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The nightmare scenario: Under new guidelines, the young and otherwise healthy, healthcare workers and police would be first in line for lifesaving care if things get really bad

A state task force of doctors and medical ethicists yesterday released guidelines for hospitals should things get so bad that ICUs become overloaded and doctors have to choose who gets ventilators or other potentially life saving treatments during the Covid-19 pandemic.

The "crisis standards of care" guidelines are designed for a hospital system in the process of collapse - too many sick people and not enough medicine equipment and healthcare providers to care for them all - possibly because they themselves might be knocked out by the virus.

When that happens, and patients are coming in faster than hospitals can provide intensive care for them, doctors will have to switch from trying to care for each individual patient to trying to maximize total "life years saved" for the community as a whole, the task force concluded.

To do that, a designated a triage doctor will assign patients scores based on such factors that include not just the severity of their Covid-19 infection but their age and preexisting conditions, with points added for each. Doctors, nurses and other healthcare workers, as well as paitents who otherwise would be involved in "maintaining societal order," however, would have points subtracted. Women far enough along in pregnancy that their fetus would survive would get a better score than non-pregnant women or men. In the event of a tie score between two patients, the younger one would "win," because of the priority of maximizing total "life-years" saved.

A key part of the determination would be based on a patient's Sequential Organ Failure Assessment score - which is based on how well six of a critically ill patient's major body systems are doing.

Patients with the lowest scores would then have their medical records color coded - so that ICU staffers know at a glance who's next for a ventilator - possibly even if that means removing somebody with a higher score from one. Red-tagged patients would be first in line, orange next and then all the older, sicker patients would be marked as yellow.

The guidelines emphasize that even in such a crisis, people denied potential life-saving care would not simply be dumped somewhere, but should be given care to help ease their pain and discomfort, at the least. "Where palliative care specialists are not available, the treating clinical teams should provide primary palliative care."

Hospital leaders and the Triage Team will make determinations twice daily, or more frequently if needed, about what priority groups will have access to critical care services. These determinations will be based on real-time knowledge of the degree of scarcity of the critical care resources, as well as information about the predicted volume of new cases that will be presenting for care over the following several days. For example, if there is clear evidence that there is an imminent shortage of critical care resources (i.e. few ventilators available and large numbers of new patients daily), only patients in the highest priority group (Red group) should receive the scarce critical care resource. As scarcity subsides, additional priority groups (e.g. first Orange group, then Yellow group) should have access to critical care interventions.

The guidelines also discuss the possibility of removing some patients from ventilators or other treatment should other patients come in with lower scores:

The Triage Team will conduct periodic reassessments of all patients receiving critical care/ventilation. These assessments will involve re-calculating SOFA scores and consulting with the treating clinical team regarding the patient's clinical trajectory. Patients showing improvement will continue with critical care/ventilation until the next assessment. If there are patients in the queue for critical care services, then patients who upon reassessment show substantial clinical decline as evidenced by worsening SOFA scores or overall clinical judgment, or demonstrate a failure to progress towards discharge from an intensive care unit, should not receive ongoing critical care/ventilation. Although patients should generally be given the full duration of a trial, if patients experience a precipitous decline (e.g. refractory shock and DIC) or a highly morbid complication (e.g. massive stroke) that portends a very poor prognosis, the Triage Team may make a decision before the completion of the specified trial length that the patient is no longer eligible for critical care treatment.

Patients who are no longer prioritized for critical care treatment should receive medical care including intensive symptom management and psychosocial support. If available, specialist palliative care teams will be available for consultation.

The guidelines emphasize that a patient's race or ethnicity cannot be used for developing a score. Boston City Councilor Ricardo Arroyo (Hyde Park, Mattapan, Roslindale), however, says that's what might happen anyway, because of higher rates of chronic disease among black and Hispanic populations.

Blacks & Latinos in Boston have highest rates of asthma, diabetes, heart disease, hypertension + others that decrease life expectancy with COVID-19.

