In the week, beginning March 15 - Trump, who now has recognized that “Horrible terrible invisible enemy - the Chinese virus”, ramped up his paranoia and braggadocio; social distancing and isolation accelerated, with a total of five states ordering stay at home instructions; there were shortages everywhere and Personal Protective Equipment, (PPE) was still woefully short; hospital bed and ventilator availability was being overwhelmed this early on and the fact that tests are only recommended with those in immediate contact with a positive patient and those with serious symptoms - leaving out those at home with minor disease - underlies the scarcity of PPE and the fact that the country is struggling to control the pandemic.
The numbers reflected the exponential growth of the infection - with twenty - eight thousand confirmed cases and three hundred and forty deaths nationwide. In the State of New York alone, at the beginning of the week there were eight hundred positives and by the end of the week there were over eleven thousand. The situation was at a crossroads with the country battling to avoid the Italian nightmare where doctors no longer treat those over sixty years of age.
On the brighter side the Governors and Mayors are not trafficking in false hope and are planning methodically and scientifically to meet the needs of their communities. The FDA has ratified a forty - five minute test which will be used in hospitals and several trials are in process including a third phase study of hydroxycloroquine and zithromax which has shown promise in China and France. Also permission has been given for that combination and an AIDS retroviral drug which was extensively administered in China to be part of the management of serious non responsive patients. The vaccination research continues apace. But all these latter interventions are not going to help now. In addition to the local government institutions the corporations, the non government organizations, welfare bodies, the philanthropic foundations and society in general have come up trumps.
Besides PPE the crucial limiting factors at the moment are Intensive Care Unit beds and Ventilators which have the potential to cut the mortality by half. The biggest fear in containing the outbreak are the many senior living quarters which are more prevalent in America than anywhere else in the world. Also the leaders are terrified that the exponential increase of infections will not flatten out and the medical system will be overwhelmed with an unmanageable number of seriously ill patients as has been the outcome in Italy.
THE FEDERAL RESPONSE
As the coronavirus crisis accelerates, the numbers of positives doubling daily, and virtual lock downs are ordered in California, New York, Illinois, Connecticut and New Jersey, the extent of the American unpreparedness becomes more and more evident. While Trump with his echo chambers have mutated into believers of the danger of the virus, he still greets every ominous situation with misinformation and his customary self praise. His refrain is that “It is under control” is patently false. He reassures as his sycophants repeatedly congratulate him for his leadership and issue false claims about millions of test kits that don’t arrive. His solution to the ICU bed crisis are two hospital ships off the coasts that are nowhere ready to be functional. While his Administration have located a few thousand ventilators, hope that they can recondition those used by anesthetists, and welcome General Motors’s efforts to move to production of ventilators, none of their solutions inspire confidence that the demand can be met soon enough.
It has been left to the few professionals to correct the POTUS where they can. In the past two days he has falsely claimed that there are two drugs, that have had very limited anecdotal evidence of efficacy, are “game changers”. (The good news is that the State of New York is about to conduct a scientific trial to assess his belief but that again will take time). He reemphasizes that nowhere in the world have they seen such a response! He non stop traffics in unsubstantiated hope is spite of being told again and again that there is no objective evidence for his “beliefs”. The daily WhiteHouse Press conferences are a strange mixture of sanity from the experts and Trump’s off the cuff lay opinions on the management of the coronavirus directly imported from his campaign rallies.
The NIH Director in Infectious Diseases, Dr. Fauci, agrees with the assessments and decisions of the Governors of California and New York. The former fears that twenty - five of his forty million population can become infected. The New York Governor Cuomo, like so many of his peers, has provided an object lesson in transparency thereby gaining confidence in his leadership. He has estimated that forty to eighty percent of population the State of New York might be infected. Governor Pritzker of Illinois, ordered a home stay of everyone and a closure of non essential businesses relatively early on not waiting to become an epicenter.
On the positive side there is no doubt that, not withstanding Trump’s shrugging off his leadership role by baldly stating that he was not a shipping clerk for the States, since the involvement of Federal Emergency Management Agency, (FEMA), the Federal Government’s co operation and help to the States has been stepped up dramatically. The Governor of California couldn’t have been more laudatory with the promise of four field hospitals, (1000 beds), and supplies.
CRITICISM OF TRUMP AND HIS RESPONSE
Trump faces the constant criticism of not enough tests, masks and Personal Protective Equipment, (PPE) and ventilators. He counters that there are millions of masks, PPE and ventilators in the pipeline. He initially claimed that everyone who wanted a test could get one. Ventilators are most crucial to prevent mortality as to have any chance to survive from respiratory failure only a ventilator can tide a patient over.
