IM Doc pt 29
Dec. 19th, 2021 10:52 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
temporaryrealityCuibono
Coercion works? As exhortation, Biden’s speech had no impact at all.
“Covid-19 booster shots have outpaced the US rate of new vaccinations. And the millions still unvaccinated could trigger ‘future waves,’ expert warns” [CNN]. “[W]ith the number of Americans getting booster shots surpassing those who are initiating vaccination, experts warn more is needed to continue the progress…. An average of 384,963 booster vaccine doses are being given daily, while roughly 281,303 people are getting their first dose every day and about 292,927 people are becoming fully vaccinated each day, according to Wednesday’s CDC data.” • So IM Doc was, unsurprisingly, correct to draw attention to how mixed this data is. I looked at the CDC page with this data, and there’s no time element which is what I want. Perhaps I can use this tool, which allows different visualizations to be created. I wish there were a FRED for Covid data…
56.1% of the US is fully vaccinated (mediocre by world standards, being just below Czech Republic, and just above Saudi Arabia). We are back to the stately 0.1% rise per day. I would bet that the stately rise = word of mouth from actual cases. However, as readers point out, every day those vaccinated become less protected, especially the earliest. So we are trying to outrun the virus… (I have also not said, because it’s too obvious, that if by Bubba we mean The South, then Bubba has done pretty well.)
White House on vaccine requirements generally:
Vaccination requirements work. They drive up vaccination rates, which makes our communities and schools safer, along with strengthening our economic recovery. Vaccine requirements are widely supported, proven successful, and quickly becoming the standard across the country. pic.twitter.com/qo1swxjbYg
— The White House (@WhiteHouse) October 7, 2021
Employment Situation: “United States Non Farm Payrolls” [Trading Economics]. “The US economy added a meager 194K jobs in September, of 2021, the lowest so far this year and well below forecasts of 500K. Job gains occurred in leisure and hospitality (74K), professional and business services (60K), retail trade (56K), and transportation and warehousing (47K). Meanwhile, employment declined sharply in public education (-161K) and in health care (-18K).” • Interesting that “essential workers” in health care and education would leave the workforce. I wonder why? Some angst over this one:’
oof
— Felix Salmon (@felixsalmon) October 8, 2021
The number is out and it’s another big miss. Just 194,000 jobs created in the month, less than the 500,000 consensus estimate.
However, the unemployment rate fell to 4.8%. Combined, these two numbers tell a story of slow hiring and seemingly tight labor markets at the same time.
Despite persistent frustration among employers that the labor market is “tight” (from their perspective), we’re still millions of jobs in the hole relative to where we likely would have been at this point in the absence of the pandemic.
Employment Situation: “United States Unemployment Rate” [Trading Economics]. “The US unemployment rate dropped to 4.8 percent in September 2021, from 5.2 percent in the previous month and below market expectations of 5.1 percent. It was the lowest rate since March 2020, as many people left the labor force and the negative effects of Hurricane Ida and the Delta variant’s summer spike started to fade. Still, the jobless rate remained well above the pre-crisis level of about 3.5 percent due to ongoing labor shortages but is seen declining further in the coming months as companies fill widespread vacancies and as more workers are expected to go back into the labor force.” • “Are expected” lacks agency…
IM Doc on Medication/Medical Supply Shortages and Political Backlash
IM Doc weighed in twice this week in Water Cooler on the dire scarcity of some critical medical products in his area, a rich pocket in flyover. While some of them may be significantly the result of being at a remove from big cities, others seemed to reflect wide-spread outages.
We’ve seen less scary versions of this movie before. A few years ago, the US was suffering widespread shortages of the bags used to deliver IV fluids because the factory in Puerto Rico that was close to the sole producer was knocked out in a hurricane.
IM Doc does not have a clear answer as to why these shortages are so numerous. Domestic trucker shortages may be part of the problem. But the US is extremely dependent on China and India for drugs. 80% of the active pharmaceutical ingredients and and 90% of generics are believed to come from them (no one knows for sure because the US does not believe in having the government know anything). So the famed coastal port traffic jams may be contributing to the problem. The Wall Street Journal pointed out in August 2020 that disruptions in product from China had generated shortages in acetaminophen, antibiotics and high blood pressure medications.
IM Doc weighed in on Wednesday and again yesterday and I though it was worth hoisting them to encourage further discussion as well as circulation to friends and colleagues. I’ve edited both comments to focus on the supply issues; he also discussed staffing shortages at his and other hospitals. As his second comment makes clear, at least in the people he treats, there’s a great deal of anger at the Administration, as in the Democrats, for not even acknowledging these potentially life-threatening and also budget-destroying shortages, even among groups like the young and minorities who would otherwise generally be assumed to favor or at least consider Democrats.
I’m amazed that there hasn’t been a backlash against the Tories for their deliberate destruction of the NHS, which has become more catastrophic thanks to Brexit and Covid. But Labour is so enfeebled that it seems unable to find any way to profit from Tory disasters, plus the Brits are a very stoic bunch.