If we deny ventilators based on conditions caused in part or in whole by racism it’ll affect POC disproportionately and is racist.

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Comments

If we deny ventilators based on conditions caused in part or in whole by racism it’ll affect POC disproportionately and is racist.

Who the heck voted for this guy?

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Yes, he's my councilor. And he's looking out for his constituents (the district is heavily minority). Good for him, that's what a district city councilor is supposed to do.

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Pointing out racial inequity is one thing, but are you defending his inflaming an already difficult situation with accusations of racism leveled at well-meaning people?

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He’s not “accusing” the “well-meaning people” of “being racists” but rather pointing out the racist consequences of a well-intentioned policy, which is an important and necessary thing to do.

When I suggest ideas that have racist consequences, even though that was not my intent, I appreciate when my colleagues point that out so that we can fix the problem. I would think that anyone who is truly “well-intentioned” would feel the same way.

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It is possible for a system that is currently run by entirely well meaning people to wind up with racist results. It's called "systemic racism" and it's no accusation against the people involved, but against a system that, in the end, winds up with bad results for a particular group - in this case that people of color could suffer more under these rules.

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Facts this is hitting our community hard and we vote and elect too. They can't do that if they do, black people will never be saved. And I'm a health care worker

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so more people voted for him then the next candidate.

I'm stuck at home for the forseeable future so I'll gladly answer any other questions you may have.

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He's right about the racial disparity of underlying conditions, but I'm not sure what he would suggest we do with the ventilator policy. Does he essentially want ventilator affirmative action? From a social justice position, that may make some sense, but from a saving the most number of lives perspective, it likely does not.

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So basically you're cool with black & brown people dying because why should they get equal help? Racism is real, bias is real. Two identical job resumes with one white-sounding name and one black-sounding name don't even get the same treatment and that's not even by appearance. You really think doctors aren't going to be impacted by bias when they're making these decisions? Wake up.

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No I'm not "cool" with that but it sounds like the issue is how to define "equal help." If there's one ventilator left and it's between a white person with no underlying conditions and a black person who has asthma because they live next to a highway, who should get it?

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And so do most of the other city councilors. Are the underlying issues a problem? Yes, depending on who you ask (the bodega owners who don't sell fresh produce will definitely say yes). But is it ethical or medically optimal? Who knows...

By the way, this always comes up when there is a limited pool of resources - be it BLS seats, college seats, any type of competitive jobs, etc. According to the social justice line of thought, any inequity (any difference in outcome, meaning equal opportunity is NOT enough) is more than enough of a reason to throw merit out the window.

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in one of my drunken internet meanderings that in the vicinity of 80% of ventilator patients don't recover. So, the turn around on them, to be very cold-hearted about it is fairly quick.

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The recovery rate is not great, but people end up being on them for about 2 weeks...

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...is that it's tied up for two weeks, then the patients are out on their feet or on a gurney. I see. I'm just wondering if the really bad cases don't last very long (I can't picture someone taking two weeks to pass away under those circumstances).

Friggin sobering.

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A bunch of people with shitty jobs, and hard lives, and high rates of hypertension and diabetes.

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that guy is correct, the factors you're basing this triage on, will affect poor (read Black/POC) communities disproportionately. This needs to be considered even though I do not know what the solution should be. Knowing this has been, at least, factored in, would help.

This is another effect of structural racism, from years of racist policies in Boston, especially redlining & white flight.

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The hospitals have not been overwhelmed. They did not get overwhelmed in NYC.

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You’re talking about one hospital for a few hours. Not that unusual and not an overwhelming of the hospitals.

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But even if that is and remains the case, it still makes sense to plan and prep for the worst possible outcome.

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They got overwhelmed in China, Italy, and Spain. So don't suggest it won't or can't happen here.

Social isolation is working very well across the US, overall. This is going to lead people think things are OK now, or worse, there was never a need to shut down so many businesses. If people go back to business as normal, in 3-4 weeks things will get really, really bad.