Trump maintains that his response was “unprecedented”, that he has had “unprecedented” praise and doctors can’t believe what he has done. By closing down borders earlier than anyone else in the world he saved tens of thousands of lives. He repeats and repeats that line again and again. He wails that his action was criticized by sleepy Joe and the Democrats. He omits to say that he had intelligence reports in January and February that warned of a pandemic while he was calling the Coronavirus crisis a Democratic hoax. He and his echo chamber, Fox News only ceased that smear ten days ago. He now claims that the Chinese hid the severity from him, “Our people didn’t have enough time” to prepare because of the Chinese deception. But simultaneously and contradictorily he opines that his good friend Xi was doing a great job. Other countries in SE Asia weren't "deceived" neither was his other "good friend" Putin in Russia.
The crisp point remains if Trump really saw this as a pandemic on January 31, as he now retrospectively claims, why didn’t he prepare America for the onslaught? Instead he denied there was a problem till March 13, when he declared a National Emergency. Furthermore, his daily Press Conferences, are sounding more and more like Campaign rallies with the ritual abuse of the reporters. All is rosy he reassures and it is just a matter of time when America returns to the greatest economy in the world. Specifically the medical situation is under control.
On the twentieth of March when all things were supposedly righting themselves and the shortages and ability to cope with the crisis was under control, the President of the America Medical Association, (AMA), sent a letter to her members which stated inter alia that she has conveyed to the POTUS the single biggest thing you had on your minds, “WE NEED MORE PPE AND TEST KITS”, (The AMA President’s emphasis).
THE CHALLENGE THAT MAY FACE AMERICAN DOCTORS WITH LACK OF ICUS AND VENTILATORS
A massive ventilator shortage is the limiting factor in the successful management of the respiratory failure that is the cause of Covid 19 mortality. Not surprisingly American hospitals are not geared for the volume of illness that models project. There are according to the National Academy of Sciences a hundred thousand ICU beds, which would be equipped with ventilators. Governor Cuomo reports that under the rosiest scenario New York alone is short of twenty thousand. He has managed to buy six thousand having scoured the world markets. In a study quoted in an article from FiveThirtyEight, Hennepin County in Minnesota given a twenty percent rate of serious cases would need forty - nine thousand extra beds in their hospitals. Those hospitals on any given day only have twenty - one vacant beds. These figures are calculated on the basis of only twenty percent of the Hennepin population being infected.
Should the above scenarios happen at once or the curve not be flattened then doctors would have to face the dilemma that Italian doctors have faced - who should live and who should die. This is a situation American doctors have never had to come to terms with before. Litigation, hospital policy and society have always left the decision up to the patient. If the patient hasn’t a Do Not Resuscitate Order on file or a Living Will as to what her wishes might be in such a situation the family may well decide that every effort should be made to keep an eight - eight year old with dementia and a previous stroke on life support. An ER doctor interviewed on television argued that there was no way that he could function in such a milieu unless guidelines were laid down and malpractice suspended.
Other countries have had policies that have evolved over the years. For example whereas age may have been the parameter in the 19070’s now it is the physical and mental status of the patient. For example cancer may be an exclusion but the guidelines would have to be defined in America because slow growing prostate cancer and fourth stage lung cancer carry different prognoses entirely. This situation has to be hanging heavily over the decision makers in society. Jay H. Ell’s guess is that there will be no help from Trump’s administration - he will leave it up to each individual State.
AT THE END OF THE DAY
There is little doubt that the Trump’s Administration, notwithstanding Trump’s personality problems, have improved their act. However they are relying on the drivers of the response to be the local governments and society in general. The latter have their work cut out and all are praying for American ingenuity to deliver the goods someway or another.
The Trump Administration together with Congress are addressing the financial disaster that this pandemic has evoked with far reaching proposals.
Whichever way this is looked at Trump himself will have a lot to answer for when the chaos dies down. He would not believe it but everyone is hoping that he is proven right that “Everything is under control” and that his “Unbelievable Medical Ability”, on the subject turns out to be life saving.
For the moment the best hope for society is isolation which again should be nationwide and not left up to the States. Trump should act. While a number of the States have fewer cases they are not following Illinois’s example of trying to keep it that way. Why are they waiting for the inevitable to happen and then only move? The basis for this deadly strategy has to be they are expecting “the miracle”Trump hoped for.
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