Triage Decisions

The word "triage" entered more common usage thanks to the TV show M*A*S*H of course. It is the difficult decision making process of deciding in a medical setting who to treat first. In that decision making can be a whole range of problems and issues. It may not be generally known that the medical and other communities are in the process of making all kinds of plans for what could happen should we have a MAJOR flu pandemic. Earlier this last week was an article on Yahoo! News that brought the issue to a painful awareness:

CHICAGO - Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding who to let die.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

These groups making these plans include Homeland Security, the Centers for Disease Control and the Department of Health and Human Services. They hope that the guidelines they develop will be a blueprint for hospitals so that they can all be on the same page if or more likely when some major health disaster hits.

The idea is to try to make sure that scarce resources — including ventilators, medicine and doctors and nurses — are used in a uniform, objective way, task force members said.

Their recommendations appear in a report appearing Monday in the May edition of Chest, the medical journal of the American College of Chest Physicians.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report states.

Local hospitals are sto set up a triage team that will have almost godlike powers to decide who may or may not be given care that could save their life. Of course those least likely to get care are those who have a much higher risk of death or a slim-chance of long term survival.

But the recommendations get much more specific, and include:

_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.

Yes, you are right. This could turn into a nightmarish situation, which it will be regardless of these guidelines. But these add to the situation some serious legal not to mention ethical concerns.

Public health law expert Lawrence Gostin of Georgetown University called the report an important initiative but also "a political minefield and a legal minefield."

The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.

If followed to a tee, such rules could exclude care for the poorest, most disadvantaged citizens who suffer disproportionately from chronic disease and disability, he said. While health care rationing will be necessary in a mass disaster, "there are some real ethical concerns here."

Well, it is not surprising to see this, as disturbing as it may be. Is it a doomsday scenario? Is it another Y2K-type of apocalyptic view? Who knows? Your guess is as good as mine. We have often found out that the disaster we plan for is not the one that happens. Such is the nature of chance. Only the survivors will like the decisions being made. I hope that I am not in the position to make those kind of decisions or to help make them.

Here is the abstract for an article about this, part of a series in a professional magazine.

In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care. However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response. This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles. Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions. The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.

(CHEST 2008; 133:8S–17S) Definitive Care for the Critically Ill During A Disaster.