Our bioethics committee has been trying to formulate a coherent plan in advance of the surge of cases we expect to encounter in the ED during the COVID pandemic. Many thoughtful, brilliant colleagues have spent countless voluntary hours trying to devise a framework that will save the greatest number of people in the most just manner possible. It hasn't been easy.
Reports from Italy and Spain are frightening in the their description of how rapidly a highly functional first world health care system can be overwhelmed and decimated in the face of a pandemic.
What are the pitfalls we are trying to look out for?
- We need to be just and equitable. Many patients suffer greater comorbidities due to reduced access to health care. Comorbidities in this case can be a proxy for lower socioeconomic status. It may be true that poorly-controlled diabetics will have lower short-term rates of survival, but if more people of color are poorly-controlled diabetics (because they lack access to decent health care), using health alone risks perpetuating existing inequities.
- We need to be sensitive to the risks that health care workers are taking in fighting the pandemic. There are many places they'd rather be than in harm's path, and if we intend to keep them where they are most needed, we need to protect them when they fall ill due to excess risk from being on the job. How do we balance caring for our colleagues while avoiding the perception that they are receiving unfairly preferential treatment?
What recent existing publications address these concerns?
Perhaps the best and most applicable guidelines come from a 2015 New York State Task Force that anticipated a potential recurrent influenza pandemic. It used validated exclusion criteria to remove those patients least likely to benefit from a ventilator, and subsequently assessed prospects for short-term survival to determine who gets a ventilator.
A paper out of Hopkins was published last year in Chest (for the non-medical reader, that's actually a pulmonology journal despite the soft-porn sounding name) which attempted to further refine these criteria by combining both short- and long-term survival prediction tools as well as incorporating community feedback to ensure the outcome of the science reflected community values.
- Prospects for short-term survival - determined using validated scores from the literature
- Prospects for long-term survival - here limited to whether the patient would be expected to survive 12 months in order to reduce the potential impact of judging patients based on disease comorbidities that might result from systemic disadvantage (reduced access to healthcare due to poverty or marginalized status)
- In cases where two patients are found to have equivalent prospects of survival, the stage of life cycle (priority given to younger patients) would enter as a tie-breaker
There were additional considerations. Pregnant patients were suggested for preferential treatment. Exclusion criteria were proposed for those with severe conditions at low risk of survivability (large intracranial hemorrhage, unwitnessed out of hospital cardiac arrest).
Beyond this, for equivalently scored patients it was suggested that a transparent and explicit criteria be applied to ensure all have a fair chance, such as first come, first served or a lottery.
This was a thoughtful and considered study, and it was derived incorporating findings from a two year period of public fora to obtain community feedback. Please keep my deep respect for the authors and their approach in mind as I register my concerns below as a pit doc in the ER.
They favored an intubate first, ask questions later approach to those in extremis. The ER could always intubate, and once more data returns to allow the algorithm to be fully applied, patients could be extubated.
Regarding this last recommendation, here is how I fear things will occur in reality:
A beloved, frail, elderly nursing home patient will arrive to the ED with respiratory complaints.
If the patient arrives in extremis, perhaps the ER doc will intubate the patient.
If the patient is intubated, perhaps the ER doc will find out after the fact that there are no more vents. After assuming a high risk of infection from the aerosol-generating procedure of intubation, it is likely the same physician will assume the high risk all over again from extubating the same patient.
Adoring local children and grandchildren, who will not be allowed near the patient, will receive the explanation (from their car, where they have been asked to remain since the waiting room is an infection risk) that their loved one does not meet criteria for a ventilator and will be hospitalized for compassionate care. Or that their loved one was intubated, then subsequently extubated. They will want to engage in a long conversation to understand what is happening and why. They will feel the ER doctor was rushed, unavailable, detached.
The floor upstairs will be crazy and full and no bed will be available for many hours, possibly days. Despite appeals from the ER doctor to please help, the ICU physicians and hospitalists will understandably be completely occupied and decline to come to the ED and take over management of the patient because they have their hands full from the inpatients upstairs.
