[skillpass]

I agree - I am worried about taking hospital capacity claims at face value though.

From what I've seen, it was common for hospitals to report being overwhelmed even during flu seasons pre-covid. I wouldn't classify that level of 'overwhelmed' worthy of mandates upon society.

I don't doubt that during these periods of time hospital resources are strained in some way, but there's a difference between this routine level of being overwhelmed and a level where freedoms should be restricted from the general public.

I don't have a good model for where the line should be drawn, but I lean towards not imposing restrictions unless massive benefit can be shown beyond a reasonable doubt.

[sib301]

Dude go to a hospital in a populated area during this surge. My wife sat in the waiting room for 3 hours with SEVERE abdominal pain, DURING A PREGNANCY and was unable to be seen. We went home. If she’d had an ectopic pregnancy, she would probably not be here anymore.

[avs733]

I had an extremely traumatic accident a week ago and came into a major city hospital as a level one trauma patient.

I came in with absolutely no wait..ambulance directly to a trauma bay, no waiting, no clothing, no nothing.

After about six hours they figure out I was not going to die and was relatively okay. Okay here means two broken legs not “walking around”. Half of the patients at this hospital had covid and I have a five month old at home who isn’t vaccinated (obviously).

Once I got admitted to the trauma floor for a couples days it was like I didn’t exist. The staff seemed totally overwhelmed and it took hours to get some simple things like water. Without visitors, a bag of belongings got delivered by being isolated in a chair well out of my limited reach. Took me eight hours to get my laptop from that bag. I was okay with that because I wanted to interact with as few potential covid vectors as possible but wow.

I think, from my experience there are a couple of things happening:

1) staff are overwhelmed to day with the ratio of patients to staff. I can’t comment why but the nurses I saw weren’t sitting they were constantly moving.

2) staff are demoralized and frustrated. You could hear it in their voices and tone and body language. They were trying but grumpy.

3) shit rolls down hill. Drs. (Save one angel who talked with me for 30 minutes about life) where in and out for brief profunctory conversations that had no communicative value about what was

They need more nurses. And like everywhere else it seems no one is willing to pay them more or treat them better. We can pay execs millions with no qualms and no evidence it works. But as a patient having the worst day of my fucking life, I interact with front line staff and they are out there getting run into the ground and being treated like shit for it.

I’m so sorry for your wife, I was so lucky I had a different experience. But the shared thing, I think, is that the American medical system is going through a full and complete collapse and no one with the power to change things is willing to do anything.

I’m terrified.

[doitLP]

Meanwhile my friend who is a nurse in the UCLA hospital complex says they’re so understaffed because they let so many people go/nurses retired or quit that all nurses are allowed to come to work if they’ve tested positive but their symptoms are improving

[avs733]

This is a perfect sign of what I’m talking about.

They fucked around with these people for so long that when they need them, actually need them, they aren’t there. They rolled the dice in an assumption that they held sufficient economic power to control them. Now they are left exposing patients to covid as a necessity to prevent their operations from completely ceasing.

That is failure by any other name.

[doitLP]

I wouldn’t blame the hospital too much — they were responding to the economic incentive of lockdowns and lack of actual patient pressure by closing entire wings of the hospital and laying people off. I.e there wouldn’t be this nurse shortage at the hospital if the lockdowns never happened.

[irthomasthomas]

Is the explanation simply that so many nurses are being forced to isolate with Omicron? Since even vaccinated staff can still spread it, so they still take the tests often, and isolate for 2 weeks if positive.

[avs733]

I would suggest the explanation is similar to the supply chain.

In the interest of profits we have wrung every ounce of every part of the system that runs healthcare. And at the end of all of those elements are human beings. Such systems are unstable. They work but are not fault tolerant at scale because no one ever really looks at the whole system they just look at a part of the system they control. I’m okay if healthcare is more like an a320 as opposed to an F22 because the F22 needs 50 man hours of maintenance to fly and the a320 does it’s thing in a much more germane fashion. Jwst can have 184 single point of failure actuators because it’s the bleeding edge, healthcare needs to have -184.

