Sunday, March 02, 2008

California's Triage Plan In A Mass Casualty Event


# 1738



Today the Sacramento Bee has an eye opening article on the new California "surge capacity guidelines" released by the state Department of Public Health.  This 1900 page document outlines how healthcare might be doled out, and by whom, during a disaster such as a pandemic or other disaster.


First, a few snippets from the article, then some discussion.  By all means, read the entire article.



In a massive disaster, care will be scarce 

State guidelines lay framework for deliberately letting some people die.


By Dorsey Griffith -

Published 12:00 am PST Sunday, March 2, 2008
Story appeared in MAIN NEWS section, Page A1


Older, sicker patients could be allowed to die in order to save the lives of patients more likely to survive a massive disaster, bioterror attack or influenza pandemic in California.


It's not how nurses and doctors are accustomed to doing things, nor how Californians expect to be treated. But it is part of a sweeping statewide plan being praised for its breadth, even as it rankles providers who will have to carry it out.


The new "surge capacity guidelines" released by the state Department of Public Health, depict a post-disaster health care environment that looks and feels nothing like the system most Californians depend on.


It provides for scenarios in which patients could be herded into school gymnasiums for life-saving care or animal doctors could stitch up the human wounded and set their broken bones.


The 1,900-page document lays the practical – and ethical – groundwork for local and county health departments, hospitals, emergency responders and any able-bodied health care worker likely to be called upon in a catastrophe.


Striking in its specificity and its frank focus on the need to suspend or flex established laws and to ration health care, the plan is being hailed as a model for the rest of the nation.


"I don't know of any state that has taken it to this level of detail in outlining a surge plan for everyone who needs to respond to an emergency of this magnitude," said Jeff Levi, executive director of Trust for America's Health, a nonprofit group that has criticized the nation's emergency preparedness. "It's exactly the kind of dialogue that has to happen."


(continue reading . . .)


A Hat Tip to Kobie on the Wiki for posting the above article.




In a pandemic, or other mass casualty event, the demand for immediate medical attention will likely exceed the supply of trained healthcare workers, hospital beds, and medicines.   Difficult, almost impossible decisions, will have to be made by thousands of doctors and nurses as to which patients to help, and how many resources can be used to save them.


It's called triage, and it is done today on a small scale at the scene of car accidents and plane crashes, and even in the waiting room of hospital Emergency rooms.   Decisions are made, based on the severity of a person's injury, and their likelihood of survival, to determine who gets treated first.


It's never easy.  In fact, it is one of the hardest things a healthcare professional can be called on to do.


The State of California has put together guidelines to assist doctors and other healthcare workers make these horrendous decisions.  This plan also envisions allowing non-credentialed healthcare workers step in to help. 


It may make for harsh reading, but it is imperative that considered thought be given to these issues before a disaster strikes.  Doctors and other healthcare workers need to know what the rules will be during a disaster, and so does the public.




In a moderate pandemic it is expected that the demand for ventilators will far exceed the supply.   What then?   Who gets the benefit of what could be lifesaving therapy, and who doesn't?    What criteria is to be used for choosing?   


Do you remove someone already on a vent to make room for someone else, even if you know that by doing so, you are effectively killing the first patient?  


How long to you allow someone to remain on a vent without showing significant improvement before you remove them, and use it to try to save someone else?


If antivirals such as Oseltamivir (Tamiflu) are in short supply, who gets the drug?  And how many pills do you allocate to each patient. 


Early reports indicate that the 10-pill regimen originally envisioned by pandemic planners is too small, and that `double the dose for double the duration' may be needed for best results.    Do you restrict patients to 10 pills, or do you use the higher dose and treat far fewer patients?


Government planners only expect that 5% of pandemic flu victims can be treated in hospitals. The rest will probably need to be treated at home.  Who do you admit?  Who do you turn away? 


And the problems will extend to non-flu related medical conditions as well. 


If hospitals are overrun with flu victims, and the staff decimated by the virus, what are the odds that heart attack victims, or trauma cases, or emergency appendectomies will get prompt and efficient care?  Relatively routine, but lifesaving procedures, like dialysis may be compromised. 


The standard of care we are used to will likely change.




While I've not seen the California plan, from this article at least, it sounds like they are doing the prudent thing and addressing these issues now, while reasoned decisions can be made.


Hopefully other states will follow suit.   Health care professionals should not be asked to make these decisions on their own in the midst of a crisis. 

1 comment:

Anonymous said...

Grim and grimmer, reading the plan for here in CA is worse than reading SciFi, few if any punches pulled. The old book "War Day" comes to mind, the rules are nearly the same. "Manual termination" ring any bells?