Even though the first discussion, of difficulties in getting liquid nitrogen, is revealing, the meat comes in IM Doc’s second topic, shortages in multiple categories of critically important medications.
I feel that the “troubles” have started in earnest now in medicine in ways I did not see coming just weeks ago. What we in medicine are simply not going to be able to abide right now is a surge like we saw last winter.
First of all, as a PCP, I have always had the ability to zap small non-invasive skin cancers. We do that with liquid nitrogen. We have been out of this for a week or so now. Sourcing a new supply is now virtually impossible. And the amounts being asked for what is left are so astronomically high that we simply cannot afford it. Medicare reimbursement (which is most of these patients) will not even come close to recovering the cost. I understand from the supplier that the same issues are occurring to some degree with dry ice and more ominously liquid oxygen (used in hospitals of patient oxygen). I heard from 2 different suppliers the reason why this seems to be happening – but the reason is so “tin foil” that I am not going to repeat it here until I can confirm this more reliably.
I run a research lab at a well-known med school. We have a -140 freezer. It was alarming, which is unusual. We had been given 1 regular tank and 1 half tank instead of the usual 2 regular tanks-1 attached and 1 for backup. Both tanks we had were empty, including the attached half tank even though it was showing half full (or half empty, whichever kind of person you are…). Our Airgas guy comes once a week anywhere from Tuesday-Thursday. I emailed the manager, got an out of office reply(great!). Called the #, got a live guy. He said he’d ring the delivery guy and see if he could swing by with a partial tank because it’s an emergency. He said there’s a nationwide shortage of LN2, and they “are having trouble getting it.” Luckily the guy dropped off the partial. I let my friends in a core facility (they have 2 huge -140s) know about the LN2 shortage and they’re freaking out (as was I). We cannot lose what’s in these, and cells can’t be stored at -80 for long before losing viability.
I did a net search, and a bunch of space industry articles came up(this stuff is needed for rockets). They said due to the spike in covid patients being put on vents, there’s a spike in the need for liquid oxygen for the vents, and that trucks that used to carry LN2 are being converted to carry liquid oxygen because the premium is higher than if they deliver a load of LN2. That’s all I found. So if there’s also a shortage of liquid oxygen, I don’t have any ideas, unless it’s the whole trucker shortage thing. Not a clue.
My friends with the core facility that has multiple freezers heard from the hospital’s procurement folks who had tracked down the Airgas manager. “He said there is no shortage of product(LN2) but a shortage of drivers for bulk tank deliveries.”
I am in a remote area – that is certainly part of the problem. But the fact we are having these troubles with vital supplies even here should be an early warning indicator that we have issues as a society. The system has thrown a rod – and what used to be reliable no longer is. Fascinating times.
Our supplier is trying very hard to get the now very elevated cost of the transport of these gases passed onto the final user – and there is just no way that is economically feasible in our area. And then another wrinkle at least here is the actual company that puts it in the cans is having trouble getting the equipment and other needs transported to their facility. “We have not had the ability in about a month”. So they do not even have product to send. So we have supply chain problems – and we have delivery chain problems. It seems like everything has a screw loose right now. I do also have multiple patients who are now on emergency oxygen compressors – because the cans of oxygen are no longer available reliably in our area – and I have just not had the time to figure out why that is suddenly happening. The compressor approach is much more expensive and I have no idea how long the insurance companies are going to be willing to pay.
As far as the skin lesions and the liqiud nitrogen, looks like it is back to the old clip them off and put in a stitch. So much more time consuming that it is hardly done anymore.
I am seriously not understanding what happened – it is like all the truck drivers just POOF
I have a feeling we are in for far more serious “troubles” in the medical realm than just nurses in the hospital quitting. Pharma issues are happening – and may reach out and touch any one of you or your family. To be warned is to be prepared.
A very pernicious problem with pharma shortages has begun to set in. For the most part, they seem to be temporary – but they are absolutely devastating to patients financially – and I want all to understand what is going on.
This mainly seems to be happening in insulin products, immunologic agents ( as in Enbrel and Humira) and chemotherapy ( of which I personally deal very infrequently).
I am now up to 11 patients where this has happened just this week alone. All of whom are under 30, diabetic and on insulin or with lupus and on immunomodulating drugs. All are taking their health very seriously.
Most modern pharmaceuticals are distributed with the use of PBMs. big gigantic companies that are middlemen between pharma and consumers. They all have contracts with each product where they get a very good price on 1 particular agent in each class. For example – XYZ PBM has a great price on Lantus Insulin – so they will only distribute Lantus to their patients. If you must have the others – well – you get to pay the 700 dollars a month out of pocket – uncovered by your insurance. It is really quite a racket if some poor soul cannot tolerate the selected drug.
We are now experiencing fairly severe shortages on insulin products and immunoproducts. Again – they seem to be temporary – but 10 days is life or death to a Type I DM. So when their refill comes up – and their particular PBM contracted insulin type is unavailable – they get to pay full freight on another in the class – often 500-700 dollars a month. The PBMs are absolutely heartless – will not budge an inch – knowing in full that the shortage is beyond the patient’s control – and also that they are completely dependent. So the patients pay the 500 dollars for an alternative – only to find out that 7 days later – their “covered” insulin is available again. But it may not be when it comes time for a refill. And because their “great” insurance (It’s a big f@#ckin’ deal! – remember that?) that Obamacare delivered to the land has often 10 or 15 thousand dollar deductibles – they get to pay the full amount.
