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How it’s going at the hospitals

In a word, it’s bad.

At Lyndon B. Johnson Hospital on Sunday, the medical staff ran out of both space for new coronavirus patients and a key drug needed to treat them. With no open beds at the public hospital, a dozen COVID-19 patients who were in need of intensive care were stuck in the emergency room, awaiting transfers to other Houston area hospitals, according to a note sent to the staff and shared with reporters.

A day later, the top physician executive at the Houston Methodist hospital system wrote to staff members warning that its coronavirus caseload was surging: “It has become necessary to consider delaying more surgical services to create further capacity for COVID-19 patients,” Dr. Robert Phillips said in the note, an abrupt turn from three days earlier, when the hospital system sent a note to thousands of patients, inviting them to keep their surgical appointments.

And at The University of Texas MD Anderson Cancer Center, staff members were alerted recently that the hospital would soon begin taking in cancer patients with COVID-19 from the city’s overburdened public hospital system, a highly unusual move for the specialty hospital.

These internal messages highlight the growing strain that the coronavirus crisis is putting on hospital systems in the Houston region, where the number of patients hospitalized with COVID-19 has nearly quadrupled since Memorial Day. As of Tuesday, more than 3,000 people were hospitalized for the coronavirus in the region, including nearly 800 in intensive care.

“To tell you the truth, what worries me is not this week, where we’re still kind of handling it,” said Roberta Schwartz, Houston Methodist’s chief innovation officer, who’s been helping lead the system’s efforts to expand beds for COVID-19 patents. “I’m really worried about next week.”

What’s happening in Houston draws eerie parallels to New York City in late March, when every day brought steep increases in the number of patients seeking care at overburdened hospitals — though, so far, with far fewer deaths. But as coronavirus cases surge in Texas, state officials here have not reimplemented the same lockdown measures that experts say helped bring New York’s outbreak under control, raising concern among public health officials that Houston won’t be able to flatten the curve.

“The time to act and time to be alarmed is not when you’ve hit capacity, but it’s much earlier when you start to see hospitalizations increase at a very fast rate,” said Lauren Ancel Meyers, a professor of integrative biology who leads the University of Texas at Austin COVID-19 Modeling Consortium. “It is definitely time to take some kind of action. It is time to be alarmed.”

[…]

Although hospital executives in Houston stress that they have the ability to add additional intensive care beds in the region to meet the growing demand — for a few more weeks, at least — the strain on hospitals is already being felt in other ways.

Houston Fire Chief Samuel Peña said his paramedics sometimes have to wait for more than an hour while emergency room workers scramble to find beds and staffers to care for patients brought in by ambulance — a bottleneck that’s tying up emergency medical service resources and slowing emergency response times across the region.

Part of the problem, Peña said, is that when his crews arrive at a hospital with a patient suspected of having COVID-19, the hospital may have a physical bed open for them, but not enough nurses or doctors to staff it. That’s a problem that’s likely to deepen as a growing number of medical workers have been testing positive for the virus, according to internal hospital reports. Just as New York hospitals did four months ago, some Houston hospitals have posted on traveling nurse websites seeking nurses for “crisis response jobs.”

“If they don’t have the nursing staff, then you can’t place the patient,” Peña said. “Then our crews have to sit with the patient in the ER until something comes open. It has a huge domino effect.”

There’s more, so read the rest. If you’re thinking that the death rate is low and that that’s a small blessing, that is true, but it’s also a bit illusory. For one thing, the sheer number of deaths will increase as the infection rate rises, not all deaths for which COVID-19 is a factor are recorded as COVID-19 deaths, and it is already the case that people are avoiding going to the hospital now for other reasons because of COVID-19, and that some of them will also die as a result. The official death count numbers have always been underestimated, and there’s no good way to spin it. Even if we were to go into total lockdown right now, we won’t begin to see the positive effects of that for another two weeks. We really need masking and better social distancing to have an effect or it’s going to get much worse. Oh, and the Texas Medical Center is above 100% ICU capacity. So we’ve got that going for us.

And as you ponder all that, ponder also this.

Despite Texas’ surge of new COVID-19 cases and hospitalizations, Lt. Gov. Dan Patrick said Tuesday evening that he doesn’t need the advice of the nation’s top infectious disease doctor, Anthony Fauci.

