30 days relative to supply. A SWE through a 30-day bootcamp would likely be better than nothing.
The other main constraint you've imagined is that they would need to save more people than they kill to be worthwhile. No, they'd need to save more people than would die without them. If it would be better to just struggle to breathe than have an amateur operator, that would be an argument against them.
Your credentials, whatever they are, haven't equipped you to clearly communicate your reasons for opposing this idea. As I mentioned, it seems like you actually support some version of it.
So in a hypothetical situation, where existing permanent healthcare infrastructure is at capacity, field hospitals are setup and existing medical professional staff need to be divided amongst the existing and newly supplemented infrastructure, what is your suggestion to save the most lives?
This exercise of sharing ideas, informing, critiquing is what this forum is for. Disagree and casting shame for a lack of first-hand professional experience is not educational and it’s not what this forum embodies.
I want to be as informed as possible so I can call BS when politicians say “nothing at all could have been done.”
So here's my idea: stop treating invasive medical procedures as something that can be trivially learned in a short amount of time. In short, drop the God complex. You're out of your depth here.
The need for action doesn't mean acting foolish. Irrational behavior in the name of "just doing something" will needlessly deplete more resources.
I am genuinely interested in what your suggestion would be though. This is me asking. What would you do to address in the hypothetical I proposed?
As I mentioned above, cross-training medical professionals in adjacent fields sounds more practical. Allowing nurses to do more of what the doctors typically do is another. Even just offloading some of the administrative paperwork for clinicians to admin staff might make a significant dent. Relaxing any bottle-neck non-essential bureaucratic requirements slowing down access to treatment or acquisition of new equipment and supplies.
Having said that, I also recognize that the ideas I just came up with in the last 30 seconds are just that: ideas off the top of my head, coming from someone with no actual experience in healthcare management.
Basically, my first priority would be to make an informed decision, and that starts with figuring out what I don't know, and filling in those gaps. Rather than uncritically insisting, quite emphatically, that medicine can be solved with a 30-day boot camp. Because, hey, if it worked for tech then it must work for medicine!
Perhaps you should take your own advice, rather than responding with personal vitriol directed at the users countering your point.
I'm still waiting for you to reply to the questions I asked in the thread that you kept trying to change the subject away from. When I wouldn't let you do that, and kept bringing you back on topic, you ran away because you'd painted yourself into a corner with glaring contradictions in the things you said, and there was no way you could resolve the contradictions except by admitting you didn't really mean what you said.
I'll share a piece of advice that a good friend of mine told me a few years ago: The mind is a wonderful servant, but a terrible master.
I didn't really understand what he was talking about at the time, I thought it was just another one of those silly platitudes that people who've smoked a bit too much drugs say. But after pondering it over the years, it has become one of my very favorite sayings.
But if you're going to claim the contrary, I take it that you have a wealth of experience administering ventilation.
For the record, I've worked in fields tangential to medicine, including lab research for FDA trials and health tech. I may not be qualified to operate a ventilator, but I'm experienced enough to understand the technical skill gap between a non-invasive procedure and an invasive one. And ventilation falls into the latter category.
Of course he saw it, but he didn't like what he saw, so now he's pretending to have missed it on purpose, so repeating the facts he's ignoring won't make one bit of difference, and is just the two steps backwards he wants.
Notice how he always tries to repeat this same pattern in so many other postings, and don't reply to any of his attempts at trolling, except to explicitly point out what he's doing. And remember to flag him every time he does it, please!
Particularly my comment which seemed to spark something; it's a pretty basic fact that Ops Research people walk into situations where they aren't necessarily experts and optimise. That is a core part of the job. Every field is stuffed with experts who don't see how anyone could help them in their domain and they are generally wrong about the administrative trivia of organising a workplace. It doesn't even have anything to do with software. Ops Research is from mechanical engineering and factory optimisation.
I know bunch of doctors. I don't believe they work in an environment where the process has been mathematically optimised. They aren't mathematicians. That observation lines up very well with the "leave it to the experts" vibe of the responses here. They won't understand queuing theory for example.
Take a look at his history. The first most obvious thing you will notice is how well the moderation system is working: so many of his postings are deeply downvoted (light gray text), flagged, and dead. But unfortunately he's still succeeding in wasting a whole lot of the moderator's and readers' time.
If you can stand to wade through his light gray walls of rambling incoherent text, you will see there is a consistency to how he writes, digresses, derails, pretends concern, contradicts himself, and regularly trolls and sealions.
As Jacques put it, "It's the online version of passive aggressive belligerence with a veneer of sincerity on top".
And when you try to pin him down on anything he actually believes, he retreats into his intellectual alt-right safe space, where it's impossible to truly know anything, and facts are a matter of opinion, since we live in a post truth society, and people all have their beliefs that they are entitled to, and everybody believes lies except for him, while nobody knows what he truly believes, but if you sincerely ask him, he derails and refuses to answer, and says you can't force him to answer your questions, because you're not the boss of him, and he's the victim.
Does that sound to you like the sincere conversation he claims he wants to have?
That means that somewhere between 1 and 5 people don't like what he says. It is so consistent I actually suspect that someone has it out for him; there doesn't seem to be a particular link between what he is saying and the colour of the text.
