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Letter Re: Triage in Emergency Mass Critical Care (EMCC) Event
Dear JWR:
I feel that there is a strong premonition in the article you flagged on Wednesday
(Who Should Doctors Let Die in a Pandemic?) This hit the Main Stream Media
(MSM) early this week and quickly fell off the news cycle. The topic is simply
too uncomfortable. The original
articles were published in the medical journal Chest (The
Journal of the American College of Chest Physicians and are very dry and
difficult reading even for a physician. This is unfortunate because it is a
salient topic
which needs to be vigorously publicly debated (instead of who got voted off – insert
various “reality TV” show). It has specific implications for those
of us reading your SurvivalBlog. Several recent postings in SurvivalBlog (specifically
two discussions initiated by questions
raised by DS in Wisconsin )
show this to be a paramount topic.
I would like to address some of these issues by means of an analogy to the
area I live and work. We have a typical, financially struggling, small (100
bed) non-profit hospital serving a population area of approximately 50,000.
Down the road is the “Medical Mecca” (actually more than one) with
total bed capacity in the thousands. Our small hospital has an 8-bed Intensive
Care Unit (ICU) which is always full, with the typical patient in one of the
various states of terminal disease processes. When a critical care patient
leaves the Operating Room (OR), there is the usual story of “Musical
Beds”, where a patient has to be transferred to “make room” in
the ICU. This usually involves transferring the least critical patient to the “Step
Down Unit” (SDU). ICU patient transfers to the “ Mecca ” typically
takes 24-48 hours because their beds are also constantly full. Our hospital
owns four ICU ventilators, and if the number of patients requiring ventilation
exceeds this, additional units have to be delivered from the “medical
supply house”, which also provides rental units to the “Medical
Mecca”. Due to financial constraints, there is no “surge capacity” in
the system. In the typical bureaucratic system, the “mirage” of
available space is accomplished by simply “redefining” a given
patient from “Intensive Care” to something less, either wholly
inside our hospital or by including the “Mecca” in the system (as
in a “larger” system). [JWR Adds: I briefly discussed
the chronic shortage of ventilators in my
static article on Asian Avian Influenza.
I agree wholeheartedly with your assessment
of the shortfalls in
medical delivery infrastructure!]
The issues addressed by the articles in Chest concerned Emergency
Mass Critical Care (EMCC) events, prototypically pandemic influenza. In such
a situation,
even the “mirage” of available space breaks down because you cannot “enlarge” the
system by including more “geographical” area since each additional
area is encompassed by the same problem. The currently circulating “bird
flu” H5N1 is a particularly nasty bug, more closely resembling the various “hemorrhagic
fevers” than typical influenza when infecting humans. The syndrome includes
pulmonary edema (fluid collecting in the lungs, i.e. drowning in own secretions),
disseminated intravascular coagulation (DIC) (internal bleeding) and multi-system
organ failure (kidney and/or heart failure, etc.). Treatment typically includes
intensive hemodynamic and ventilatory support until the body can clear the
infection and heal. Even in our relatively rural area, it would not be unreasonable
to expect to have tens, if not hundreds, of patients needing this level support
in order to survive. The “Mecca ” will see proportionately more
demand.
The recommendations of the authors of the Chest articles are well reasoned
and intelligent, but totally impractical in our financially strapped and egalitarian
healthcare system. These recommendations include providing for the ability
to surge to three times the ICU capacity and provide for 10 days of service
without resupply. Due to shortages of trained nurses, our ICU depends on locum
tenens (contract agency) nurses to staff the ICU and medical care is provided
by a single pulmonologist (physician specializing in lung diseases). It is
totally impractical from a staffing issue to provide 3x surge capacity. As
far as inventory, 10 days is an eternity. Where will the money come from to
stockpile these items and medications (our hospital only has about 30 days
of operating cash on hand)? Will the staff forego a paycheck in order for this
to occur? Additionally, the “medical supply house” typically only
has a couple of unissued ventilators at any given time, before having to “tap
into” their larger supply chain (i.e. maybe a dozen or so “extra” in
the entire State). Where do you expect these to be issued in such a crisis
(try not to be cynical, but I suspect it will be near the State capitol)?
The most difficult (albeit the most logical) recommendations concerns the rationing
of the scarce healthcare resources. They suggest that the effort should go
to those most likely to survive, instead of those likely to die (i.e. those
most likely to benefit from the therapy). This is described as making a medical
decision for the entire population, instead of an individual patient. The goal
is to maximize survival in the population (at the expense of individual survival).
The difficult question is: Who should get the resources and whom should be “redefined” into
the “expectant” (i.e. expected to die) category? Should the ventilator
go to the college student with severe pulmonary edema or the nursing home patient
with the stroke? Should the neonatal/pediatric ICU bed space go to the 20 week
premature infant or the previously healthy two year old? If only these decisions
would be this straightforward. Who is going to tell the family that grandmother
doesn’t meet criteria? Who is going to care for the other patients while
the situation is explained (repeatedly) to these families (typically hours
with each family)? Do you think that that family will quietly accept the decision
or will there be riots? Do you ever wonder why during a food riot, the first
thing destroyed is the bakery? Do you think healthcare providers will show
up for work at an armed camp with constant rioting or stay home and care for
their own family? Would you go to work in a similar situation?
As in most things health related, an ounce of prevention is worth a pound of
cure. With communicable diseases, isolation and personal hygiene are the most
important. These are issues which do not need to be described to the SurvivalBlog
family (look at the archives), but should be seriously discussed within your
own family/group. In regards to the questions raised concerning emergency medical
transport and personal/retreat medical stockpiling, it is an important consideration.
In such a crisis situation, transportation is likely to be futile, if not fatal.
While nobody should expect to have a personal ventilator in their medical kit,
a supply of IV fluids and electrolyte preparation should be standard for those
who know how to administer it. Antipyretics (fever reducers) and antispasmodics/antiemetics
(diarrhea and nausea medication) should also be standard fare as well as easily
digestible foods. A broad-spectrum antibiotic would also be warranted for bacterial
superinfection, although everyone should already know that antibiotics do not
treat viral infections. The data on antivirals (amantadine, rimantadine and
oseltamivir/Tamiflu) is inconclusive at best and contradictory at worst concerning
H5N1 [Asian Avian Influenza], but if they are available it may be prudent to
have some on hand.
It is unfortunate that the public discussion of this topic has died such an
untimely death. Perhaps a little more debate would spare a few hospitals from
the ultimate riots, but I am not enthusiastic, human nature being what it is.
In this era of “Hope and Change”, especially with regards to healthcare,
it will undoubtedly be continued deterioration. We will continue to spend the
majority of healthcare dollars in the last six months of life, instead of helping
the survival of those most likely to survive. In summary, logical evaluation
of such a crisis leads to an illogical result (riots and destruction of the
healthcare system). We will likely be left with taking care of ourselves and
our family. - NC Bluedog