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In fact China Italy Spain and France kept people in their homes on penalty of imprisonment or fine. They had the most drastic fall in public space usage and the worst outcomes.

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That isn't true in the slightest. Deaths lag by 3-4 weeks. The countries with the highest fatality rates were late to the game of testing and social isolation. By the time they started restricting movement, a large portion of the population already had the virus and it was too late.

Countries which responded proactively are generally doing well, comparatively. This is why Trump's "It's only the flu" is so damning.

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The WHO isn't covering itself in glory here. Neither did the Chinese Communist Party. Remember this little gem?

IMAGE(http://i.imgur.com/YQ9hFoF.jpg)

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JennyR what planet are you on?

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It is good to point out the positives, but "They did not get overwhelmed in NYC" is still optimistic at this point as they seem to be in their peak. But it is correct that so far, despite the fact that things have been difficult, our hospitals have been managing.

But that is when these plans *should* be made. It doesn't help to wait until the crisis is in full swing. I hope that these plans do end up being unnecessary, but it is usually better to make unnecessary plans than need unmade plans.

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Hospital ERs are seeing drastic falls in usage. People are scared to go to the hospital and are dying needlessly in their homes.

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There's no evidence people who can't breath are opting to die at home.

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https://www.insidesources.com/unexpected-consequence-of-covid-19-crisis-...

I have no idea about the veracity of this website, but...it's making the point that ER load is lightened for a number of reasons that do sound plausible. They quote an NH paper, "There was no wait at the CMC [Manchester, NH] emergency department on Tuesday, March 31, said hospital spokesman Lauren Collins-Cline. “There are fewer people admitted to the hospital right now, so we’re able to move people out of the emergency department and into a bed very quickly if needed,” Collins-Cline wrote in an email."

Most presumptive positive cases are apparently being routed in such a way as to provide minimal exposure to the rest of the admitting hospital.

The original reason the USNS Comfort was sent to NY was to take non C19 patients to reduce the load on the regular city hospitals.

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It's called a #Plandemic.

Crash the economy and use the China Virus mayhem to defeat Trump.

Anyone seen Joe Biden? Bernie?

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Another nitwit troll.

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Yeah, the Democrats can control world politicians, but can't seem to convince US voters without doing this... They're the Scooby-Doo villain of the world and would have gotten away with it if it weren't for this comment.

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This whole cluster could use a lot more light and a lot less heat. Trump shuts down air travel from China on January 31 and it was all, 'orange man racist'. In retrospect, it was very effective at reducing the amount of asymptomatic spreaders in the US. But, it harshes the narrative of Orange Man Bad. So, now, the complete turnaround...Trump didn't do enough in the beginning so he put the US at risk. Meanwhile Marty Walsh, Bill de Blasio of NY were going into their respective Chinatowns to virtue signal.
Then the whole fucking thing blows up. Plastic bag bans rescinded. Toilet paper replaces Bitcoin.
You want a Scoobee Doo villain?
How about the City of New York Health Commissioner? One of the Very Smart People we listened to...in the beginning.

IMAGE(http://i.imgur.com/r5FkLn7.jpg)

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Than anywhere else in Boston.

Back when restaurants were still open, Chinatown was seeing a pretty racially-provoked dropoff in business, in a way that the North End never saw, which is what Walsh and Wu and others were trying to counter.

But we've been over this before.

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Joe Biden was on CNN last night making way more sense than the orange man.

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The hospitals have not been overwhelmed. They did not get overwhelmed in NYC.

In what fever-dream, bearded-Spock, Trump-&-Giuliani-are-competent mirror universe is that last part any sort of an accurate statement?

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I don't know where you're coming from, but the way you keep making unsubstantiated claims about New York hospitals not being overwhelmed suggests it's not from a facts-based world, so I've blocked your account. It's one thing to disagree with the way something was done, it's another to just ignore facts like that.