> Trolling by claiming to agree with people, and saying some things that happen to be right (while throwing much much more bullshit against the wall to see what sticks), and being insincerely and cloyingly polite, is still trolling, and classic sealioning behavior.
If a sealion happens to be right I'm on the side of the sealion. Facts matter.
And it is a very fair question - given the number of people who are potentially going to asphyxiate this year it is reasonable to ask and have explained what the issues are surrounding ventilators. I don't know the answer to it, for example.
This is why I'm saying that mistermann had a point - questions aren't assertions. It isn't reasonable to interpret a question as an assertion. There isn't any evidence here of people looking down on the (rather lofty!) skills of the medical profession.
https://www.youtube.com/watch?v=hKc_1gc1pLg
>"Ahem!"
https://www.youtube.com/watch?v=Xs7r5xfucPs
>"Well, this theory of yours certainly seems to have hit the nail on the head."
https://www.youtube.com/watch?v=49H8HuqEcFo
>"Not necessarily. I could be arguing in my spare time."
It's uncanny.
There's actually a surprising amount of anti-intellectualism on HN, as evidenced by the persistent "People don't truly need a CS degree to be a qualified software developer; it's just gatekeeping." rhetoric one sees.
Do you know how to operate a ventilator? Why do you think that volunteers couldn't learn to do it?
Doctors would still be responsible for reviewing the care protocol and making decisions on treatment, but one doctor could oversee many respiratory therapists, each caring for many patients.
HN denizens apparently seem to disagree, and believe that if you can learn some JavaScript framework in 30 days you can do anything in 30 days, but the world doesn’t work like that.
This is not universal in the US. You can do Bac + Med School in six years even there[1]. That’s the standard route outside the US’ former colonies and those countries with colonial cringe. Medical school in the UK and Ireland varies from five to six years with undergraduate entry. Graduate entry is four years like in the US, but pre-med doesn’t exist; you can start med school with a degree in dance[2]. Even in the US you can do med school in three years[3]
[1] https://www.forbes.com/sites/noodleeducation/2018/06/18/3-bs...
[2] https://www.ul.ie/gems/programmes/bmbs-programme
[3] https://med.nyu.edu/education/md-degree/accelerated-three-ye...
This is not general purpose training - but very bounded / specific notes.
That's got to be better than exhausting more vital personnel.
I have not been able to find any larger case reports. Though on Tucker Carlson a few nights ago, a doctor on the front lines in NYC was interviewed and gave a similar report: If you reach the point of intubation and ventilation, the chances of survival is quite low.
A lot of these stats now coming out are going to be harder and harder to interpret going forward, regardless of the true numbers, as the media twists things around for their own political purposes. If ventilators turn out to be not the difference between life and death, even according to the raw stats, the media who wants to use lack of ventilators to blame one political party or another for the incompetency, isn't likely to tell the truth anyway.
From what I’m reading the treatment of COVID19 seems to require a pretty narrow set of practices. Mostly around monitoring, administering of medication, ventilation / oxygen and general bedside care. If this is true can we not cross train adjacent areas like EMT, army medics etc fairly quickly to provide care? They don’t even need to perform diagnostics.
https://pbs.twimg.com/media/EUNYuOuU4AApgBX?format=jpg&name=...
Still want to gamble on that 'narrow set of practices'?
and the fact that we think about "ramping up production" of "medical personel" leads the way to terrible industry-like education systems which emphasize cost-efficiency rather than quality education.
Once you are on a ventilator for covid19 you tend to monopolize it for 2+ weeks, hence the endless need for more machines
https://morningstaronline.co.uk/article/w/us-pressures-count...
There is a lot of money to be made by keeping these barriers in place, through legal, technical means and by limiting people’s access to “experts” that know what to do with them.
Those are a lot simpler and safer than a mechanical ventilator, which requires intubation or a tracheostomy, which you might say is highly invasive of the respiratory abstraction layer, and can cause correspondingly subtle and messy failures.
Your idea is to take a bunch of people who are not experts in ventilating, who have minimal experience with ICU vents, and give them a training course on ICU and anaesthetic vents and hope that they remember the difference and can work out the different panels, while exhausted, while in full PPE.
This is happening, but it's scary.
Your wider point - can we reskill a huge amount of the existing workforce to do a different job - is a good point, but that's already happening. Lots of people are doing jobs that they were not trained to do and they're doing those jobs with minimal re-training. This may help some patients, and it may cause harm to others.
Get guard reservists and order them to squeeze the airbag by hand if 5 million American health professionals are not up to task
The actual very interesting issue right now with ventilators is that there's companies in the US that make them and they say no one is ordering them. They cost around $25,000 each. Hospitals and states are sitting around waiting for the federal government to buy them and gift them to them, and whining that everything is the government's fault when that doesn't happen.
I learned through a personal connection who was actually on the ground in Hubei (but not Wuhan) caring for serious but non-ICU patients that doctors and nurses in their ward outnumbered patients, and they were at capacity. The staff-to-patient ratio should be higher in the ICU. With an overwhelming number of patients you simply can’t care for them, whether you have the machines or not.
It’s relatively easy to ramp up production of machines. It’s much harder to ramp up production of medical professionals.