Matthew Wynia, University of Colorado Anschutz Medical Campus for the conversation
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With the Omicron variant bringing with it a new wave of uncertainty and fear, I can’t help looking back to March 2020 when US healthcare professionals watched in horror as COVID-19 flooded New York City.
Hospitals were overflowing with sick and dying patients, and ventilators and personal protective equipment were in short supply. Patients sat in ambulances and hallways for hours or days, waiting for a hospital bed to open. Some never made it to the ICU bed they needed.
I’m an Infectious Disease Specialist and Bioethicist at the University of Colorado’s Anschutz Medical Campus. I worked non-stop with a team from March to June 2020 to help my hospital and state prepare for the massive influx of COVID-19 cases that we expected to flood our healthcare system.
When health systems move towards crisis conditions, the first steps we take are to do everything we can to conserve and reallocate scarce resources. Hoping to continue to provide high quality care despite the lack of space, staff and staff, we do things like canceling elective operations, moving OR staff to inpatient units for care and placing patients in the emergency room when the hospital is full. These are known as “emergency measures”. While they can be uncomfortable for patients, we hope they will not harm them.
But when a crisis escalates so far that we cannot provide all the necessary services, we are forced to carry out a crisis. At this point in time, the care of some patients is admittedly no longer of high quality – sometimes even significantly less.
The supply under such an extreme scarcity of resources is referred to as “crisis supply”. Crisis standards can affect the use of any type of resource that is extremely scarce, from staff (like nurses or respiratory therapists) to staff (like ventilators or N95 masks) to space (like ICU beds).
And because the care that we can provide in times of crisis is far below normal quality for some patients, the process should be completely transparent and officially approved by the state.
What triage looks like in practice
In the spring of 2020, our plans assumed the worst – that we wouldn’t have enough ventilators for all the people who would die safely without them. So we focused on making ethical decisions about who should get the final ventilator, as if such a decision could be ethical.
But an important fact about triage is that you don’t choose to do it or not. If you don’t, you choose to act like things are normal and if you run out of ventilators the next person won’t get one. It’s still a form of triage.
Now imagine that all ventilators are off and the next person to need one is a young woman with a complication in giving birth to her baby.
We had to talk about that at the beginning of 2020. My colleagues and I didn’t sleep much.
To avoid this scenario, our hospital and many others have suggested using a scoring system that counts how many organs in a patient are failing and how severely. That’s because people with multiple organ failure are less likely to survive, which means they shouldn’t get the last ventilator if someone with better odds needs it too.
Fortunately, before we had to use this triage system this spring, we got a respite. Mask wearing, social distancing, and business closings went into effect and they worked. We turned the curve. In April 2020, Colorado had a few days with nearly 1,000 COVID-19 cases a day. But in early June our daily case rates were as low as 100. COVID-19 cases would spike again in August as these measures were naturally eased. And Colorado’s December 2020 surge was particularly sharp, but we dampened those subsequent waves with the same basic public health measures.
And then what felt like a miracle happened at the time: a safe and effective vaccine became available. At first it was only intended for people at the highest risk, but then it became available to all adults later in the spring of 2021. We had been in the pandemic for a little over a year and people felt that the end was in sight. So masks fell by the wayside.
Too early it turned out.
A haunting memory of 2020
Now, in December 2021, the hospitals here in Colorado are full to the brim again. Some have even been over 100% utilization recently, and a third of hospitals are expecting a shortage of intensive care beds in the final weeks of 2021. The best guess is that by the end of the month we will be overcrowded and intensive care beds running out nationwide.
But today some citizens have little patience to wear masks or to avoid large crowds. People who have been vaccinated don’t think it fair that they should be forced to cancel vacation plans when over 80% of people hospitalized for COVID-19 are unvaccinated. And those who are not vaccinated … well, many seem to believe that they are simply not at risk, which couldn’t be further from the truth.
As a result, hospitals in our state are faced with tri-like decisions on a daily basis.
The situation has changed on a number of important points. Today our hospitals have a lot of ventilators but not enough staff to operate them. Stress and burnout take their toll.
So those of us in the health system are reaching our limits again. And when the hospitals are full, we are forced to make triage decisions.
Ethical dilemmas and painful conversations
Our Colorado healthcare system now anticipates that by the end of December we could have 10% overcapacity in all of our hospitals on both intensive care units and regular floors. In early 2020, we looked for patients who would die with or without a ventilator to receive the ventilator; Today our planning team is looking for people who could survive outside of the intensive care unit. And because these patients need a bed on the main floor, we are also forced to find people on hospital beds who could be sent home earlier, even when it may not be as safe as we would like.
Take, for example, a patient with diabetic ketoacidosis, or DKA – extremely high blood sugar with fluid and electrolyte imbalances. DKA is dangerous and usually requires admission to an intensive care unit for a continuous infusion of insulin. But patients with DKA rarely need mechanical ventilation. Therefore, under crisis triage circumstances, we could move them to hospital beds to free up some intensive care beds for very sick COVID-19 patients.
But where should we get regular hospital rooms for these patients with DKA, which are also full? Here’s what we could do: People with severe infections from intravenous drug use are regularly hospitalized while on long antibiotic treatments. This is because injecting medication with an IV catheter at home could be very dangerous, even fatal. But under triage conditions, we could let them go home if they promise not to use their IV set to inject drugs.
Of course, this is not entirely harmless. It is clearly not the usual standard of care – but it is a crisis standard.
Worse than any of this is the anticipation of discussions with patients and their families. These are what I’m most afraid of, and we had to start practicing them again in the final weeks of 2021. How should we tell patients that the care they are receiving is not what we want because we are overwhelmed? This is what we might have to say:
“… too many sick people come to our hospital at once and we don’t have enough to care for all of the patients as we would like …
… at this point it makes sense to try the ventilator for 48 hours to see how your father’s lungs react, but then we need to reassess …
… I am sorry, your father is sicker than others in the hospital and the treatments did not work as we had hoped. “
When vaccines appeared on the horizon a year ago, we hoped we would never need these conversations. It’s hard to accept that they are needed again now.
matthew Wynia is Director of the Center for Bioethics and Humanities at the Anschutz Medical Campus of the University of Colorado.
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