Last month an AP story titled Who should MDs let die in a pandemic? Report offers answers hit the wires and Flublogia; here is the discussion as it unfolded on P4P.
The concept of medical triage is not new to those who have been following the issue of PanFlu (Pandemic Influenza) and on several occasions I have raised the issue of Law Enforcement Triage, and this story touched both, in a big way. Unfortunately, it hit at a very inopportune time for me to address it in depth, and only now does my time allow the attention it deserves from the very narrow perspective of our law enforcement and fire fighters.
Who should MDs let die in a pandemic? Report offers answers
LINDSEY TANNER, AP Medical Writer
May 4, 2008 9:23 PM
CHICAGO (AP) - Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding who to let die.
Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.
The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.
The proposed guidelines are designed to be a blueprint for hospitals ''so that everybody will be thinking in the same way'' when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.
The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.
Their recommendations appear in a report appearing Monday in the May edition of Chest, the medical journal of the American College of Chest Physicians.
''If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing,''the report states.
To prepare, hospitals should designate a triage team with the Godlike task of deciding who will and who won't get lifesaving care, the task force wrote. Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific, and include:
-People older than 85.
-Those with severe trauma, which could include critical injuries from car crashes and shootings.
-Severely burned patients older than 60.
-Those with severe mental impairment, which could include advanced Alzheimer's disease.
-Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.
Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force. He said the report would be among many the agency reviews as part of preparedness efforts.
James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans even if they don't follow all the suggestions.
He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.
Bentley said it's not the first time this type of approach has been recommended for a catastrophic pandemic, but that ''this is the most detailed one I have seen from a professional group.''
While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.
Devereaux said compiling the list ''was emotionally difficult for everyone.''
That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.
''You never know,'' Devereaux said. ''SARS took a lot of folks by surprise. We didn't even know it existed.''
I titled my last post "Rules" since it dealt with the rules countries are in general agreement on when dealing with each other. I made mention that some "rules" are loosely defined and some are immanent, so universally understood that they do not need to be codified, although in service to a civil society they are.
Aristotle held that sometimes what was just by nature, "natural justice", was not necessarily just by law, i.e., dependant on society's rules. We are all aware that there have been many laws throughout human history that could hardly be considered "just"; valid legally, but a violation of natural law.
There is an understood "contract", "unspoken rule", a "natural law" if you will, when a police officer or fire fighter is injured or wounded in the line of duty everything that can be done will be done until all hope is exhausted. That is as it should be for those who risk limb and life to protect us.
The reason these guidelines are relevant is because, as everyone who understands the implications of a severe pandemic knows, medical supplies, mechanicals, and personnel will be in short supply, if not absent altogether. The reason they are so shocking is because those who would otherwise receive medical care would likely survive, if only until their next medical crisis in the case of the chronically ill. Stated plainly: It is assumed that treatment carries a high probability of success.
Setting aside the question of the likelihood of having any advanced medical care available during a severe pandemic, where, exactly, will our severely injured/wounded police and fire fighters fall in this triage scheme?
It is widely assumed that during a pandemic personnel levels will be affected, heavily dependent on the pathogen's virulence and pathogenicity. Official assumptions place absentee levels at 25% or more. The staffing levels for our first responders is apportioned according to current, non-crisis needs, just as the staffing levels for any well run and fiscally responsible business. Those that do show up for a shift will be performing their jobs without the safety margins built in with a full squad/squadron.
One assumption leads to another: With reduced manning levels the incidents of injuries requiring medical care are likely to rise in lock-step. Under normal operations the likelihood of suffering something life threatening is quite small hour-to-hour on average, given training, equipment, and—adequate personnel to mount a tactically sound response (police or fire), but that is under normal operating conditions.
Our social contracts are being re-written against a future threat. How long will our police and fire fighters remain blissfully ignorant of these issues? I've read any number of outraged rebuttals from the elderly and social advocates, but you in uniform serving and protecting us remain silent.
It is important to understand that guidelines are to be applied uniformly, strictly speaking that leaves no room for considerations of how you found yourself requiring treatment.
Where are your voices? Will you wait until you are severely injured and denied treatment to speak? If so, I have my doubts that anyone will be in a position to hear your outraged arguments—or those of your fellows and family.