The problem is we see humans as humans. A machine breaks, it is not perceived as having agency, autonomy, or humanity we don’t blame it. When people die waiting in an er or healthcare personnel are short with patients or quit in droves there is a person whose actions and motives we can question and blame. We understand that experience slightly more and can find ways to question it.

It isolates the problems from view. When no one’s looking at the whole system (and being listened to) no one can shift course. It was not efficient to build capacity for truly abnormal events, so it didn’t make financial sense For anyone to do so. And now nurses are testing and isolating…and. Not just. And.

[kube-system]

This has been relaxed greatly in 2022 at many hospitals. Most are isolating only for 5 days now under the new CDC guidelines, and some only if the person is symptomatic.

[hutzlibu]

"Is the explanation simply that so many nurses are being forced to isolate with Omicron?"

A explanation why people are frustrated, who work hard and intense, take all the risk - but only get low pay?

[kurthr]

Exactly, "you've been a nurse for 30 years, you're 60yrs old, you tested positive for COVID and you still have symptoms, but if you don't come back into work after 5 days (without pay) you'll also face punishment when you return". Of course, if a patient get's COVID while under your care (and symptomatic) and chooses to sue you, "you're on your own babe!". Also, "it is mandatory that you get vaccinated/boosted, but also come into work the next day or you won't be paid and it will count as one of 4 unscheduled days off per year before termination".

And people wonder why nurses are pissed off?

[avs733]

We focus on human causes because we connect to them better. And because for many many people these are the concrete things that can understand when I’m a stressful situation. Abstract problems like decades of “capacity management” “workflow improvements” and “right sizing” are so abstract they don’t resonate with someone who is standing in an er in pain. They aren’t dumb they are stressed out. Stress is basically fight or flight…it makes us stupid.

Stress is why I made the firefighters put in safety glasses and got angry at them that I couldn’t find my glasses. Both while trapped under a literal oak tree

[Lammy]

To be fair I had exactly that same experience at the UCSF Emergency Room in 2017. Four hours in the waiting room, and then the only bed they could give me was against one wall of a busy hallway.

[saiya-jin]

Yes its very common even in richest places. Case point #2 - Geneva, Switzerland has the biggest public hospital in whole country (HUG). They employ around 10k personnel overall, and Geneva is relatively small city (they call it the smallest metropole for a reason). There is no shortage of money or high tech equipment.

But if you came pre-covid during say weekend night and you were not clearly about to die, 10+h waiting time in emergency was not unheard of (wife was serving there for some time as doctor, those folks deserve some proper respect). Simply overwhelmed, not enough staff comprised mostly by junior doctors. Now they are properly good in diagnosing whether your excruciating pain is life-threatening or not, but it must suck big time to be on patient's side.

This is by far the biggest emergency in whole canton. Any private clinic or smaller medical centre will send serious cases straight there.

Its not something discussed frequently but that's just how things are, in one of the richest and well-organized countries in whole world. Don't expect much better experience if you have bad luck with timing.

[hutzlibu]

Well, here in germany it is quite similar.

That means, I had to wait only a short time once, but that was after a dog bite to my face and it just looked horrible with blood all over it.

But the next time, with an deep open wound in my leg, which was actually way more dangerous, I had to wait quite some time, before they even checked.

[christophilus]

I think I’d read your biography.

[dekhn]

this describes many ER visits I've had, ones with my kids and ones I had myself. ERs are the worst possible places to go for medical care, except for near-immediate death. Over time, especially in the US, more and more people use the ER as first-line care (especially on the weekend).

Last week, my son had COVID (tested positive) but mild symptoms. At some point he says "I have a blue tongue, I don't remember having that before". Doctor and wife want to rush him to the ER and I say no. My daughter and I debugged it a day later (he had just taken a blue gummy pill, and somehow didn't think to mention that). What would have happened if we went to the ER? Shrugs from the doctor after sitting around the ER at midnight-5AM ("yeah I guess it's not cyanosis and it's gone now"), my wife and I have increased exposure to COVID in the ER, and a $3K bill for looking at a tongue.

