The AP has a story that a task force composed of medical and other experts from academia, professional groups, the military and government executive branches and agencies like the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services has been considering how to ration scarce medical resources in the event of a pandemic. Before I give you their suggested answer I want to consider the underlying problem. This may be too abstract a way for some to think about this, but it is the logical bare bones of the matter.
Suppose you have ten ventilators and a bunch of people who need them right away. If the vents are numbered one to ten, you apportion them by pairing off each vent to a person. What that does is to force you to number or sequence people. If there are more people than vents, some people won't get one. The problem then is how you construct a sequence of people.
You may have some rules you want to use to sequence people: a 65 year old physician or a 17 year old single mother might come ahead of a terminally ill 90 year old using a ventilator for life support and a 40 year old critical care nurse might come ahead of either the mother or the doc, based on the nurse's utility to help others if he or she recovers (or based on the effect on the morale of the still healthy workforce). But does the mother come ahead of the doc or vice versa? Hard to say. Here's a diagram:
This kind of set up is called a partial order in mathematics. It is partial because some things come ahead of (above) others but some pairs are not comparable: the mom and the doc, for example. The real world is like that. Would your rather walk to work or carry your lunch? In the case of the doc and the mom, you might argue it both ways. But you have to make this partial order into a sequence. There are two possibilities (technically they are called linear extensions of the partial order). One is nurse > doc > mom > 90 y.o. and the other is nurse > mom > doc > 90 year old. Either sequence honors the given ordering (nurse above both doc and mom who are both above the 90 year old) but where the partial order is silent each chooses differently about the doc and the mom.
Now assume there are two vents. The two possible sequences now both assign a vent to the critical care nurse but give the remaining vent either to the doc or the mom.
Pretty abstract but it allows us to see a little more clearly what this task force, whose report appears in the medical journal, Chest, has done and what it hasn't done. First, it recommends each hospital establish a "triage team" to make clear and then implement an objective set of criteria of rationing resources and services. Then it suggests a principle: that the system ignore people at high risk of death and a slim chance of long-term survival. In particular:
- 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.
What we have here is a very sketchy partial order. The people lower down in that list aren't ordered among themselves since they won't be part of any sequence; the vents will give out long before we get to them. This says who shouldn't even be considered, not help deciding what to do about the huge number of people still on a list that exceeds the available resources. The bottom of the pile aside, one can imagine the huge number of possible sequences that would still result in a real world forced choice situation for those remaining.
So are we ahead? The list is shorter. If you think putting those cases at the bottom of the order is the right thing to do, implementing this would prevent a sequence in which that very crude ordering isn't respected. But as some point out, the shortened list might even be a violation of federal law prohibiting discrimination by age or disability or income. If the task force report provokes discussion and argument, that's a good thing. But it doesn't provide a way to settle the issue, so it isn't necessarily progress.
Maybe instead of arguing who will go in the lifeboats if the ship sails into an iceberg we should be building safer boats with more lifeboats. Of course it's not a question of one or the other. We can do both. Unfortunately we are only doing one.
Medicine & Health
Comments
It's a scary thought, but not far-fetched. During Katrina, medical personnel were forced to make decisions without any guidance but their own (and I'd argue, did a fairly good job).
During this latest flu season, resources were taxed. We turned day rooms into patient rooms, had "virtual beds" in hallways...
No one in the public is going to be happy about this.
I agree with you that turning this into a lifeboat scenario, rather than trying to change the underlying problems, is important, but there will be times that, no matter how many lifeboats we build, they won't be enough.
Tough stuff.
Posted by: PalMD | May 6, 2008 8:31 AM
Clout will rule the day. The Mayor's son, the Doctor's sister, these will be the chosen few.
Security will have to be at maximum strength so that grieving father with the Glock on his hip doesn't make room on the list for his wife. Sound apocalyptic??? Perhaps, but without pre-identified pandemic flu treatment areas (schools, auditoriums, etc.) the hospital system will collapse.
We aren't building bigger better lifeboats. The lifeboats we have are going into "bypass mode" (read full) on normal weekend nights. Come pandemic time it will also be pandemonium time.
.
Posted by: gilmoreaz | May 6, 2008 10:24 AM
It is past time for this subject to be openly discussed. And as Revere stated above, this is only a partial list of who lives and who dies. Do we take old and dying people already using the vents off of them? What about premature infants? Do we take the smallest off to allow an otherwise healthy infant a chance at beating the disease? As vents are already used at capacity, someone will indeed have to play God. Some of the decisions will be made for us, first come first served is a good example. But, I suspect as Gil has already stated, a great many of those who will be given the gift of care, will be those who have the monetary or political clout to demand a bed and get one. Unless the single mom is a Senator, I don't think she will make the cut.
Most people don't have the luxury of self-quarantining for months. And even fewer who do have the means, will not be able to maintain isolation until a vax is available. Hopefully, the next time we run into a pandemic of epic proportions, we will be better prepared than Defoe describes in his book. Let's hope we only see a CFR of less than 5% otherwise.......
Posted by: Shannon | May 6, 2008 12:55 PM
Free full text access to the triage documents can be found at
http://www.chestjournal.org/content/vol133/5_suppl/
Posted by: bc | May 6, 2008 5:00 PM
bc: Many thanks. Have been looking for it.
Posted by: revere | May 6, 2008 6:13 PM
In my mind revere, after the initial shock and realization of a pandemic, everyone will try to do the right thing. And there will be many good ordinary people who realize on their own that they must truly give up their lives so another can live.
As far as a violation of federal law prohibiting discrimination by age or disability or income, well come on now, in the midst of a pandemic that will have to be worked out afterwords, that is if any one is still willing to pursue such utter nonsense.