“Fauci said today he’s concerned about states like Texas that ‘skipped over’ certain things. He doesn’t know what he’s talking about,” Patrick told Fox News host Laura Ingraham in an interview. “We haven’t skipped over anything. The only thing I’m skipping over is listening to him.”

Patrick also said Fauci has “been wrong every time on every issue,” but did not elaborate on specifics.

Dan Patrick does not care if you live or die. You and everyone you know mean nothing to him.

Another scooter injury study

Keep ’em coming.

Photo: Josie Norris /San Antonio Express-News

Electric scooter injuries have surged along with their popularity in the United States, nearly tripling over four years, researchers said in a study published Wednesday.

Nearly 40,000 broken bones, head injuries, cuts and bruises resulting from scooter accidents were treated in U.S. emergency rooms from 2014 through 2018, the research showed. The scooter injury rate among the general U.S. population climbed from 6 per 100,000 to 19 per 100,000. Most occurred in riders aged 18 to 34, and most injured riders weren’t hospitalized.

For the study published in JAMA Surgery, researchers at the University of California, San Francisco, analyzed U.S. government data on nonfatal injuries treated in emergency rooms.

“Improved rider safety measures and regulation” are clearly needed, the researchers said.

See here, here, and here for previous studies, and here to see this one. Clearly, helmets are going to have to be mandated, and from there it’s going to be up to cities to figure out how to safely incorporate these things into their transportation infrastructure. Bikes have been around for a long time and we’ve mostly figured them out, but scooters are new and sexy and are being pushed by Silicon Valley startups, so there are a lot of bumps in the road still to come. Hopefully we can begin to bend the curve on this. And no, I have no idea what the status of scooters coming to Houston is. Maybe that will be on an upcoming Council agenda. Assuming that scooter expansion is still the plan for these companies, which may not necessarily be the case any more. Maybe that’s why we haven’t had any news lately. CNet has more.

The down side of scooters

Watch out for that tree. And that pedestrian, and that street light, and that strange bump in the sidewalk, and that abandoned scooter someone just left lying there…

Photo: Richard A. Marini, San Antonio Express-News

In September 2017, Tarak Trivedi, an emergency room doctor, and Catherine Lerer, a personal injury attorney, started seeing electric scooters everywhere. Santa Monica, California, where they live, was the first city where the scooter company Bird rolled out its rechargeable two-wheelers, which could be rented with a smartphone app and dropped off anywhere. Lime and other scooter companies soon followed. As riders zipped down the street, reaching speeds of 15 miles per hour without helmets, both Trivedi and Lerer thought of the inevitable injuries.

Soon enough, victims of e-scooter accidents, both riders and pedestrians, began to show up in the ER. “I started seeing patients who had significant injuries,” Trivedi recalls. Calls about scooter-related injures poured into Lerer’s office. She says she now gets at least one new call a day. “We recognized that this is a very important technological innovation that has a significant public health impact,” Trivedi says.

More than a year after the Birds landed, Trivedi and researchers at the University of California-Los Angeles have authored the first study to quantify the public health impact of e-scooters. Their peer-reviewed study, published in JAMA Network Open, details 365 days of scooter crashes, collisions, and wipeouts. Digging through records from two Los Angeles-area emergency rooms, the researchers found 249 patients with injuries serious enough to warrant a trip to the ER. In comparison, they found 195 bicyclists with injuries and 181 pedestrians with similar injuries during the same period.

The goal of the study was to characterize how people were getting hurt, as well as who was getting hurt. Of the 249 cases the study looked at, 228 were riders, most of whom were brought to the ER after falling, colliding with an object, or being hit by a moving vehicle. The other patients were injured after being hit by a rider, tripping over a scooter in the street, or getting hurt while attempting to move a parked scooter. About 31 percent of patients had fractures, and around 40 percent suffered from head injuries. Most were between the ages of 18 and 40; the youngest was eight and the oldest was 89. While many of the injuries were minor, severe and costly injuries like bleeding in the skull and spinal fractures were also documented. Fifteen people were admitted to the hospital.