I have no idea why these shortages are happening. It is however constant. Again – not just insulin – the arthritis drugs are a real problem as well. My office staff is spending large chunks of time on this. Nothing like this has happened before in my career. This is new territory.
500-700 dollars is a lot of cash for these young people – and they are struggling under the load. I have not experienced young fathers crying in my office like I have this week. Again, the “troubles” have just begun.
We have here a pharmacy from a national corporation and also a local owned and operated pharmacy. The national chain basically tells the kids to pound sand. The local owned outfit, whose owner is in multiple civic organizations is giving them their alternative at his cost – and indeed I think he is giving it to them at his own expense as well. This fact is not going unnoticed in the community at large – and who do you think the goodwill is being bestowed upon? And who is getting the evil eye? I do not find it strange that we are suddenly seeing many prescription requests transferred to the local guy.
Furthermore, these young under 30s, black white and Hispanic – historically in the Dems back pocket – are now repeatedly discussing their politics with me. Unsolicited. I hear “FJB” all day long now.
I am very sad to report that the coddling of Big Pharma, the year of one lie after another from our medical leadership, the disaster that Obamacare actually is on the ground, the promise to “follow the science” and then clearly act more political than anything before, and the raping that our populace is getting from these PBMs is absolutely causing a sea change in where I have normally seen young people politically. Again many minorities as well. They are very angry. Right or wrong, they perceive the Dems and people like Biden and Pelosi as directly responsible. And I live in a mostly blue area.
And I do not blame them for a minute. One man explained to me very kindly that he had to be discharged from his federal job because of the vaccine mandate – and reported to me with great contempt that Biden had him fired – but was going to hand out half a million dollars to all kinds of illegal immigrants. “I voted for Obama twice, Clinton and Biden – but they can suck it if they think I am voting for them again.” I simply do not engage politics in my office. If they bring it up, I listen. Clearly, the kids are indeed beginning to realize what is at stake in their future.
As a life-long Dem, I am very concerned that we may be seeing another Whig implosion. The thing that bothers me is I do not see any evidence whatsoever that anyone in the Dem leadership even cares. They have anchored themselves to some very troubling things that really affect people in their daily lives – and the bill is coming due. Again – I am seeing enough tragic things being ignored and lied about that for the first time in my life, I will be voting a straight GOP ticket until the bad apples are rooted out. I do not think in my life I have ever seen a group of politicians that need some time in the wilderness more urgently.
Needless to say, the fact that problems of this seriousness are happening and aren’t even being acknowledged means that the situation can and likely will get much worse.
I’ll add in my observations about what has been happening in my neck of the woods.
I’m an ER Doctor in a community hospital in Canada.
In the past month we’ve had shortages or outright disappearances of the following equipment:
Crutches
Knee Braces
Plaster Slabs
The paper sheets we line beds with for hygienic reasons (completely disappeared on my last shift)
We are also hemorrhaging nurses. I used to know all the faces in my department, and most of the names, and could accommodate and get to know a new face. Now when I walk into work I don’t recognize half the nurses I’m working with – the new folks are a mix of agency (temp) nurses and new grads. This has lead to more medical errors, as it’s difficult for our department to integrate THIS many new folks at once. Also even with their help (and don’t get me wrong, I’m VERY grateful they are here), we are still routinely short 5-6 nurses per shift. The attrition seems to be due to a mix of early retirements, burnout and transfer to other departments, and firings due to the vaccine mandate.
We are also getting slammed due to increased patient volumes – a percentage of family doctors in the community are still not seeing their patients in person, and not all patients are okay with totally virtual care or they are being sent in by their MDs who think the patient needs a physical exam but won’t do it themselves.
My question is – what is truly worse: having a nurse who *may* be at increased risk of transmitting Covid because they are unvaccinated, or having no nurse at all?
Myself and my partner make no bones about seeing any patient that comes in the door. I do virtual visits only if the patient requests it.
There are a couple docs in my community who just will not see people in person. You cannot even imagine the number of transfers that my partner and I have had.
The problem though is that eventually the brick wall is hit – you just simply cannot keep it up.
There is a massive shortage of PCPs in this country. And I suppose in Canada too. There is this big huge push to get nurse practitioners to fill the void. Hysterically, the NPs too avoid primary care like the plague and most of them end up in oncology, ortho, GI or cardiology or general surgery.
The PCP crisis we have been working on for decades that this pandemic has brought to the forefront has just now started to seriously implode.
And do not get me started on ER docs. God bless em. Just months ago – the venture capitalist firms in the USA that own the group ER practices were laying off the docs right and left. Everyone in America should remember this fact when they go to an ER and take in the just unbelievable chaos. I hope your lot in life in Canada is much better.