Sometimes the "rules" have to be broken.
Posted by: Lea | May 6, 2008 7:22 PM
What about premature infants? Do we take the smallest off to allow an otherwise healthy infant a chance at beating the disease?
I think this example in particular highlights the difference CFR would make. If the CFR doesn't drop, and I mean precipitously, the smallest uninfected micro-premie might have a better chance at survival than an infected "otherwise healthy" infant. (And "otherwise healthy" in this context makes me think, "other than that, how did you enjoy the play, Mrs. Lincoln?")
Furthermore, even if the CFR was 1 or 2%, even for infants, doesn't putting someone on a ventilator imply their lung capacity is already seriously compromised? IOW, they have a particularly bad case? Even with a low CFR, the micro-premie might still have the better chance.
Of course, then there's the question of, if the premature infant needs the ventilator for months, and other patients a week or so each.
Posted by: caia | May 6, 2008 9:25 PM
Just some thoughts (haven't read all 5 articles yet):
1. These guidelines have received a lot of press/blog coverage but the controversy to me seems somewhat misplaced. On the one hand, some editorials and comments have inveighed against the unfairness of 'abandoning' the elderly, etc. On the other hand, some blogs and commentators talked about how the public just 'doesn't get it' when it comes to the reality of what might happen during a pandemic. But this sort of decision making happens already happens everyday to some degree with organ transplants, difficulty accessing care by the uninsured, etc.. Last week, an article in the Wall Street Journal talked about how some hospitals are actually denying chemotherapy to patients unless they are first paid for care upfront(http://www.wsbt.com/ news/health/18353979.html)! Another article discussed the use of medical marijuana (even with a doctor's approval) as a disqualifying factor in patient eligibility for organ transplants.(http://seattlepi.nwsource.com/ local/361630_marijuana03.html?source=mypi). Patients already are denied care because they lack insurance/wealth or lead what some may view as questionable lifestyles. This is wrong under 'normal' circumstances and would be no less disturbing during a pandemic. The only difference is that more people would be affected by these types of value judgments and some of the criteria used for making these judgments might be somewhat altered during that time. (Or maybe not that altered when you get right down to it).
2. Right now, the overall case fatality rate for H5N1 appears to be much higher among those ages 10-40, rather than the very young or elderly (See http://www.who.int/wer/ 2007/wer8206.pdf). So that 85-year old discussed above may actually have a much greater chance of survival than, say, a 40 year old critical care nurse. It's also worth noting that the case-fatality rates vary greatly among men and women; for instance, the case fatality rate for women aged 20-29 is almost 20 percent higher than that of males in that age group (in other age brackets, men seem to die at much higher rates than women). Are we going to make gender (or ethnicity for that matter) a factor in decision making as well as age if that impacts survival? Why is it (apparently) 'ok' to take into account a person's age or a person's mental status (e.g., severe dementia) -- even when being older may actually improve survival -- but presumably would not be acceptable to anyone under any circumstances to take into account gender or ethnicity if these factors were to impact patient survival? While these sorts of triage schemes superficially appear logical and evidence-based, I sometimes think what they really do is codify and condone our existing biases and judgments.
Posted by: msb | May 7, 2008 9:29 AM
We may need this kind of "incentive" for people to really think about community mitigation (aka NPI, aka "school closure and all the rest").
We can't afford to have too many people falling ill at the same time.
See most recent discussion (even argument) here: http://newfluwiki2.com/showDiary.do?diaryId=2416
Posted by: lugon | May 7, 2008 9:40 AM
And, of course, CFR=1% means hospitalisation rate is higher than 1%. How much higher? As higher as possible, if not-too-severe cases are hospitalised "just in case".
It will be messy.
Thing is: will it be unnecessarily messy?
Yes.
Posted by: lugon | May 7, 2008 9:46 AM
msb: I think the main point here is that this is an opportunity for discussion of the topic (lugon makes the same point). Your comments assume that it is the chance of survival that should be the criterion rather than the "worth" of the person to society. That is a position that some but not all would agree with. Those in the comment thread who say it is irrelevant because in an emergency people will do what they want to do are only partly correct IMO. Yes, many "rules" will go out the door but structures and ways of thinking put in place after due deliberation before the emergency will also affect things. They may not determine outcomes but they will affect them. And the discussion is important not just for pandemic planning but also for the kind of rationing and triage that already exists, a point you make. This issue has given you an opportunity to make that point. So all in all, I think it is a good thing this has come up.
Posted by: revere | May 7, 2008 9:53 AM
Or folks, you can do it as it should be and that is first come first served.......
The McDonalds approach to handling this particular pandemic is what will end up being done, likely at gunpoint at least here in the states. Until a state of emergency comes into being and a declaration allowing those protocols to go into effect (wont take long) they have to follow the law. Thats what a state of emergency, or declaration of martial law will do give them the out to enforce those protocols. Temporarily. After a short bit of time they wont work.
Wont matter though. The Senators wife will be already heading out the door medically speaking, along with just about everyone one the list above. The 65 year old doctor statistically should make it, but be nearly invalid for several weeks or months (The chinese truck driver took six months). The 40 year old might make it... but the numbers are not in her favor.
The numbers suck across the board. The 17 year old is toast and the 90 year old should just be at home and just waiting for the inevitable. I dont want to discard anyone at all but the realities are, ventilators, supplies and what have you just dont work on this stuff. No equipment works. Nor does the mass dose Tamiflu. Relenza might but has anyone seen that being stockpiled? Revere's statin drugs also might but it again leads to a distribution nightmare. Everyone is worried about healthcare if it happens? Statistically what outcome? I havent seen anything but a few walk out of this. They are able to care for most of them now using extreme measures and produce about 1 out of 4 for a favorable outcome, but extreme measures cost money, supplies and physical efforts on the part of the doctors/nurses/hospitals. Wont have that luxury for panflu. They'll be making rounds of several hundreds if not thousands of patients a day and the HCW numbers will be dropping steadily with each day we are in it. Then what? Cant put that ventilator in without an order, and you have to have someone to do it. How many docs have done it recently?
