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Hard Questions in Emergency Critical Care

THE FEDERAL GOVERNMENT and the medical profession are taking a close look at the country’s capacity to provide critical care in a pandemic or other large-scale emergency. Medical facilities would likely be unable to handle the level of demand for services, raising tough questions about who would and would not receive emergency treatment.

As a part of the government’s examination of the country’s preparedness, the staff of the House Committee on Oversight and Government Reform audited 34 Level I trauma centers in seven major U.S. cities earlier this year. Their objective was to gauge the centers’ ability to provide medical care to a sudden influx of critically ill or injured patients, referred to as “surge capacity.”

The congressional investigators found that even without a large-scale disaster, the centers were beyond their ability to care for those walking in the door. In Los Angeles, for example, at the time of the audit, three of five centers were “on diversion,” meaning rescue services had been instructed not to bring any patients. In Washington, D.C., neither of the city’s two Level I centers had available beds. One of them, Washington Hospital Center, was at 286 percent capacity.

That lack of capacity poses serious concerns given what occurred, for example, in Madrid after the March 2004 train bombings, when 966 patients needed some level of medical attention.

In addition to surge capacity is the issue of knowing how to triage patients and where to send them. In Madrid, the injured were taken to 15 hospitals. Facilities discharged ambulatory patients and directed noncritical cases to hospitals with less sophisticated trauma care capability, freeing up space for more seriously injured victims.

The process of determining where to send patients for treatment in a crisis requires not only surge capacity but also sophisticated communications and realtime tracking of available bed space. At a hearing on the issue, Health and Human Services (HHS) Secretary Mike Leavitt told lawmakers that his agency is funding projects on communications and realtime patient and bed inventory tracking nationally.

While supplies, such as beds and respirators, provide hospitals and government with metrics to demonstrate preparedness, Dr. Kristi Koenig of the University of California-Irvine and the American College of Emergency Physicians, says that leaders must also consider human resources, such as the elevated staffing demands that will arise from emergencies. Doctors, nurses, and support staff may be unable to reach hospitals or may be unwilling to leave loved ones at home.

“Whether the sociology literature is right, it states pretty clearly that people aren’t going to show up to help unless they’re given assurances their loved ones are safe,” Koenig says. Forward-thinking hospitals have pledged that in emergencies they will provide expanded employee services, such as day care and priority access to vaccines or medication for family members.

States, meanwhile, are implementing surge plans that call for discharge of ambulatory patients and conversion of available spaces within hospitals—places like hallways, diagnostic areas, and waiting rooms—into care facilities.

A major disease outbreak, such as pandemic influenza, could produce victims over a long period and pose a greater challenge than a localized incident. In that type of scenario, need would clearly exceed capacity. That harsh reality led a group of leading critical care physicians, together with HHS and the Department of Homeland Security, to draft a recommended list of patients who would not receive critical care in a pandemic.

Those on the list, published in Chest, the journal of the American College of Chest Physicians, include people over age 85, trauma victims, those over 60 with burns, those suffering from serious chronic disease, and those with mental impairment such as Alzheimer’s disease.

In one of the four articles supporting the recommendations, a team of more than a dozen doctors suggests the standards “be applied for all hazards causing moderate or large surges in critically ill patients, as well as for those that compromise existing critical care infrastructure.”

The authors suggest use of a mathematical formula to determine whether patients should receive continued care, considering the resources they would require for treatment that could be used to save other lives. In one of their articles, the authors acknowledge the potential legal pitfalls of this type of triage, suggesting that “government endorsement of the algorithm” would possibly help to shield hospitals and practitioners from malpractice claims.

In a separate report issued early this year, the American Civil Liberties Union (ACLU) criticized the government’s approach to pandemic planning, specifically urging equal care for all.

“Public health measures must not be based on…age or disability” regardless of whether “there is good reason to believe particular groups are either at much higher risk of death or have a much higher likelihood of spreading the disease if not vaccinated or treated,” the report stated.

Professor George Annas, chair of the Department of Health Law, Bioethics & Human Rights at Boston University’s School of Public Health, co-authored the ACLU report, but sees no problem with the new recommendations. He explains that civil libertarians’ primary concern with emergency preparedness is to ensure that there will not be discrimination in preventive measures, such as distribution of vaccines or post-infection medication.

Guidelines for the more traditional form of medical triage—deciding not to spend resources on patients who would likely not survive anyway—is acceptable, to the degree that the guidelines “are consistent with good medical practice” Annas told Security Management.

“It sounds very harsh, but it’s absolutely reasonable. You want to save the most people you could save, which is good medical practice,” says Annas, who is glad the subject—however unpleasant—is being discussed. “You want to make this public and talk about it, because you don’t want to be making this stuff up during an event.”

That was essentially what happened in New Orleans in the aftermath of Katrina. In 2006, a physician and two nurses from New Orleans’ Memorial Medical Center were charged with the second-degree murder of four elderly patients who had allegedly received lethal doses of painkillers amid the evacuation from hurricane Katrina. Charges against the nurses were dropped, while a grand jury later declined to indict the doctor.