Posted on by Californiacontrarian

World War III ? . . . Triage


No, this is not about an actual military conflict, but rather about the worldwide battle against Covid, and the ethics of triage. In major battlefield situations the wounded must be triaged. Decisions have to be made concerning the ultimate viability of an individual and the necessary allocation of resources, especially time. 

For example, consider that severely wounded soldier, ‘A,’ needed urgent surgery and this surgery would tie up two surgeons each for four hours with the estimated chance for survival of 20% with surgery and 0% without immediate surgery. Compare that to the wounded soldiers, B,C,D, and E in the same medical tent who also needed surgery. If their surgery was done expeditiously by a single surgeon, their individual chances of survival would be 75% with surgery, and 25% without surgery. Who should get the immediate surgery(s)? This decision making process is called ‘triage,’ or a determination of priority in order to increase the number of survivors. 

In this day, fortunately triage decisions are needed only very rarely. However, with this Covid pandemic, this has already started to change. The limited resource with Covid does not involve the surgeon’s allocation of time, but rather the allocation of other resources, namely the availability of ICU beds, and the number of ICU nurses needed to adequately care for these very ill patients. In some places there are no further available ICU beds and ICU nurses taking care of these patients are already stretched too thin – taking care of up to three critically ill patients, instead of one or two.

Methodist Hospital in L.A. County has already formed a committee whose responsibility is to triage patients as to the priority of ICU bed allocation. On this committee there is a physician, a community member, a bioethicist specialist, and a spiritual care provider. One  of the major issues with Covid ICU care is the length of time that these individuals can often need to remain in the ICU . . . sometimes upwards to two weeks. As a practical matter this sort of committee needs to consider the factor of limited turnover of these ICU beds when making a determination as to which Covid patients then get the very limited number of available ICU beds.

If there is only one available  ICU bed, do you give it to a critically ill elderly Covid patient with Alzheimer’s and an O2 sat of 80%,  (a normal O2 sat is >93%), or to a 65 year old with an O2 sat of 90%? To many, this triage decision would be easy, but most of these Covid triage decisions will be a lot tougher, as once an individual is in ICU on a ventilator, it will very difficult to to take him/her off the ventilator.

About a week ago a medical colleague and I sent a letter to the editor concerning the prudence of having an Advanced Medical Directive. Those who do not want to be on a ventilator because of Covid can avoid the ventilator by having an Advanced Medical Directive, and I would recommend that everyone have one. It would be a tragedy if an ICU bed was filled by someone who did not want to be there, while someone else died because no ICU bed was available.

FYI: this letter was not deemed important enough to publish!

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