Then there is the gunpoint. Theirs and ours. This gets down to what I have spoken about before. Is healthcare a right or a service? The implication that the Senators wife might get care is fine, but what do you do if someone comes in packing firepower to take the ventilator away from her? The military will be pulled out to maintain order but these are all people who would for the better part be sick themselves w/wo vaccine distribution. Hey, everyone is going to get it at some state and stage. Complete and utter chaos is going to rein supreme. So to me the guidelines and updates to them are based upon the fact that order is maintained and that is something that will not be there for at least the first two months. Couple it up with the previously posted infrastructure collapses especially in the populations centers in the North of the US and other countries, I cant see that their protocols mean squat. What is this for, post pandemic litigation?
For my way of thinking all of this medical preparation stuff is pure pie in the sky. We dont need to spend a trillion dollars on beefing up healthcare, we need to spend a billion or two and develop a vaccine that works. Works in this case would be acceptable if it just keeps you alive and in moderately good condition. Nothing yet has proven that. The supplies alone to support the patients above would be out of date or used up so fast that it wouldnt come close to being able to take care of even one of the above people because it will have been used up long before they get there.
Costs? Remember it cost 50,000 bucks USD two years ago to keep one Chinese guy alive for a month. Use that number on a population of 300 million or even a third of it and see what you come up with. The average daily cost of a hospital stay was $697 per day in the US.
http://query.nytimes.com/gst/fullpage.html?res=940DE5DA1438F936A15756C0A96E948260)
Would this be average? I doubt it. But for grins the 697 x 100 million citizens and staying for 14 days is $975,800,000,000.00. Sorry folks but its just not going to happen. What do you do when the hospitals turn around and just say no? They cant turn people away you say? Wanna bet? Those private hospitals can and will because they will not be able to afford it. This will become something like a Hurricane Andrew or Oakland fire. The insurance companies will start getting the bills in, find that they are insolvent and then the system collapses. It would happen if it were UHC too. You are never get close to that ventilator so its a moot point.
Government takeover and forced labor by HCW's, Uh-huh. Who says so? Going into one of those places would be like taking a Sunday drive in to Hell. Sure there will be pockets that are able to hold up, most wont and then a whole new set of protocols will come into effect. That will be the protocol of reality. I asked three of my doc's if they would go and they to two men and woman said only as long as their own health wouldnt be jeopardized and as long as there were supplies and workable facilities.
So I am skeptical about the above. Its nice to produce what we is for all intents and purposes a medical rule of engagement. But this is going to last about 10 seconds after the last ventilator is used. Once in and on, they are going to find themselves in it up to their necks for all services.
Anyone want to write a nastygram to Siti Supari?
puskom.publik@yahoo.co.id
Posted by: M. Randolph Kruger | May 7, 2008 12:04 PM
Much over looked is keeping it simple. Yes, it's great this has finally come up for discussion however, humans have a tendency to complicate matters.
Cover the basics please and then when necessary use sound judgement in having to make the hard decisions.
lugon hit the nail on the head basically. Thing is: will it be unnecessarily messy? Yes.
Posted by: Lea | May 7, 2008 5:26 PM
Lea: OK. Keep it simple. Such as . . .
Posted by: revere | May 7, 2008 5:51 PM
Im glad this topic finally came into the public realm. Maybe it will get people to actually think about the fact that a pandemic is coming. Might wake the ostriches up and get some of them prepping...or at least talking.
My family has come up with its own protocols. After much discussion, we concluded that a hospital is absolutely the LAST place any of us would want to be. Therefore:
1 - We will SIP as long and as completely as we can. Anyone who enters the compound does so with the understanding that they will NOT be taken to the hospital, no matter what. We will also likely be the last of the last to get vaccinated, if a successful vaccine is ever developed. We dont want to be standing in line with a bunch of other people who may already be infected, and we dont trust any plans being made by either the Feds or the PHD.
2 - We will do whatever we can medically to protect and maintain each other, but if anyone gets sick or injured, they will either die at home or get better.
3 - We will make sure that we have enough jerry cans of diesel fuel put aside to run the tractor and backhoe. We will bury anyone who dies on our own property and will not surrender any bodies until the pandemic is completely over. Maybe not then either.
4 - Anyone still standing is responsible for taking care of the others. If no one is still standing, it probably wont matter much.
Posted by: SaddleTramp | May 7, 2008 6:17 PM
revere/Revere: Cover the basics, just as was done in this AP release. Come up with a plan, as was done according to this AP release, draft it, revise it, finalize it. Distribute it and then let it go.
It most likely will come down to personal decisions anyway. In the end no one will want to be forced to make any decisions when it comes to choosing who lives and who dies, really.
My greatest "hope" would be enough pain medicines that will be given freely to those who are going to die.
Along with companionship, no one truly wants to die alone.
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msb: Glad you mentioned the medical marijuana patient, it's a travesty indeed.
Hepatitis C Patient Denied Transplant Based on State and Doctor Approved Medi-Pot Use - Seattle, WA:
University of Washington Medical Center (UWMC) officials have denied a 56-year-old hepatitis C patient from receiving potentially life-saving surgery because of his state-approved medical cannabis use, according to a news wire report by the Associated Press.
According to the report, Timothy Garon may die within days without a liver transplant. Previously, Garon has used medical cannabis under his doctor's supervision and in accordance with state law -- to treat his hepatitis C related nausea, abdominal pain, and lack of appetite. Garon's physician has stated that he was not aware that his patient's medicinal cannabis use would deny him transplant eligibility.