Trivedi thinks that the actual number of scooter injuries was likely higher, since the study took a conservative approach to tallying up patients, focusing only on standing electric scooters and dropping many ambiguous cases. (It also eliminated instances where riding a scooter was not the cause of a scooter-related injury—such as assaults where a scooter was used as a weapon, or injuries during attempts to steal a scooter.)

That’s from California, and it’s a partial picture of what has been observed in Los Angeles, based on two emergency rooms. The authors didn’t extrapolate from there, but it’s clear there would be a lot more than just what they focused on. That’s the first study of its kind of scooter injuries, but we do have some anecdotal evidence from Texas cities where the scooters have invaded, including San Antonio, Austin, and Dallas, where there has also been one reported fatality, though it is not clear if that person (the victim of a hit-and-run) had been using the scooter at the time of his death.

Let’s be clear, cars cause vastly more havoc every day than scooters do. The magnitude of injury and death resulting from our automobile-centric culture just dwarfs anything even an onslaught of electric scooters can do. In the long run, more scooters may lead to less vehicular damage, if it means more people rely on them in conjunction with transit to take fewer trips by car. That doesn’t mean we should ignore or minimize the potential for injury that scooters represent. It’s up to cities and states to figure out how to regulate these things in a way that maximizes their benefit and minimizes their risk. That means we need good data about the real-world effect of scooter usage, and we need to avoid being unduly influenced by the scooter companies and the venture capital behind them. Let’s pay attention to this stuff and be responsible about what we learn.

Now how much would you pay for that emergency room visit?

Guess higher, and it is a guess because who knows what you’ll wind up getting charged for it.

Fifteen months after Texas enacted a law to bring transparency to the state’s for-profit free-standing emergency rooms, many of the facilities continue to send mixed messages about insurance coverage that could expose unsuspecting patients to surprise medical bills.

A Houston Chronicle review of websites representing the 52 free-standing emergency rooms in the Houston area shows a pattern in which many of the facilities prominently advertise that they “accept” all major private insurance. Some even list the insurers’ names and logos.

But often tucked under pull-down tabs or at the bottom of the page is a notice that the facilities are outside the networks of those insurers, followed by a reassurance that under the Texas insurance code, network status does not matter in emergency treatment, implying patients needn’t worry about coverage.

What the websites fail to disclose is that out-of-network status can result in insurance reimbursements far below the charges, leaving patients on the hook for the remainder of the bill — sometimes thousands of dollars.

“The word ‘accept’ means something very different to them than to the consumer, and they know that when they write their websites,” said Stacey Pogue, senior health policy analyst at the Austin-based Center for Public Policy Priorities. “They do not tell the rest of the story.”

For example, many of the Houston-area facilities advertise that they accept Blue Cross and Blue Shield of Texas, the state’s largest insurer. But the Chronicle’s review found that only five — about 10 percent — are in that insurer’s network.

Those findings are consistent with a statewide report by AARP Texas, to be released Monday at a state Senate committee hearing, that found 77 percent of the state’s 215 free-standing emergency rooms said they “take” or “accept” Blue Cross and Blue Shield insurance, but were out-of-network.

Free-standing emergency rooms defend their websites, describing concerns raised by advocacy groups and Texas lawmakers as manufactured outrage.

“I don’t see a problem with saying they ‘accept,’” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program. She insisted that patients understand that accepting someone’s insurance is different from being in that company’s network.

It may seem like a hair-splitting distinction, but it can carry high costs, health policy experts said.

Obvious point #1: It’s ridiculous that we live in a society where basic medical needs, including emergency care, are not met. It’s utterly scandalous that prior to the Affordable Care Act, there were thousands upon thousands of bankruptcies caused every year by medical issues. Plenty of other countries have figured this out. Our standard of medical care is no better than theirs. It’s just more expensive.

Obvious point #2: For those who believe in the power of the free market, why is it that medical services, especially those tied to emergency and hospital care, are so utterly opaque when it comes to their pricing? Think of all the other goods and services you buy. In nearly all of them, you know up front how much it’s going to cost. That is universally untrue for the vast majority of medical services, from basics like painkillers and bandages to anaesthesia and specialist fees to higher-end products like EKGs and colonoscopies. There’s no such thing as a free market with unknowable prices. You want to move towards something like a free market in health care, fix that.