Vintage Big Med – D Newman | Ethics and Triage: A Nasty Scenario – Dec 2006

Ethics and Triage: A Nasty Scenario by David A H Newman

[Dec 12 06]

If only the rich could pay the poor to die instead of them, Then the poor would make a very good living. (Ancient Yiddish Joke)

A Flu Pandemic has begun. The hospitals are crowded. Staff is overworked: many have come down with the flu – one sort or another. The ‘normal’ flu doesn’t vanish just because of a pandemic. Even before the flu’s came, the usual ailments and conditions have just about taxed the limits of the system’s capacities; and the pandemic is a long way from peaking.

It’s bitter cold outside. People, old and young, are dragging themselves, or loved ones, or neighbors, to Family Practice offices, and to hospital Emergencies. Taxis refuse to take them – this stuff is dangerous! – public transit is barely operating: drivers are sick, or calling in sick and maintenance is non-existent. Who would want to ride the bus and breathe in undiluted virus? So people drive, or walk, or stumble, or are wheeled to their local version of purgatory.The paramedics and first-response people, like many doctors, nurses, and orderlies, have, in some cases, literally worked themselves to death. Others are genuinely seriously ill at home. In any case, hospitals won’t allow ambulances to unload: the situation has become too serious for ambulances: they are irrelevant against the scale of the emergency. This puts the First Responders in a Catch-22 bind: what are they supposed to do with the living, the dying, and the corpses? The fire-paramedic and police stations have become hospital wards, and mortuaries.

Family Practice offices are crowded; there weren’t enough to begin with, and now more and more are closed – the doctors and nurse practitioners have strived valiantly for weeks, working round the clock; but many have succumbed to the illness and are too sick to carry on. Some have already died. The sufferers keep arriving – and are told to go to “Emergency.”

The Emergency is so crowded it’s impossible to move: too few staff, too few Triage Officers’, too many forms and too few to fill them in. More tests needed? – long waits; supplies dwindling.

It’s not just in “Emergency” – the corridors are lined with sick and dying. The ‘lucky’ ones have beds; others are wrapped in blankets on the floor. The sound of coughing, hacking, groans rasps and rattles adds to the background. The place doesn’t smell- it reeks.

The only ones around to help are family and volunteers; but they too are a dying breed.
The kitchens have shut down. The Tim Hortons a few blocks away is the main source of hot soup and beverages.

The chaos extends outside the hospital. Every few minutes a car pulls up to the curb and someone terribly sick is pushed out or loaded into a wheelchair; and then abandoned. People are desperate. People don’t want to watch loved ones die. They want to get them to where help is available, but there is no more room at the inn.

There’s no room and the authorities have instituted a quarantine. There are fierce barriers to admission – -even to approaching the hospital. Police and Military, guns evident, are supposed to enforce the ban, but they didn’t sign up to turn away the sick and dying to perish of exposure on the street; at the very gates of supposed aid and comfort. They try to keep a semblance of order: lining up the wheelchairs – many with their frozen dead occupants — in neat rows. Some are in tears; none will ever be free again in their minds. This is not a job: this is hell.

Worse yet are the ones who have lost it, watching their loved ones going downhill with no access and no hope. Some arrive in a rage, screaming threats, demanding access — armed and very dangerous. Are they to be gunned down on the spot? Is there time, patience, and skills to talk them into calm? Can it be done?

Pharmacists (legitimately part of the Front Line) are also besieged as people line up to request, demand, and plead for something – anything – to help their loved ones. They are worked off their feet doing what they can, but they are hampered by government irresolution in deciding what powers pharmacists should have. It would have been an enormous assist to everyone if government had given them emergency powers to prescribe and dispense on the spot; and if government had also picked up the tab for all pandemic-related drugs. Some go ahead and prescribe anyhow; but supplies are dwindling.

As in all pandemics, even in our supposedly enlightened age, the miracle-workers with trumped up testimonials from the crowned heads of Europe, quacks with nostrums, and ‘end is nigh’ callers to repentance all have their moments of glory — and riches: its remarkable how expensive the goods and services are which these selfless folks ‘freely’ offer. Human nature is eternal in its often excellent ways — and in its folly.

At the other end of the chain, the mortality rate among those admitted to hospital is much higher than predicted: in part because the virus is especially virulent; in part because the system has broken down; and in part because all attempts to establish interior quarantines (cohorting) have been defeated by increasingly over-worked staff, and a shared air-circulation system. The usual crop of hospital-specific infections is proliferating.

There are no more resources left and little chance of getting any anytime soon: suppliers and distributors are at their limits and manufacturers are forced to ration dwindling output.

The hospital mortuaries are full. Autopsies will have to come later — much later; if at all. Meanwhile, bodies, neatly toe-tagged, are stacked like firewood in a more-or-less exterior courtyard. The weather is cold enough: they will wait there quietly. Anyhow, morticians have closed up shop for the duration. Those with the courage and strength retrieve their dead and go to join the long lines at the crematoria.

The death rate is also high among the thousands cleared out from the hospitals to make room for the pandemic flu sufferers: sent home, or to long-term care facilities, or otherwise moved out of sight and out of mind. They live, or die, or will be debilitated for the rest of their lives.

Scalpers are thriving: they don’t mind the cold as they wait patiently on the streets around the hospitals for new arrivals. The going rate for an admission for one is $25,000 (up front in cash). There are enough takers to make the middle-men wealthy, and to handsomely reward the good folks inside who are ready to pocket the bribes. Being a triage officer, or a key person in the paperwork chain, is a license to print money.

Anyhow, a disproportionate number of highly placed bureaucrats and politicians, and their friends, family, and lovers, seem to get rooms and beds and ventilators, and the world’s gone mad around you, so why not get some benefit? After all, you’re one of the few still on the job, taking the big risk with your life, so why not?

There are still some who are trying hard to stay ethical – to do the right thing because it’s in their nature. But it is hard; because so much has gone wrong and it’s not a matter of pointing blame. It doesn’t mean the Plan was flawed. It doesn’t mean that society, and the system, were at fault. There may have been flaws and errors, but that’s only because we are human and frail and mortal and come with the full set of emotions. This emergency is overwhelming – like a millennium storm it has surged through our cities and buried our best plans and hopes in an abyss of tragedy. (It happens).

PostScript

Worst Case scenarios seldom happen: by definition, they are unlikely. But when they do happen, they tend to be much worse than anyone could imagine.

I wrote this scenario to try to answer a lurking question: are Ethics and Triage at all compatible? Worst Case scenarios test the limits and when I think about what could happen at the limit, I don’t at this point see any room for Ethics (or Morality) in a Triage situation — unless, and this may be key – the Ethics are built in to the Triage Design.

However, stating a set of lofty humanitarian principles up front is not the same as ensuring they are followed in the field. With the best will in the world, Triage has to be based on other principles – such as making the most effective use of limited resources, and the greatest good for the most.

Fairness is a worthy test of a system – in the sense that Triage and what follows must not be arbitrary, and should be equitable (without fear or favor). In the main, that is feasible – though there will always be queue-jumpers. But Fairness has little to do with Compassion.

Hard choices — sometimes the trade-offs are wrenching, at best.

I’ll try to work some more with these issues. Your views, in the light of your own experiences, would help.

Be well.

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