Posted by: Lea | May 7, 2008 6:38 PM
Hospitals might send a lot of people home to get nursing care and basic medicine from their families. The mortality rates for people over 50 are pretty grim. I've prepared for the next pandemic by putting life insurance on my credit card balance.
Posted by: Monado, FCD | May 7, 2008 9:59 PM
Lea-Be happy in knowing that morphine is one of the drugs they HAVE been stockpiling in the federal stockpiles. Stab and push syrettes. I think that the people that will be raising the most hell will be the have not at alls. Those that have never worked or depend on the government for everything. Smelly has as pragmatic approach as I do to it.
I also think that they should be bellowing it out loud about preparations at every turn. It would appear that H5N1 is here to stay and it will not go until it cleans some more of humanity from the face of the earth. Indonesia-300,000. Myanmar-100,000. I would say its not done by a stroke... Quakes are next on my list that cause huge tsunami's followed by Bird Flu.
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Re: T. Garon... I think this was the reason here: http://www.sciencedaily.com/releases/2008/01/080128140840.htm.
They probably didnt want to lose a perfectly good liver if the guy had been using weed. My best guess on that.
Posted by: M. Randolph Kruger | May 7, 2008 10:05 PM
Hospitalization costs (if handled in a traditional fashion) would be even more outlandishly impossible than MR Kruger suggests above. His nearly $1 trillion rough estimate for hospitalizing 100M people for 2 wks relied on "The average daily cost of a hospital stay was $697 per day in the US.
http://query.nytimes.com/gst/fullpage.html?res=940DE5DA1438F936A15756C0A96E948260
But that $697/day figure was from 1987. (And as an average, it's not for specialized care.)
Besides the urgent need to make more ventilators and other "lifeboats" (and stop closing hospitals), hospitals must feel they can afford to treat uninsured people. We need a law establishing ....
Emergency Relief Medicaid that any governor could invoke under defined circumstances when evidence indicates a pandemic or other calamity is starting, without having to wait for days/weeks/months for federal approvals as happened after Katrina. Then a governor should be able to announce everyone is presumptively covered and hosps/docs are entitled to federal reimbursement.
All that, of course, is a separate issue from deciding whether to encourage people, and which people, to go to hospitals vs. stay home.....
Posted by: Debbie S | May 7, 2008 10:24 PM
Heck yes MRK, they should be "bellowing it out loudly about preparations at every turn." But it ain't happening.
I'm still being laughed at by certain people.
Glad to hear morphine is being stockpiled.
SaddleTramp: Your "we concluded that a hospital is absolutely the LAST place any of us would want to be."
That is our mantra too.
In addition you may want to consider lime, it helps the body decompose faster if burial isn't possible.
MRK: your link didn't work, just got a bunch of annoying pop-ups. Won't link to it again anyway so don't bother, you already know how passionate I am about medical cannabis.
Posted by: Lea | May 7, 2008 11:39 PM
Saddletramp,
Like your plans-I'd much prefer to die at home rather than the present pre-pandemic hospital setting, much less after TSHTF. We plan to pre-dig several graves on our property and if cold weather,store the dirt in a warmer area, like a shed.
Doesn't say much about the current state of the American hospital system, which is on a cliff, leaning over and on a banana peel... Most people don't understand how bad things are now in health care....
Posted by: Grace RN | May 7, 2008 11:45 PM
They stay at home they dont get sick Debbie. The NPFP specifically states that they will not be providing the coverage you indicate. We will be struggling economically enough post of a panflu that we couldnt even begin to spread the costs as suggested under a UHC. States might cover their people individually but no federal bailouts. This would make the Great Depression look like a slight pothole on the road to life.
BTW the 1988 costs were about the only ones I could find that were from a lefty newspaper. They tend to inflate that a bit so that was the one I used. Specialized care would never happen.... they cant take the heat and there is no kitchen. First couple in are going to get the ventilators. There are about 100,000 as I posted last fall in the US and thats it. Please, post this notice in the hallways of the hospital. "Patients who are lingering along, please kindly bag it within the first week so someone else can get a shot at a ventilator" .;>
Yes, 1 trillion doesnt even begin to cover it. I checked with the State of TN Healthcare Commissioner about the reserves that the insurance companies are required to carry, its appalling. At the 5% number and if all people are covered by CoverTN, or one of the non state insurance gigs and if even 1/3rd of the state gets sick but doesnt die, we will be out of money in under three weeks. We would be at the billion point five number if If it creeps in like it is now, its manageable. If its a fell swoop that hits with the power of a nuke.... All gone.
Brings up another thing. The infrastructure that I spoke of. The fell swoop would finish the NE and LA Basin in about a month. No electricity. Keep it in mind.
________________________________________________________________
Lea....
ScienceDaily (Jan. 29, 2008) — Patients with chronic hepatitis C (HCV) infection should not use marijuana (cannabis) daily, according to a study published in Clinical Gastroenterology and Hepatology, the official journal of the American Gastroenterological Association (AGA) Institute. Researchers found that HCV patients who used cannabis daily were at significantly higher risk of moderate to severe liver fibrosis, or tissue scarring. Additionally, patients with moderate to heavy alcohol use combined with regular cannabis use experienced an even greater risk of liver fibrosis. The recommendation to avoid cannabis is especially important in patients who are coinfected with HCV/HIV since the progression of fibrosis is already greater in these patients.