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Equally non-reality-based.

(There are others I simply disagree with, but O-FISH-L regularly spews complete Fox News nonsense.)

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Granted a perverse entertainment. Fish offers ample opportunities of recognizing poor reasoning. Recognizing his arguments' fallacies is like shooting fish in a barrel.

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Yeah she was scary stupid.

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Good chance "she" works for a disinformation campaign.

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Because she's active on a thread from today.

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The hospitals have not been overwhelmed. They did not get overwhelmed in NYC.

Tell that to my friend, the ER doc who works in a NYC hospital and who can attest first-hand to how overwhelmed the system is.

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how this is a reality in America 2020. Ok, maybe I can fathom how. But certainly not why.

Are we great again yet?

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Well, the Secretary of Defense made the Acting Secretary of the Navy apologize to the crew of the Roosevelt. That's something.
The Acting Secretary of the Navy resigned. That's also something.
...
Two tiny glimmers.

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Should give up their ventilators if things go bad, it's for the good of the people.

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Don't kill the messenger. I'm glad someone, whose day job is to consider what is the most ethical thing to do, is thinking about this in advance. There's got to be a plan.

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But the profession has others who say its unethical to put worth on one person over another based on age or level of illness, the ethical thing to do is try to save as many as possible, even if its difficult.
And politicians pandering to one group over another is cringeworthy.

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And politicians pandering to one group over another is cringeworthy.

There's no pandering here. If they did what you're suggesting, THAT would be pandering.

the ethical thing to do is try to save as many as possible, even if its difficult

This isn't a matter of "difficult". It's a matter of only being able to save so many people. There's a limit of the number of ventilators, beds, staff.

Triage is a reality. Anyone who trains in emergency medicine learns about it. Green tags, yellow tags, red tags, black tags. Two people are bleeding to death in front of you. You can do direct pressure on one. Which do you choose? In normal situations, it's the person who is most likely to survive if given help. In a mass casualty situation, you cannot save everyone, and if you try, you will save no one. That's the hard truth.

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Those in the right wing saying us old people should volunteer to die to benefit the economy are certainly pandering. Remember death panels? They were supposed to be a consequence of Obamacare. Turns out they're actually a feature of Republican economic policy.

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If two people are bleeding to death in a hospital and the hospital can provide only one person to stop the bleeding then the hospital deserves a bankrupting law suit.

The hard truth is that we are the wealthiest nation on the Earth. Yet we are trying to figure out who has to bite the big one because our medical system - so well supported by the powers of the nation - is failing.

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In normal situations, it's the person who is most likely to survive if given help.

Yes. ...and in normal situations, it doesn't go beyond figuring out "most likely to survive" and add some attempt to quantify the value or importance of that survival.

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a couple years ago. (Because they knew this sort of thing could happen.) And they in fact went with the "maximize lives saved" approach, with no consideration of "quality life years gained". They make one exception for age, as a tie breaker (basically, children get priority if all else is equal).

I think maximizing quality-life-years would be better from a utilitarian perspective, but it's impossible to do so in a fair way (how do you quantity quality of life?), so maximizing lives saved is the best we can do in practice.

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If there's got to be a plan, the plan MUST remove race, name, and identifying characteristics so that there is less bias when deciding who lives and who dies. And it's still really f#cking awful. Imagine being someone who is already being told that they're going to be the first choice to die. Wouldn't you think the medical community and white/abled/etc. people are just throwing you away? Wouldn't that confirm how little you are valued by society?

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There is a substantial difference between making care decisions based on race, and tracking care decisions and outcome based on race (among other things). Decisions...outcomes. See the difference?

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based soley on having FAR too much time on my hands, is this;

The curve will flatten and the coasts will get hit but not as hard as some predicted (thank god).

This will be used as "proof" that we were lied to by the "Deep State", that the Democrats and the media just hate Trümp, and all this "winning" is too much for Liberals to take, etc.

