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02/17/2017

BioethicsTV: Mass Casualties & Triage

by Craig Klugman, Ph.D.

Chicago Med (Season 2; Episode 14). Over the last few years I have been working in the area of crisis standards of care. In fact, just today I presented the conclusion of 3 years of work on an ethics white paper to the state of Illinois crisis standards of care task force leadership. Serendipitously, tonight’s episode of Chicago Med dealt with a limited mass casualty situation: A multiple car pile-up on a freeway brings a large number of patients to the hospital. However, there is a major snowstorm and there is no chance of additional personnel or supplies coming to the hospital. How do they deal? First, they moved all able-bodied patients in the ED to the waiting room. Second, they canceled all non-emergency surgeries and reassigned staff to the ED. Both are good moves and follow what most crisis guidelines to prepare for the influx of crisis patient.

One of the patients brought to the ED suffered third degree burns over 90% of his body when his car caught on fire. Dr. Latham declares the patient to be “black tag.” In a mass casualty incidence, triage comes into play to determine which patients to treat and in what order. There are those who seem okay, those who need treatment but can wait, those who need treatment quickly and have a good chance of survival, and those who require massive resources in their intervention and have a low likelihood of survival. Patients are sorted into these categories and given tags with the color of their group. The last group is “black tags” and in most cases, they are not given aggressive treatment. Black tag patients are brought to a quiet space, and provided comfort-care only.

Dr. Choi—remembering the soldiers he treated in the Middle East who never got to say goodbye to their families—wants to intubate the patient so that he can say goodbye to his family when they are able to get to the hospital. Normally a black tag patient would not be intubated, but this patient is. However, when the ED runs out of vents, they decide to remove the “terminal patients” from vents to support patients with a higher chance of survival, Choi refuses. The triage team overrules him. The Illinois ethics task force has thought about just this situation in creating our white paper and in constructing sample scenarios for statewide town hall meetings. Removing a ventilator from a patient with a low likelihood of survival to treat a patient with a high likelihood of survival is ethical when looked at from a justice standpoint as a fair distribution of limited resources, as well as through the eyes of public health principlism which looks at solidarity (reducing morbidity and mortality in a community) and efficacy (empirically supported; culturally, socially and politically feasible). The problem for this show, which is based in Chicago, and for the work of the task force, is that in Illinois removing a ventilator from a patient to give to another patient subjects a physician to liability and may open the practitioner to homicide charges. The ethically right thing to do puts a physician in jeopardy. Obviously legislative work is needed.

Still, Choi is unwilling to face the reality, so he decides to hand bag the patient—that is to manually squeeze air into the patient’s lungs until his wife can arrive. This could be many hours. One might say this is a Solomonic solution—the vent goes to the patient with a higher likelihood of survival and the first patient is maintained. Remember though, that this patient is going to die; even with extreme interventions, he will die. Plus, the ED is shorthanded. By Choi spending his time bagging this black tag patient, he is not helping other people in need. This comes to a head when Choi is needed to assist on another case and he refuses to leave. The patient makes the decision for him by grabbing Choi’s hand and giving him a soulful look that the viewer is to interpret as understanding and permission. Choi stops. The patient understood the hospital’s situation better than the doctor. This demonstrates one of the problems with mass casualty operations: Health care professionals need a great deal of education and training on how to function in these situations that differ so greatly from everyday practice.

In a second storyline, two cousins are pulled from a car in the wreck and both need 2 liters of O- blood. However, 2 liters are all that remain in the hospital and no more blood is forthcoming. The triage team debates and Dr. Latham says that clinical criteria need to lead: One child has a greater chance of survival than the other. They present the situation to a woman who is the mother of one boy and the aunt of the second. She is faced with the choice of sentencing her son or her sister’s son to death. The doctors offer their opinion that the nephew has the greater likelihood of survival. She says that she can’t possibly make this choice so the team decides to give the blood to the nephew. She is later chided by her husband and is hard on herself for not having fought harder for her son: “How can I face him when he finds out I didn’t fight for him?” The triage team and doctors emphasize to her that they made the choice, but she feels as if she betrayed her son. These impossible situations of deciding who lives and dies in very emotional and unclear circumstances are common in crisis care situations. One lesson from the largest modern American crisis incident (Hurricane Katrina in New Orleans) is that ethical decisions should not be made by a single individual, but rather by a small group trained to make them. This small group decision-making helps avoid one person from feeling totally responsible, and helps to moderate decisions made rashly, emotionally, or from exhaustion.

The staff and waiting room patients donate blood in order to find a compatible donor for the son. The process is slow because, we are told, the FDA requires all of the blood to be screened for communicable disease in the lab. When the son begins to crash and all stop-gap measures have been exhausted, Dr. Choi declares that he is O- and is regularly tested for these diseases by the Navy. Administration Goodwin agrees to violate the FDA rules and allow Choi’s blood to be directly transfused into the child. Although violating federal regulations, ethically this is reasonable choice—the benefit of saving the boy’s life outweighs the risk of a transmittable disease from Choi. Both boys are saved. Having staff who are responding to the crisis donate blood is not unusual, but their efforts are so needed that they should not donate if the action would compromise their ability to complete their functions.

By the end of the hour, the snow has let up and supplies are coming in. Staff are coming in. The crisis passes quickly. When developing responses and decision-making for crisis situations, one cannot assume that the crisis will be limited to a single hospital or even a single city. One can also not assume that the crisis will last a short time; it may last days, weeks, months or longer. Whether this staff could have sustained caring for patients in this way, for a longer period of time is in doubt: They used up all of their supplies as needed rather than thinking that they may get nothing else for weeks. And they worked all of their staff around the clock: What if no more staff were available for weeks? Thus, planning for a short term, limited crisis is in many ways simpler and less complicated than the crisis that covers a large region or an entire nation for a long period of time.

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