[smileysteve]

2012 checking in.

[mfer]

I know a lot of nurses and have been following what's happening in hospitals. It's complicated. Here are a couple things I've learned...

1. Many hospitals are under staffed. Schools that produce nurses have stayed steady state while demand has increased. This was before the pandemic. During the pandemic many nurses left due to mandates, being treated poorly (by hospital mgmt and people in the hospital), being overworked during shortages, and more. This has all made staffing a huge problem.

When hospitals don't have the staff they close beds down and can't operate at full capacity.

Hospitals that used to only hire RNs with bachelor degrees and wouldn't consider an associates (it's the same amount of schooling in the nursing portion) are now trying to hire LPNs.

2. Some emergency rooms are seeing a crazy number of people. More than usual. This is for a variety of reasons. COVID is one but also people putting off having things treated so they are now emergencies is another. Couple this with the staffing shortage and it's even worse.

[lowercased]

My mom had to wait for ~ 5 hrs in ER waiting room in relatively severe pain. Was another 8-9 hours 'inside' just to be sent home. Years ago she'd had been admitted and stayed overnight to be on the safe side (older adult, known health issues, etc) but ... no room, over capacity, stretched way too thin.

[umvi]

Busy ERs are not unique to covid. I've had many experiences with multi-hour ER waits pre-2020

[dont__panic]

Ugh, I'm so sorry you had to go through that. For other folks reading this: yes, three hours doesn't sound like that long a wait. But I'm willing to be those felt like the three longest, most stressful hours of your life when your mind is racing with possibilities and fears about the future of your wife and/or baby.

[brimble]

If it's anything like my Dad's recent trip (I went with him—kids who haven't had to deal with hospitals, always make sure someone else is with you to watch out for you if you have to go in, there is a good chance you'll have a bad time if you don't) the waits are super-long even for people who are obviously in a lot of distress, and they also don't communicate at all about where you are in the triage pool, so you're looking at people who you overheard saying they've already been there three hours when you got there, and they do seem like they need help, and you're like... how fucking long am I going to have to wait? And there's no answer, which I get, but if they could at least tell the ones who definitely aren't getting in "you're low-priority and we have no hope of seeing you today, we're just waiting until you get frustrated and leave" (this was the end result for like 50% of the people in the ER that day, from what I could tell, some of whom really did seem like they needed to get in) exactly that, it'd relieve some stress to know you're not in that group. The lack of communication bordered on abusive, for that reason, and I get they can't give an exact wait time, but at least saying "yes we do actually intend to get you in at some point" would be nice.

[iskander]

Similar experience in my family, father-in-law spent 18 hours waiting in a ER. Needs a biopsy and imaging which are taking weeks to get done because, as several doctors have admitted, the hospital is both overwhelmed with Covid patients and short-staffed due to infections among doctors and nurses.

[skillpass]

I'm sorry about your experience. I do wish your wife would have received better care, but I'm not sure we can jump to the conclusion that the experience you had implies mandates and restrictions upon society are worthwhile.

Do you know that it would have been a shorter wait time during a period where the hospital wasn't overwhelmed? If so, how much shorter? Perhaps the medical staff were able to tell the signs of ectopic pregnancy in a way that allowed them put your wife lower on the triage priority list than you thought she should have been.

Does your area have any sort of restrictions? If not, how would the amount of time you had to wait be changed in a world where your area did have restrictions?

Even if you can show some benefit from the restrictions, are the benefits great enough to be worthwhile given the costs?

[amluto]

Restrictions would likely achieve essentially nothing right now. Reducing R from insane to merely very high might slightly flatten the curve, but not likely enough to make much difference. Restrictions on a level like China are a different story, but that’s not about to happen here.

Vaccines are entirely different story. They seem to have little effect on transmission (maybe enough to be useful after three doses but maybe not), but they seem to substantially reduce the number of people who end up hospitalized. So more vaccines would lower the curve, not flatten it.

