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Two Letters Re: Triage in Emergency Mass Critical Care (EMCC) Events

Dear Jim,
This letter is in response to NC Bluedog’s very informative article that appeared today. Here in rural Wisconsin, we have the same problems as he noted–shortage of high-technology life-saving devices. This is due to the overall situation that our medical care industry is dollar-driven. He have a small hospital, and two more within a 15 minute dash via ambulance. Each hospital has at least a four-bed Intensive Care Unit (ICU) with a ventilator per bed, and at least two extra ventilators that can be used outside of their ICUs. Beyond that, there are none available. Extra units would have to be imported from major hospitals within the state. To get these units would take time, along with the funding to lease them–providing the disaster is confined to my area. The hospitals in my area are not sufficiently wealthy to do this in a mass emergency event.

So, in a TEOTWAWKI [1] situation, what can you or I do? There is a solution. Each EMT and Paramedic have in their Rescue bags, a set of airways and a bag-valve mask. Some even have a device called a “Pulse Oximeter.” This unit measures the amount of oxygen in the blood. When an airway, bag mask, and Pulse Oximeter are used in conjunction with each other, you have a primitive ventilator. There are more devices that are available to the EMT/Paramedic, but all require more advanced training in their use. I won’t go that way here. However, to use these devices requires training, and I suggest that you enroll in the proper program to use them correctly. The only down-side to ventilating a patient in this manner is very time-consuming and labor-intensive. If you must do this for any length of time, I suggest you have several individuals willing to take over and give the proper ventilations to the patient. This method is used in our hospitals as a back-up should there be a ventilator failure.

How much does this cost? The basic set of six airways will run approximately less than $5, and bag-valve-mask starts at approximately $10 and goes up, and the killer is the Pulse Oximeter. I’ve seen them advertised starting at $300 and continue on up through the roof. If you are a family, and have the need for such a unit, (an asthmatic child, etc.) talk to your insurance company and see what can be done. If you are a member of a group, talk it over and have each member donate toward the cost. Then get proper training. These units together are not hard to use or understand. Think about this when you have your next group meeting. All of these devices can be purchased Over The Counter (OTC) from the better Medical/EMT supply companies.

I hope this small solution will answer a lingering question that any of you have concerning the availability of ventilators in an emergency. Start thinking about, and plan for, the addition of airway management tools to your medical preps. Doing so now will give you an edge up when the day comes. – DS in Wisconsin

Jim:
The other dirty secret that isn’t described is that at some point, you will run into staffing issues. I’m an Intensive Care nurse at a big teaching hospital, and I find the challenge of a complex patient: managing ventilators and “dancing on the vasopressors” is second nature and even quite fun.
NC Bluedog makes a good point that the hospitals are chronically short of staff an money, but let’s play with the idea further. We’ll grant that we’ve been able to find intrepid and dutiful nurses and physicians who will work for free and will work more than a hundred hours a week. And the Ventilator Fairy drops all of the vents (and warmers, IV pumps, heart monitors, Swan-Ganz monitors, etc, etc, etc…) that we need. Even with the Hollywood Scenario, at some point there will not be staff. Certainly in an outbreak, but I wonder about it often during especially bad flu and pneumonia seasons. There will be no staff because they’re all out sick themselves (the stress and long hours having weakened their immune system in the face of super bugs, or just the “run-of-the-mill the native drug-resistant ones we have in the hospitals now), or because they’ve got a sick family member to care for. Or they have their own kids to look after- recall earlier this year when Singapore (or was it Hong Kong?) closed the schools for two weeks to prevent the spread of an especially bad infection. Someone’s going to have to stay home with all those quarantined kids. I can’t put them in day care while I head to the hospital after all.
And at some point the devotion to duty will start to fail. Even with the threat of lost licenses (State Boards of Nursing frown on folks who walk away from their patients or who don’t show up when needed), folks will feel the need to be home with their kith and kin.
And that’s when we reach Kunstler’s “World Made by Hand” – Regards, Michael G.