Thought Experiments
Thought Experiments
An brief exercise in considering the impact of human interventions on mortality
Imagine a city of 8 million people — I’ll call it The City — is stopped in its tracks like we saw in March 2020. The perceived threat is not a virus, but potential successive bomb strikes by another country.
The directives from government officials are familiar. For two weeks - maybe four, if necessary — only “essential” activities permitted. Schools & churches must close. No theatre, no restaurant dining, no gathering in groups. Stay home, citizens are told, and stay away from hospitals unless you have a critical health issue.
By how much would you expect all-cause mortality to increase in those four weeks, assuming no bombs are dropped? What are all the possible ways people could die, simply from those orders? Would there be any rise in mortality? From what causes?
Now imagine the same city in an alternate scenario…
Still no virus in the mix, and no potential bombs, but The City’s hospitals have agreed to participate in a study as the experimental group to a comparably-sized city’s control group. Hospitals in The City have agreed to do the following things for four weeks:
Disallow vistors.
Mask the staff and patients at all times.
Allow resident doctors and interns to make decisions without the approval of an attending physician, including decisions about changing do-not-resuscitate orders (or lack thereof).
Receive patients from nursing homes at twice the normal rate, after adding staffed beds to accommodate the influx.
No other changes are made.
Do you predict inpatient mortality would go up, go down, or remain basically the same in The City’s hospitals? Why?
I look forward to readers’ responses in the comments.
My stab at your query after 35 years of hospital practice: 1) Restricting visitors would increase mortality substantially because the most powerful brake on medical malpractice is the threat of lawsuits by family members against doctors and hospitals who treated the deceased. The visitor is the patient's most crucial witness and advocate in the course of any hospital episode. 2) Masks might marginally worsen mortality because they (like flu shots) have no effect on nosocomial viral transmission. They are a physical encumbrance, a distracting and time consuming ritual, and an impediment to communication between all participants in patient care. 3)Authorizing physician trainees to function without senior supervision would clearly kill many patients. Seasoned attendings while not infallible are certainly more experienced and skilled, and are more conscious of the professional liability risks inherent in their responsible position. 4) Double the case load = double the fatigue, stress, inattention and mistakes. It's beyond obvious to me that lockdown killed many people, especially in acute and chronic care facility settings.
Mortality would go up. Skewing the inpt population to older-sicker, inexperienced decision makers=more errors, and disallowing pt advocates(visitors)=more errors.