(Take this with a grain of salt. Great data on vaccine efficacy in the US is a bit hard to come by, and I haven’t run the numbers.)

[jokethrowaway]

Coming from the UK and Italy - 3 hours is nothing. If you're about to die they'll send you to emergency, otherwise you'll have to wait hours. If you're unhappy, pay for a private insurance and get decent service.

Actually I had to go to the hospital (not covid) and it was almost deserted with reception coming to check the desk they were supposed to be attending half an hour after we were supposed to be there. People generally went less to the hospital because of the pandemic (which causes other problems).

[cogman10]

IDK if it's gotten worse, but circa 2004->2006, my experiences with the NHS were nothing but pleasant. I mostly dealt with northern hospitals and GPs, but it was pretty much in and out. Appointments didn't take long, we were in and out in almost all cases.

[ectopod]

Where can you find a private A&E in the UK?

[ipaddr]

3 hours? In the best of times it's an 8 hour wait before covid.

[ryan_lane]

Where has this happened to you? I've been to the ER 6 times in the US and never waited more than 2 hours (pre-covid) in New Orleans, San Francisco, and New York.

The time I had to wait 2 hours in SF, with a kidney stone was not pleasant, but it was at 3 AM at a hospital that does charity for the homeless, so that was a bit exceptional.

[bko]

Hospital capacity is a technical problem and can be solved by building more hospitals, hiring more workers or changing the roles to allow nurses to handle more issues. The hospitals are meant to serve people, not the other way around. Covid didn't arrive overnight. If there are capacity issues they should be addressed independent of everything else.

[AnthonyMouse]

The thing they don't always mention is that hospital capacity is always close to being overwhelmed, by design, because otherwise you're sitting around with a large amount of extraordinarily expensive idle hospital capacity. A small change is enough to go from "almost full" to "over capacity."

The seemingly obvious thing to do would be to build some temporary capacity specifically for COVID patients. We've had quite a long time to do this now so I'm not sure what's preventing it. Maybe it's caught up in that thing where captured regulators are gatekeeping medical certifications to maintain labor scarcity or some such thing?

[notriddle]

> The thing they don't always mention is that hospital capacity is always close to being overwhelmed, by design, because otherwise you're sitting around with a large amount of extraordinarily expensive idle hospital capacity. A small change is enough to go from "almost full" to "over capacity."

If that was true, it would not be okay. There needs to be enough capacity to handle unpredictable spikes in load. This can be described using the same sort of queueing theory that anyone legitimately operating at scale needs to worry about: you don't just track average latency, but also track tail latency.

Luckily, emergency hospital buildings are not "always close to be overwhelmed." Their staff is always close to being overwhelmed, but the buildings are not. Instead, they maintain a reserve capacity of temp nurses, who get called during brushfire season and New Year's Midnight to handle the unusually high load. They are paid well by the hourly wage, but don't get any benefits, and either have a second job or a retirement plan to carry them over the rest of the year.

Only this time, they were never sent home. And, since some of them are being forced to quit their jobs, they're demanding the benefits package, which is getting expensive.

Edit: and, of course, this all goes to crap once a brushfire happens on top of the pandemic

[spookthesunset]

> The seemingly obvious thing to do would be to build some temporary capacity specifically for COVID patients.

Many states did exactly that back in march of 2020. Most of these temporary facilities were closed virtually unused.

[jupp0r]

> I'm not sure what's preventing it

It takes time to to train doctors and nurses, they don't grow on trees. Opening immigration for these professions could be a short term solution but getting a US license is complicated too (maybe rightfully so).

[hutzlibu]

This is a hard problem, because you do not only need beds, but also humans tending to the patients.

And while you can just build another hospital if you have the cash - you cannot just build another doctor, if you need one.

[jstarfish]

> you cannot just build another doctor, if you need one.

So take your pool of existing NPs and give them a temporary promotion.