"Hepatitis C is a major public health concern and the number of patients developing complications of chronic disease is on the rise," according to Norah Terrault, MD, MPH, from the University of California, San Francisco and lead investigator of the study. "It is essential that we identify risk factors that can be modified to prevent and/or lessen the progression of HCV to fibrosis, cirrhosis and even liver cancer. These complications of chronic HCV infection will significantly contribute to the overall burden of liver disease in the U.S. and will continue to increase in the next decade."
Researchers found a significant association between daily versus non-daily cannabis use and moderate to severe fibrosis when reviewing this factor alone. Other factors contributing to increased fibrosis included age at enrollment, lifetime duration of alcohol use, lifetime duration of moderate to heavy alcohol use and necroinflammatory score (stage of fibrosis). In reviewing combined factors, there was a strong (nearly 7-fold higher risk) and independent relationship between daily cannabis use and moderate to severe fibrosis. Gender, race, body mass index, HCV viral load and genotype, HIV coinfection, source of HCV infection, and biopsy length were not significantly associated with moderate to severe fibrosis.
Of the 328 patients screened for the study, 204 patients were included in the analysis. The baseline characteristics of those included in the study were similar to those excluded with the exception of daily cannabis use (13.7 percent of those studied used cannabis daily versus 6.45 percent of those not included). Patients who used cannabis daily had a significantly lower body mass index than non-daily users (25.2 versus 26.4), were more likely to be using medically prescribed cannabis (57.1 percent versus 8.79 percent), and more likely to have HIV coinfection (39.3 percent versus 18.2 percent).
The prevalence of cannabis use amongst adults in the U.S. is estimated to be almost 4 percent. Regular use has increased in certain population subgroups, including those aged 18 to 29.
I cant put anything else in because of the fair use gig. I can email the link if you want.
___________________________________________________________
Grace... Its supply and demand as best I can tell. We are importing nurses from Canada and their work visas are being stamped as fast as they can arrive. We are no kidding 18,000 short in the State of Tennessee today and we are not graduating them like we used to. They are becoming medical malpractice attorneys instead. Add in all of these damned tests and well, you get the expenses that we are familiar with.
Posted by: M. Randolph Kruger | May 8, 2008 12:14 AM
Just as you are stubborn in many areas discussed here MRK I am stubborn over the biased "studies" of cannabis. While I respect your choices please no more links.
I'm in the pissed off stage of the grieving process now so give me a break.
Monado, FCD said: "Hospitals might send a lot of people home to get nursing care and basic medicine from their families."
This is where I take the doomer's point of view, or call it what you will.
My take: Hospitals will call relevant authorities and a lot of people will be shipped off to pandemic quarantine camps.
Posted by: Lea | May 8, 2008 1:27 AM
It is interesting that the report of the people that will get treated (from last fall), wasn't included in this article. I can't seem to remember who put it out. Military was first, I believe pregnant women and those with children under 2 were third, I think. Wouldn't that have been a good combination? Maybe a bit too overwhelming for the general public.
Posted by: DebP | May 8, 2008 9:38 AM
Dear All,
You people really frighten me. This smacks of Nazi Germany and its dogma of utilitarianism. I cannot go into my objections right now, but I do want you to consider this guideline from the Catechism of the Catholic Church:
"Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of overzealous treatment. Here one does not will to cause the death; one's inability to impede it is merely accepted. THE DECISIONS SHOULD BE MADE BY THE PATIENT IF HE IS COMPETENT AND ABLE OR, IF NOT, BY THOSE LEGALLY ENTITLED TO ACT FOR THE PATIENT, WHOSE REASONABLE WILL AND LEGITIMATE INTERESTS MUST ALWAYS BE RESPECTED (emphasis mine). (page 549, #2278)
You all should be encouraging citizens to consider writing a "pandemic living will" to get the people ENTITLED TO MAKE THESE DECISIONS (patients and families) to think about your concerns.
Gotta go see Mom, I'll check with you later.
Love,
Library Lady
Posted by: Library Lady | May 8, 2008 10:42 AM
DebP: We did discuss it here. I questioned why the military should be on the list in any preferred way. The main point, though, is we should be discussing it. My problem with LL is that she considers the discussion closed (by her church). We are already denying help to people on the basis of money so this isn't just a pandemic question. If we don't like this we need to make the pie bigger, not argue over how big a piece of the existing pie people will get. But people would rather argue that than pay any more taxes I guess.
Posted by: revere | May 8, 2008 11:11 AM
A bigger pie is needed. More supplies and equipment are needed. Honest conversations and public reactions to this policy are needed. During the implementation of this triage approach I expect we will see rules change as people become aware that there is no objective way to ration care. Better to speak up now then wait.
I'm just not comfortable in letting anyone make a Sophie's Choice for me. I'll be joining the at home crowd to ride this thing out.
Posted by: ST | May 8, 2008 4:41 PM
I don't believe the Church's teachings actually cover what the discussion is all about. There is a difference between choosing who will likely live and who will likely die in the ventilator debate above and what LL quotes about the Church's teachings. You have one ventilator, you have a sick nurse and a sick 17 year old unwed mother, both will likely die without the ventilator and both will likely live if given the ventilator. But you can't have them both on the ventilator. Someone will have to make the decison and convince either the nurse or the unwed mom (or families) that by likely dying its a good thing for humanity. Good frickin'luck with that. Unless you can consider the ventilator treatment as "burdensome, dangerous, extraordinary, or disproportionate to the expected outcome" for one and not the other. Especially if the expected outcome is life for both. Good luck with that too.
Hey revere I guess, in your mind, it would be a good thing for the flu (or whatever) to wipe out the military, sort of like what happened in WWI. The flu just didn't kill enough American/British/French/German/Austrian troops though to stop WWI. I don't think the US Government will allow putting this nation at risk by letting the military weaken because of a pandemic. That is why the miliary is a priority.
