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.