[spookthesunset]

Or anything like that. It's an emergency, right? So what about people in medical school who have yet to be licensed? Grab them and have them do stuff. Retired doctors? Go get them. Whatever. It's an emergency. Get creative. You don't need things perfect. You need things to work. It's an emergency. Every second you aren't focused on solving overwhelmed healthcare is a second you are stealing from people through lockdowns.

I really don't understand why people are completely incapable of using their imagination to solve "hospitals over capacity". The only thing I can think of is perhaps hospitals have never actually been overwhelmed because if they were... we'd have fixed the problem already.

[hutzlibu]

"So what about people in medical school who have yet to be licensed? Grab them and have them do stuff. Retired doctors? Go get them. Whatever. It's an emergency. Get creative"

Would you prefer a student, or a seasoned doctor to decide on you - if you are in a critical condition in the hospital?

But sure, I would take any advanced med student over being ignored while in need of care. And since this is not rocket science, here in germany all the retired doctors, trained military medic, ... have been registered and contacted in the beginning - to be ready if needed, but as far as I know, it was not made use of (much?).

And YES. It should have been invested massivly in healthcare in the beginning of the crisis and it was. But mainly just in infrastructure it seems. Or high level corruption.

Because today there are de facto fewer hospital beds avaiable, than in the beginning - because apparently it was not invested enough in the people. The ordinary health workers. They are leaving burned out.

For a short amount of time, you can enlist lots of reserve stuff so to say. But not for years.

[spookthesunset]

It’s an emergency, remember?. It doesn’t need to be perfect. It’s an emergency, remember?

Find ways to make it work. Fire the naysayers. Figure it out.

Or alternately accept there never was a problem with healthcare capacity because if there was, we’d have demanded it to be fixed already. Because any reasonable person can state it can and should be fixable. Problem is too many people lost their mind and forgot what it meant to be reasonable.

[nradov]

2018: "Hospitals Overwhelmed by Flu Patients Are Treating Them in Tents"

https://time.com/5107984/hospitals-handling-burden-flu-patie...

This pandemic has been extremely hard on many healthcare providers. But hospitals in many areas were routinely overwhelmed during winter respiratory virus season in previous years. They dealt with it as best they could, and we didn't impose mandates or restrictions on the rest of society.

https://peterattiamd.com/covid-19-current-state-omicron/

[frickinLasers]

Covid has been something like ten times as deadly as the flu. I imagine those hospital beds put way more strain on the system as a whole than a bad flu season (see: ventilator sharing). I think any human with a shred of empathy for their tribe would agree, that this level of misery warranted collective action on the level of our response to measles, mumps, rubella, tuberculosis, diphtheria, pertussis...

And though I really hope it's the case, I've heard no news yet that Omicron will be the last significant variant.

[nradov]

Did you actually listen to that panel discussion I linked where several leading physicians explain what's been happening and the mistakes that have been made?

[frickinLasers]

Given the amount of time between when you posted and when I replied, it's safe to say I hadn't listened to the three-hour conversation between two physicians and a professor. Initially I scrolled down, was put off by the stack of text and images/embeds with no clear organization, skimmed the Cliff's notes, and failed to understand how it correlated with "we didn't impose mandates or restrictions on the rest of society."

They make several good points about policy moving forward and vaccinating children, but they were disregarding Omicron before we even knew much about it. Their general position aged like milk, now that there are more people in the hospital with Covid than at any point in the pandemic. They complain about Fauci holding rigid positions, while my science-illiterate family complain that the rules keep changing/are confusing. None of this addresses the fact that masks and vaccines are consistent with past policy in America and have been more effective than nothing, at least as far as people complied, or that comparisons to the flu are a bit of a stretch.