Posted by: pauls lane | May 8, 2008 5:35 PM
No, pauls, I don't think it's a good idea for the flu to wipe out anyone. I object to giving the military preference over others for scarce resources. On what grounds? So they can kill more people in Iraq? Do you think we should give Congress preference so we don't let the country go without a government? Since we need taxes to pay the military and everything else, should we give the IRS preference so we can keep funding the military? Since research is necessary to know how to make new weapons should we give scientists preference to keep our competitive edge? Etc., etc. The question is not whether you want to save the military (the military is not a person, after all; it is made up of people whose lives have value) but what kind of choices you want to make and I don't see the military as a priority over other priorities, for example, police, fire, manufacturing of critical goods and workers in critical infrastructure, health care workers, etc., etc. In that hierarchy they seem fairly low on the list.
Posted by: revere | May 8, 2008 6:36 PM
I agree with Revere. They are establishing this now to provide them cover if it comes.
Truth be known...It wont matter if either are on a ventilator statistically speaking if they are below the age of about 48 which seems to be a cutoff line for "surviving" BF. Even then 1 out 3 in the 49-65 age group dies.... Ventilators just make sure that the patients breathing actually happens. If there is funk in the lungs it doesnt matter if its in there at all. They still die.
The Doctor and the Nurse would get the vents if it were up to me. The 90 year old would just be a loss and the mom and child would be next on the list to save if possible. The miltary guys if they were on the example would be on the same level as the HCW's. We will still have a population that will need policing, we will still need doctors and nurses afterwards. Full military control might be needed to keep things under reasonable control but I would be very cautious of that...Maybe as support forces submitted to the local control as the new laws post of Katrina would allow.
For me and if I knew they were heading out the door I would hit them with 3-5 syrettes of morphine and ease their suffering. I wouldnt hesitate for more than one second.
LL-You are a pretty even hand here most of the time but Church dogma in the face of reality sometimes doesnt fly. I am Episcopal and very conservative but in this case the true nature of the beast will be that the system will collapse, reconstitute and collapse several times before its over. Just when you think you have heard the last horrific story or edict, another one will roll out. That will mean hard choices will have to be made. Do you boot a dying 90 year old with metatastic cancer from a Catholic hospital to accomodate a survivable 18 year old. IMO yes. I have posted on this before. We have to have little taxpayers growing up and the choices above are tough. Do you put extraordinary measures on a patient that has nothing left to contribute to society except that they are 90 and living on S. Security?
A doctor turns and says this kid is savable where can we put him? Well the 90 year old is breathing assisted just to wait out the end of her cancer. The kid can make it if he gets the ventilator....Not a hard decision for me, but I wouldnt do it without legal authority to do so. I would require two doctors to sign off on it at the least but not run it by some damned committee.
Even if we spent 1 trillion dollars it wouldnt change the outcome right now. As I said a billion dollars to make a vax would be better.
How would someone in a Catholic hospital be treated if the above criteria was in place? Just as they would any other day until there is a declaration of emergency or martial law. After that the docs will either refuse to do it, or they'll do it. Or if there is total refusal they will get corpsmen to administer morphine to a level that will take them.
Its not frightening... But it does tell me fully that they believe its coming and they want to have their shelters built before it arrives. Full immunity from prosecution and lawsuits for this one is whats needed. Else, the docs wont show up. I wouldnt blame them as people who havent done a medical round since graduating med school will be put into terrible positions. I want them to have the law and/or an edict that allows them to do what is necessary with no ambiguities in the process. No person may be deprived of life, liberty or pursuit of happiness or property without due process of law. If they enact it now, its not a question.
Posted by: M. Randolph Kruger | May 8, 2008 6:42 PM
yeah revere so the military can kill more bad guys in Iraq or wherever the bad guys happen to be.. Well it would appear the military is high on the list. Get over it.
My parents lived through WWII and they told me what it was like. The miliary got priority on scarce resources, including my father who in my mom's opinion was a scarce resource (duration +1). Anyway, if it ever comes down to it, you can best believe Congress, the WH, the Supreme Court, staffers of all, and the rest of the Feds will get whatever before the rest of us will. Then the state governments including police, followed up by all you doctors and nurses.
We are going to need the miliary and the police to kill the rest of us unclean, rioting average folk. My goodness, pestilence, famine, and 4 dollars for a gallon of gas! Get your guns ready revere!!!
Posted by: pauls lane | May 8, 2008 7:17 PM
pauls: Don't own a gun -- not for moral reasons but for public health reasons. So you will be able to kill me easily if you want to. The issue is not whether to save you dad. Red herring. The question is how to decide how to apportion scarce resources. If your idea is that it should be done with guns (or political power), fine. That may be a cynically realistic proposition but it isn't one that we fight to defend in this country. At least I didn't think so. Maybe you do and that's why you want to preserve the military. Because that's what your argument boils down to. We need the military to preserve what we have and what we have is a system where the rich and powerful get to live and others come later, if at all.
Posted by: revere | May 8, 2008 7:58 PM
Realistically, it will come down to saving only those in the first stage of the flu.
No hospital system has the resources to save everyone.
Posted by: victoria | May 8, 2008 8:49 PM
victoria: Except that those in the first stage of flu won't need to be and won't be in the hospital. The health care facilities will only be seeing the ones who are really sick.
Posted by: revere | May 8, 2008 9:03 PM
Which Revere is right about. Pandemics generally wave into populations if the bio book from the military is to be respected. That is unless its a superbug that mutates as it goes to ensure it cleans a populations clock. But the herald wave cases will be mild to moderate, the ones after that are going to get hammered by it. Saving everyone isnt an option if its a rapid onset pandemic sweeping across the globe in a few weeks as models suggest. Ah, but if it comes slowly we will lose people more slowly and the system can adapt. We still lose say 5-30% but we can apply our resources as they go. Vaccines could be produced rapidly enough to give them to people albeit likely with no testing but it would indeed keep them alive mostly.