The ER will functionally become an inpatient ward.
The patients in the ER will deteriorate.
Some will die.
The emergency physician will be required to explain to the patient what is happening, explain to the family what is happening, and continue to care for the exploding emergency department full of COVID patients.
It will be an exhausting scenario.
Despite many bright people doing the best they possibly can to anticipate a crisis that exceeds our imagination, it will not be enough.
These are the nagging skeptic's thoughts that haunt me and keep me awake at night.
A classmate from residency, one of our former chiefs, repaid his debt to the Air Force through service during peak Iraq and Afghanistan. He returned to the states when his commitment was complete and promptly found a position in a dermatology residency.
I reached out to him via email, and he told me politely that after serving during wartime he was done with emergency medicine.
I fear that after this pandemic, many others in the field may feel that they, too, are done.
Comments 8
You and your fellow ER docs are rockstars in the medical community. The burden of this pandemic falls squarely on your specialty’s shoulders more so than any other.
My worries of getting exposure and bringing it back home to family pales in comparison the the level of risk the front line workers are facing (as a radiologist in a closed personal reading room I am more protected than most).
I am reading stories of how docs are staying in separate quarters and not even being able to hold infants/toddlers during this dark time. Breaks my heart.
Hope you and your colleagues pull through this without any harm.
Author
Xray,
Thanks for the kind words, but this effort has been so supported at so many levels – radiology included – that each leg of the stool feels critical.
If you want a hero to compliment, I’d suggest Dara Kass – an ER doc in NYC. She dropped her kids off with their grandparents for weeks apart.
I don’t think the article mentions it, but part of the reason is that she has a child who is a liver transplant recipient. She donated part of her own liver to her son – in a podcast interview I listened to, she said something along the lines of, “I figure I gave him the faulty parts, so I ought to honor the warranty.”
Thinking of you and your daughter as well during this time.
CD
Good luck.
And take your Plaquenil.
I would disagree the Italy and Spain have first world systems. While it’s not Cuba, or China, it’s not really first class either.
That said, some docs in NYC find themselves mandated to take rotations in the ER and ICU.
Orthopods, derms,..
And if they refuse they are terminated.
How ethical is that? How even responsible?
I don’t know.
The mayor of NYC (DeBlasio) is asking for a medical draft from the whole country to serve on the front line in NYC.
Is it legal? ethical? responsible?
With no pay (other than food and community housing) , no medmal, no disability/death coverage for self or family.
And no PLaquenil.
Strange times indeed.
Author
Hey Realdoc,
The entire situation is bizarre. There’s a big difference between enticing someone to serve and coercion. I’d read that certain employee docs who were sidelined had been offered either continued pay contingent on seeing patients in the new roles you describe, or else unpaid furlough if they declined. It does not pass the sniff test. Yet another reason to strive for financial independence as early as possible in career – to put you in a position to say no should such situations arise.
As for a medical draft? I don’t see it happening. There’s a fascinating history I read in college by Paul Starr, The Social Transformation of American Medicine, which distinguishes how Canadian physicians went on strike and lost some critical degree of popular support early in that nation’s history, in the process reducing their collective bargaining position. The docs in the US, lobbying collectively via the AMA, were able to avoid a similar fate through the tactical exercise of political power. Long digression intended to say that physician independence is still our societal expectation.
Appreciate your observations,
CD
You are giving me chills, Crispy Doc. I hope your awful scenario doesn’t play out as you fear. Hopefully your ICU and hospitalists can come together to give better information to you in the ER about available resources (in real time).
Right now my work load is incredibly light, but I am scheduled to return to the hospital wards about the time we expect our local cases to surge. I am mostly nervous, but also a little bit excited, to do the work.
Stay safe!
Author
It’s certainly a weird mixture of nervous excitement – “Will I bring something awful home to my family?” offset by the sense of service at a time of historic need.
