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