But take the official 5% number and then take your city or county or region population being served by your hospital system. Then count the number of beds, then count the number that have to be in them at 5% even if its to die... The numbers dont work now do they? They could never ever amass enough support for a rapidly spreading bug to change the outcomes very much. Mostly its going to be you and your immune system.
Two posts up Revere postures that the rich get to live and etc. I disagree with that. The smartest and the strongest/healthiest via whatever means rise to the top... Survival of the fittest. To me the assertion is that if you get rich at the expense of others is immoral or a crime is wrong. The military is there to protect the people from the public enemy both foreign and domestic. We wont be in Iraq if the shit hits the fan with BF. They would have at least two brigades back here in a month as suddenly even with a 5% event, there will be no need for oil from the middle east. Domestic production for the better part. Besides, the dollar and euro would be worth nothing anyway, how to pay for it?
Posted by: M. Randolph Kruger | May 8, 2008 10:23 PM
Pauls
The price of petrol is already way above $4 a gallon. Nobody pulled a gun out over it.
Posted by: Nat | May 9, 2008 1:38 AM
Revere,
Good point. We're screwed.
Posted by: victoria | May 9, 2008 3:25 AM
Ah Nat old buddy, not here yet anyway, besides you need to add the pestilence and famine parts of the unholy triangle. Although, MRK has a point, if most of us die from the flu and/or famine, gas prices will probably drop as demand drops. Basic economics.
Posted by: pauls lane | May 9, 2008 10:00 AM
Dear Revere,
I did anticipate you objecting to my interjecting the Catechism onto the thread, but it had to be done. That statement in the Catechism give believers the comfort that they do not have to submit to procedures that are "disproportionate to the expected outcome". You can refuse treatment. The choice is the patient's not the doctor's.
In your reply to msb above you say, "Yes, many "rules" will go out the door but structures and WAYS OF THINKING put in place after deliberation before the emergency will also affect things." (emphasis mine)
I object to the graph, the way it is presented, the idea that some people are expendable and some are precious.
The WAYS OF THINKING that I see here are disturbing. So many of you just slid right by the morality of what you are THINKING into the mechanics of what you will DO.
Why is the 17 year old mother "unmarried" in your chart? Is that not a prejudicial adjective meant to sway the reader? Why are there two medical people on the chart? Save yourselves first? Just how many 90 year old hopelessly doomed and useless people are on respirators right now, wasting your precious resources and time? I intensely dislike your categories. I intensely dislike your premise.
Your WAYS OF THINKING and the planning that results from the THINKING has happened before. The Nazi Party had WAYS OF THINKING and acting long before Hitler invaded Poland.
The build up to the invasions corresponded to the emptying of hospitals, mental institutions, orphanages. They anticipated not wanting to feed those mouths, change those beds, wash that dirty laundry for those useless people.
So they starved a few at first and when that was too slow they directly euthanized the rest.
Your chart smacks of utilitarianism--the doctrine that the worth or value of anything is solely determined by its utility.
Revere, MRK, no DOGMA there?
MRK, the Catholic hospital would say NO to booting a 90- year-old to save an 18-year-old. They would try to save both. If the military confiscates the facility, so be it, that is out of the Church's control, but their consciences will be clean.
Sophie's Choice was the most devastating movie I have ever seen, even worse than Schindler's List. The cruelty to Sophie was that the camp soldiers gave her a FALSE choice, suckered her into thinking she could save one, so she chose the boy over the girl, but he died too. The Nazi's not only murdered Jewish persons. They murdered the will, destroyed the peace of mind, and obliterated the sense that the world was good in the survivors that lasts down to this day. Sophie commited suicide.
Do not let yourselves be suckered into considering FALSE choices. You don't have to go there.
Consider promoting THOUGHT about a "pandemic living will" that states a person would forego treatment in times of disastrous shortages. Write a draft, see what it would look like. I know that if I needed a respirator and a 5-year-old next to me needed one I would give mine to that child in a heart beat. I would put that in a living will. You have forgotten the self-sacrificial goodness in humans once they understand what's at stake. Build on that goodness. All you have to do is ask people, and they will come through for you.
Love,
Library Lady
Posted by: Library Lady | May 9, 2008 10:53 AM
LL: The graph was based on what has been talked about, not what I think is right. I deliberately chose an unwed 17 y. o. to make the choice more difficult. She is young, has a dependent but also suffers the scorn of society (not my opinion but the premise that much of our work to welfare policies are based on and a reality). If you refuse to discuss these issues ahead of time only the powerful will have their way. You are hiding behind the catechism because it is based on a false premise -- that everyone is in fact equal in our society. Would that it were so. But it isn't. So we need to think what kind of safeguards can be put in place so that the deciding qualities will not be only the ones favored by the powerful. The choices you deplore -- and I agree with you -- are being made today by default by refusing to recognize social inequalities in our world and the catechism refuses to recognize those inequalities. The catechsm is thus the unwitting handmaiden of Nazi thinking (IMHO). It allows it to progress behind a veil of piety.
Posted by: revere | May 9, 2008 11:50 AM
Dear Library Lady:
I wish that you can post often here. You have provided distinctive perspectives as fresh air to this thread; full of humanness and clear conscience.
Get rid of utilitarianism is a very hard task; nevertheless, you are talking to the right person- I feel that Revere never feel tired and never happy staying in the second rated quality. He just needs constant reminding and occasional soft punch. You have done a great job!