The summer comes and goes, and we enter a routinely beautiful New England autumn.

Then just like in 1918 when they HAD to have a Liberty Loan parade in Philly to fund the war;

The virus will be back and (possibly) stronger than before.

The November election is gonna be an absolute cluster$^@%.

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If we had a trustworthy President that everyone could look to for the truth, we wouldn't have all this division about things which, in many ways, are black and white. I didn't vote for or like George W. Bush, but there was a moment after 9/11 where he was decisive and Presidential. We could use a hell of of lot more of that kind of behavior today.

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These guidelines should have remained confidential. The public does not need to know any of these details.

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like the conditions on the CVN 71 Theodore Rossevelt?

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I strongly disagree with you.

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People who need to know the details include disabled people who rely on ventilators *now* and therefore have them at home.

They need to know that calling an ambulance could mean being taken to a hospital and having their ventilators taken away and given to someone who the hospital considers more important. Those people are being advised to write their names and something like "Private Property" in large, indelible letters on the equipment. And "don't call an ambulance" may still be better advice, because there's no guarantee that labeling the ventilator as private property would make a difference.

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You really think "the government" is going to come in and steal ventilators out of people's homes? What on earth are you talking about?

In reality, what we have is the federal government making decisions about which states get allotted the *stockpiled* ventilators.

(Also, the incidence of invasive ventilators in use in a home care setting must be extraordinarily small.)

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Probably not out of people's homes (though the feds have been confiscating pandemic-related medical supples). The danger is that someone who owns and uses a ventilator, and is admitted to a hospital, may then have the ventilator taken away and given to someone "more worthy."

Yes, hospitals may have to make hard decisions. And individuals are also already making decisions like whether to go to the hospital. For some of us, it's whether going to the hospital, in this situation, is likely to save your life, or is the choice between dying alone in the hospital, versus being able to see or speak to your family.

Whether a person is going to be lower, or higher, on the priority list for a ventilator because of their age, occupation, or pre-existing health condition is something they might want to take into account. As is whether being hospitalized will improve their chances of survival, overall.

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These guidelines were primarily based off a white paper from New York when it was envisioned post-SARS that there could be a ventilator shortage if there were an influenza pandemic for example.

It was never much publicized but they have been drafted for a while.

It's been generally known in most critical care circles that there were not enough ventilators if there was a pandemic flu that affected the entire country but since we've had so many close calls (SARS, MERS, H1N1) it never really rose to the forefront on what we'd do if we ever got to that actual situation.

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Potentially denying access to care for those with preexisting conditions driven by decades of racist environmental and economic policy, doing nothing for grocery and other essential workers who have been put on the front lines of this crisis through no choice of their own and left under prepared by their bosses and the state, but the police get their own special privilege beaches they help protect private property?

This is an act of genocide.

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What if the police officer or nurse is overweight and has high blood pressure? Do they get priority over a healthy supermarket clerk? I don’t even understand how these decisions can be fairly made.

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What are the opinions of who lives and who dies from:

Charles Koch
The Mercers
Clarence Thomas and his brothers in sex and drink
Grover Norquist
Sheldon Adelson
Mitch McConnell

Not as thought these folks lack either power or money. What are they doing to prevent what amount to the creation of a scoring systems of life and death?

Or will the next stop be Death Committees? Certain folks love bringing up that dystopian image. Perhaps this is an accidental perfect moment for people who never ever worry about food, housing and medical care.

One irony is Covid-19 is that it will produce an unexpected reduction in the long term claims against Social Security and Medicare. Considering people such as Charles Koch want to stop paying their employer's share into Social Security this could be a boon for their argument to stop taxing them.