We are getting daily emails with amazing information – # of COVID + and COVID suspected inpatients, # vents used and free for COVID and non-COVID patients, # days on hand of N-95 masks/gloves/PAPR masks/face shields, # of surge beds available and in use both on floor, telemetry, in ICU. The hospital has done a pretty stellar job of preparing with a central command.
Now it’s a matter of sitting and waiting in the eerie calm that has overtaken the ED during a drop in volume that is everywhere.
Stay safe, IM-PCP, and thanks for putting yourself out there to care for us all.
Hey Crispy Doc,
We have been having the same discussions here. I haven’t blogged in a while since I got sucked into the Covid surge vortex.
We came up with a triage policy similar to what you describe back in 2009 for H1N1. Of course, it got moth-balled and only a few of us remembered it. Watching Italy unfold was like reading it verbatim. Same with New York. Horrifying.
Our government actually took triage seriously this time and came out with a provincial policy. Fortunately, we haven’t seen near the volume of the U.S. for Covid. So, our government is now quietly downplaying it and hoping our peak will be manageable. We all hope that we never get to a triage situation, but this is the type of thing best planned well in advance – although most people aren’t ready to think this way unless forced to.
Operationally, our plan is the frontline MRP (ED, GIM, ICU) compares all patients to the triage criteria. A second opinion of whether they meet criteria is sought by a critical care physician and if they don’t meet criteria, then it is sent to a third party triage committee of admin/doc/ethicist/community (real-time 24/7 group with all the info of competing patients in a region) that decides. An attempt to separate the decision burden from the front-line clinicians. That is important for the frontline psyche I think. So, is a regional approach rather than a hospital approach. You can’t gave a perception of different treatment depending on which hospital you present at.
Anyway, my thoughts are with all the providers facing this challenge. On the one hand, the stress of this type of situation can make some feel like they are done. On the other, for many it is a chance to actually make a big difference in a situation where few others can. I actually find purpose in that. I think one thing important to help with a resilient personal outcome as a physician is to remember that you can only do the best that you can when choosing between bad options and having the courage to do that means the most good for the most people even though their will be individual tragedies. We need to mentally/emotionally account the successes with equal weight to the times where we couldn’t succeed. A common difficulty in medicine.
-LD
Author
LD,
We are once again shown to be kindred souls separated by little more than our tolerance for subzero temperatures.
While it would make far more sense to consider regional rather than individual hospital capacity, the reality in the US is that we seldom have a sense for what the hospital 5 miles down the road from us is dealing with, and the hospital you end up arriving at will largely determine the resources you are offered.
This cuts both ways: In a beloved community hospital like the one where I work, both docs and local donors are deeply invested in its continued success. Docs like me because my kids were born there, and my daughter was admitted / had surgery there when she broke her femur in the first grade. If you happen to live near a less resourced/less beloved hospital – often you travel further from home to get your care. It dramatizes the disparity. But I digress.
I’ve been taking voluntary 24 hour home call one day a week as part of our institution’s bioethics critical care triage team. Our goal is similarly to 1) support physicians making difficult calls, to reduce mental anguish and 2) apply a transparent set of criteria that is equitable, just, and consistent should we reach the point of crisis. Why are we testing the team now when we have adequate resources? We want to make certain that it operates smoothly ahead of time, and get all stakeholders accustomed to how it flows.
One idea I’m curious if you have grappled with in the North: Do you have hard exclusion criteria? The original NY ventilator allocation guidelines used hard criteria such as age. We’ve moved toward a system based on Doug White’s framework out of U Pitt, explained by his recent JAMA article.
Perhaps one of the most hopeful signs to arise from this crisis is the degree of ethical convergence in thinking it through that I’ve found among colleagues involved in the bioethics effort with me. Our framework was validated by the recent guidelines issued by the California Department of Public Health issued this past week.
In the meantime, going through the process of discussing desired code status, particularly with our elderly nursing home admissions where we’ve had multiple clusters of COVID outbreaks, is preparing us for the difficult days we hope never arrive.
Glad to know you are involved in doing this important work in your neck of the woods, LD.
Fondly,
CD