Paiwan
from Phuket
Posted by: paiwan | May 9, 2008 12:41 PM
Again, I agree with Revere. The decisions are not going to be made by patients or their doctors. It will be made by people who have orders. Conscience isnt going to come into play and yes, in my Episcopal mind I would try to save both if I could as long as there is a reasonable chance at a favorable outcome. As I know you are religious but likely never having been in the military you probably never had to send anyone into combat. Or that in doing so you knew that there was a better than 50% chance that you wouldnt see them in the afternoon. It is an application of course of a military situation to a medical one that will go from medical to military in very short order anyway. But it will sound good on the news as they report it.
LL-Think of it this way. This is a test. For the next 4 months after the day of inception of high path pandemic flu, mankind will be put to the test. Which comes first a Nazi way of thinking or, thinking beyond the pandemic? What you assert is the "final solution." Thats not what this is. I for one would NOT send my medical staffs into harms way unless there was a clear reason to do so, that by doing so it would change the outcomes, and only on a volunteer status. Look up "Devil in the Freezer" and the accounts of the 1960-1970's accounts of doctors refusing to enter smallpox wards. They could not change the outcomes and one out of every ten people who got it survived. The doctors? All but three died. Again, can it change the outcome to try to treat both? Does it make anything but belief system sense to send them in. No. Might it change the outcome to treat one by taking from another? Maybe.
The real heroes will volunteer but this does turn it into a military situation. Would those docs and nurses come out of it alive? Maybe the 65 year old, likely not the 40 year old nurse, the 17 year old mom with a dependent very unlikely, the 90 year old God help me would just get the OD of morphine. I would then remove it and give it to one of the other three. Death sentence to the 90 year old? Look beyond what happens if they make it. Starve to death post of the pandemic.
I would though ask if a family member would volunteer to stay with them and not do the morphine and care for them. Once in, that family member would not come out statistically. By doing so it ensures once again that all criteria are met for all and they are treated. But are we talking about just ventilators?
You also have to consider that food production in the US at least if it happens going out of winter into spring it will drop to nearly zero. So a full season before the next harvest. You miss in August, you miss until the next August. That means that even if you prepped up, you likely are not sitting on a years worth of food. So in fact, we are looking at nearly 2 years of no food. As we are the breadbasket for many parts of the world, this has farther reaching impacts on more than just us. This is of course the worst case scenario with a high path virus running thru us like herpes at a frat party. We might get a slow onset. We should be so lucky.
You LL represent what will be considered to be an old school of thought and the Catechism is important. It is what will be put back into place post of this. We will be involved a huge war post of this as many areas will be ripe for the taking. Old scores will be settled and likely at the head of a religious leader. In the same breath, that war might also be of our choosing to take those resource laden areas. But all of this is intermingled and goes back to the one thing that starts us all spinning out of our orbits...pandemic with no vaccine. Prepare, prepare, prepare. Revere wont prepare with the idea being that he is too old. Our government might screw up his plans too by putting him into the fray and forcing him to perform as a doctor as volunteer or as forced labor. Yes, forced labor and thats where this gets into Nazi ways of thinking. Euthanizations, totalitarianism and "selection" for survival. I can just about bet you that if it goes beyond 10% that we will see "you work, you eat."
Best way to ensure that it never happens is to grab your neighbors and make them read as I do by emails all of the daily news on bird bug. Thats what really got them moving here and of course telling the neighborhood busybody. It will create pockets of humanity that will survive. They will be the "smartest and the fittest" to take over control of the earth.
LL-Events will change for a time how and what we do, but even after the Black Death it returned to a belief based system. It will again. The US and other countries might not survive as named entities but society will simply begin again. If I am there I would move quickly to reestablish it as the US. It might not be possible, but the thoughts that you and I hold dear will come first in that new society eventually.
Posted by: M. Randolph Kruger | May 9, 2008 1:01 PM
My Dear Revere,
I am not hiding behind my Catechism. I am right out front with it, pages open, trying to show you a different way of thinking about the problem you posted today. You would not know what the Catechism has said over and over, that everyone is equal in the sight of God (not society). Society is a human invention and is imperfect. We are called to help each other. You do this and I do this as best we can.
MRK, the patients HAVE to make these decisions. There is no other way for us to trust Revere, or you, or the other health care workers and military who might work under you. If citizens find out that you are thinking this way there will be anarchy. We HAVE to have a say in what happens to us. Each human has dignity and worth beyond their income, marital status, number of children to care for, age, occupation, and on and on.
Please, no more charts and discussions about humans being expendable. Revere, I have re-read all of the above and I cannot see anywhere that you disagree with the exercise as written. In other words, you did not say, "This is crap!" like you do on so many other posts.
It hurts me to see you and MRK thinking this way, because I really like you both.
Be Good.
Love,
Library Lady
P.S. Dear Paiwan, Thank you. I needed a hug.
Posted by: Library Lady | May 9, 2008 7:14 PM
revere I believe the Church teaches we are all equal before God, not that we are all equal in society.
MRK - after the Black Death the Church was very much weakened as an institution both spiritually and politically. The Church never regained its political power and in fact lost it with the Reformation. So after the Black Death humanity might have returned to a belief system but not quite the same belief system.
Posted by: pauls lane | May 9, 2008 7:52 PM
I should say Western Europe might have retured to a belief system but not quite the same belief system.
A bit pretentious of me. Sorry.
Posted by: pauls lane | May 9, 2008 7:57 PM
pauls, LL:
That was exactly my point. Since we aren't all equal in society, to say we are all equal in the eyes of God is irrelevant unless you do something about what is going on in the world. Unless all you care about is what happens after you are dead. Since many of us are non-believers you might understand that isn't of any interest to us. To invoke that is to hide behind the catechism as a way to evade the reality of the here and now.
Posted by: revere |