[nradov]

Actually, their general position has aged very well and has been proven largely correct. They consistently recommended vaccination for the majority of people with perhaps a few very limited exceptions. You should listen to the follow up panel discussion in which noted infectious disease expert Dr. Monica Gandhi explains why mask mandates are bad policy.

https://peterattiamd.com/covid-part2/

https://profiles.ucsf.edu/monica.gandhi

[walterbell]

There are operations research PhD's who use decades of aggregate demand data in dynamic pricing algorithms for the purpose of revenue and queue management in perishable services, e.g. software for pricing of airline seats, rental cars and hotel rooms.

In countries with universal healthcare, price cannot be used for queue management, but the US isn't one of those countries. Did any hospital use queue management software to adjust pricing as a mechanism for demand throttling, due to limited capacity in 2020-2021?

In any case, if supply-vs-demand is both a policy driver and metric of intervention performance, we need public, detailed hospital capacity data for analysis and optimization of net societal costs vs benefits. Utilization of space and skills is eminently quantifiable and software already exists for demand mgmt.

[zrail]

> Did any hospital use queue management software to adjust pricing as a mechanism for demand throttling, due to limited capacity in 2020-2021

No one shops for healthcare in the US based on price, for three reasons. First, prices are unknowable in advance. Second, if you have insurance the insurance will fulfill their end of the bargain if you need to be admitted (i.e. they will pay as agreed upon in the insurance contract). Third, emergency rooms in the US are required by law to stabilize any emergent patient that walks in the door, which means anyone can go to any ER anywhere and get treatment.

[depereo]

Isn't there a new law, partially rolled out, that requires US hospitals to disclose the cost for a procedure or treatment in advance?

[vel0city]

They're required to publish their prices, which results in giant PDF documents with thousands of different charge codes and prices. Its almost incomprehensible to analyze unless you're in healthcare billing. Plus, you'd need to know what services/medications/equipment you'll need before you even get to the hospital, which is pretty dang tricky unless you're a doctor yourself.

I was recently in the hospital for abdominal issues. How would I know what drugs they would give me? How would I know if they were going to give me some kind of scan? If they were going to give me a scan, are they going to use a portable machine or use a stationary machine? Are they going to need to use some kind of endoscopic scope? Will I need other things to assist with those scans (sedatives, contrast materials, etc)? Which blood work tests is the doctor going to order? Which urine tests is the doctor going to order? Are they going to order stool samples? How many samples are they going to need, how many times are they going to need to re-run tests? What if I get there and determine I need surgery? How should I have known I needed that ahead of time? What kind of surgery is it going to be? What drugs are involved in that?

Its not like you can walk up and see a board that says "INTESTIONAL DISTRESS -- $175"

[brimble]

> Its almost incomprehensible to analyze unless you're in healthcare billing.

Considering that hospitals seem (anecdotal evidence only) to fuck up their own billing codes like 20% of the time, I'm not even sure that's enough.

[ericd]

I briefly tried using the results of that, they're totally unnormalized, so even lining up identical line item charges is difficult. We have a deep learning language model that normalizes the language and lines up potential matches. But even if that works, it still doesn't get you the bill, because a single encounter includes a big batch of billing codes, depending on what the doctor tries to give you. And to get normal baskets, you probably want claims data. And the claims data providers we spoke to wanted 6-7 figures for a small dataset.

It's an incredibly parasitic industry, I've never seen anything quite like it. It's a pretty stark contrast to the largely altruistic motives of many of the healthcare professionals themselves.

[abduhl]

Hospitals don't comply with it. What is the government going to do, shut them down or fine them into closing during a pandemic?

Private companies have coopted the power over our government during this pandemic, and we have gladly given it to them in fear.

[nradov]

Pricing is mostly fixed for at least a year at a time by contracts with payers (insurance companies), or by Medicare fee schedules. Hospitals have almost no legal flexibility to dynamically adjust prices based on demand.

[Tade0]

A few of my friends are doctors. When it hits, it's hell. Here in Poland 300h of work during the month the infections are at their peak is not unheard of.

[Fomite]

I work with a lot of clinicians.

Normal flu seasons don't leave them with 1000 yard stares.

[mrcrumb1]

Can you give me an example of a scenario where you would be in favor of restriction like the ones that have been implemented?