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This is irresponsible on the part of everyone who is making a story out of this -- its guidelines for a hypothetical -- very low probability scenario
But that's what planners do -- Plan

To put it into context -- when the US invaded Iraq in 2003 the original plans included:

  1. the 4th Infantry Division invading from the North
  2. Several months of hard fighting
  3. Finding lots of WMD in numerous places
  4. Many Tens of thousands of casualties to US, UK and other Coalition Forces

None of the above happened:

  1. Turkey blocked the use of the 4th Infantry Div. -- we had to accommodate by using Special Forces & Kurdish Peshmerga
  2. The Coalition knocked-out Sadam's Government in 26 days
  3. There were no active WMD sites located although there was some evidence of WMD in the past
  4. The U.S. and other Coalition forces had 3000+ killed in action

Or consider three other examples:

  • Operation Downfall -- Gen Douglas MacArthur's plans for the Invasion of Japan -- which thankfully never happened
    A study done for Secretary of War Henry Stimson's staff by William Shockley estimated that invading Japan would cost 1.7–4 million American casualties, including 400,000–800,000 fatalities, and five to ten million Japanese fatalities*1
  • In the autumn of 2014, modelers at CDC projected that the Ebola outbreak in West Africa could reach 550,000 to 1.4 million cases in Liberia and Sierra Leone by late January if nothing changed. As it happened, heroic efforts to isolate patients, trace contacts, and stop unsafe burial practices kept the number of cases to 28,600 (and 11,325 deaths).*2
  • Initial estimates for the COVID-19 infection for the UK & US from Imperial College Model
    In the UK, the epidemic peaks in mid-May and reaches levels that are far beyond what the country's critical-care infrastructure can handle, resulting in about 22 deaths per day for every 100,000 people. That works out to about 14,000 people dying a day for a couple of weeks, with half a million total deaths. In the United States, a younger and more diffuse population means the peak comes a bit later and doesn't rise as high per capita, but the larger population means that over 2 million people end up dead.*3

Moral of the story -- Stay safe but don't believe every projected outcome
The modelers don't really know anymore as to how things will evolve than do we -- the lab rats -- in this global experiment

*1
Wikipedia article on Operation Downfall
*2
Article in Stat
https://www.statnews.com/2020/02/14/disease-modelers-see-future-of-covid...

Disease modelers gaze into their computers to see the future of Covid-19, and it isn’t good
By SHARON BEGLEY @sxbegle
FEBRUARY 14, 2020

*3
Article in Ars Technia not quite a month ago
https://arstechnica.com/science/2020/03/new-model-examines-impact-of-dif...

SOME MODELS ARE USEFUL —
Inside the model that may be making US, UK rethink coronavirus control
An Imperial College report considers whether anything short of a vaccine will help.
JOHN TIMMER - 3/17/2020, 5:47 PM

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Multiple Boston hospitals are now running well over 100% ICU capacity, with a substantial number of these patients on ventilators and therefore not well suited to moving to lower levels of care. Given the slow recovery time of some of these patients (2+ weeks) it is very possible to run out of ventilators even if we can move ventilators from one hospital to another in-town.

This is not a hypothetical but an unfortunately very real possibility that appears to be looming over us.

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Adam,

the brass tacks on how this is actually going to be implemented is undergoing active discussion in probably every hospital in the city (and likely the country). I can speak to at least the two that I personally am aware of that there will be a triage committee of "senior clinicians" who are going to put forth recommendations if we get to this unimaginable scenario of having to choose who to pull off a ventilator.

I wish this information were made the leading story on every news program in the country because people need to pause their non-social distancing and "it's just the flu" posturing and their thought process that they are healthy and it won't affect them for a few moments and contemplate whether they would like to be the person being triaged.

And for the people living in their rural "safety" with their rural hospital that only has 5 ventilators, what do you tell the 6th person that arrives and needs one?

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Norway! Goddamn, Boomers, this is your system. Not your fault it exists, but your fault you want to KEEP IT? WTF???

It works so well

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And your solution is?

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"Crisis standard of care..."

Indeed.

Criteria to score the sick on some sort of perceived worth.

Adam, this might be the most crucially-accurate headline you have ever written: Nightmare Scenario

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