Jan 31, 2002 (CIDRAP News) A bioterrorist attack that caused mass casualties would very likely lead to shortages of medical resources, so preparedness planning must include a careful look at how to ration those resources fairly, an emergency medicine specialist told a conference audience in Minneapolis this week.
"We have to consider triage, we have to consider prioritization, or rationing, if you will," said Nicki T. Pesik, MD. "Essentially we have to anticipate that bioterrorism may very well result in a resource-scarce situation. Patients you can normally treat, you just may not have the resources."
Pesik, an assistant professor of emergency medicine at Emory University in Atlanta and a visiting scientist with the Centers for Disease Control and Prevention, suggested that rationing in some situations could be done by lottery. She also asserted that proper resource use in a bioterroist attack could require treating healthcare providers first. She made the remarks at a symposium on "The Law and Ethics of Bioterrorism," held Jan 29 at the University of Minnesota.
A bioterrorist attack could stress the healthcare system for days or weeks, sending large numbers of sick and "worried well" people to hospital emergency departments, Pesik said. As examples of the potential drain on medical resources, she noted that treatment for anthrax exposure can require a 100-day regimen of antibiotics, while a patent with botulism might have to be on a ventilator for 4 to 6 weeks.
Further, if people potentially at risk fear a shortage of medical resources, they may seek treatment sooner, she said. And on top of that, "We have a critical shortage of nurses, we have decreasing hospital beds, and I would say our surge capacity is minimal at best." As a result, the number of people who could be managed in an "all hell breaks loose" scenario will be very limited, she predicted.
In such a setting, triage will be unavoidable, in Pesik's view. "The objective of triage is to use the available resources as effectively and efficiently as possible," she said. In place of the usual goal of doing everything possible for each patient, "Modern triage uses the utilitarian principle of doing the greatest good for the greatest number. . . . I believe the resources need to be used for the patients that are going to have the best outcomes."
Providers will need objective criteria for deciding who will get treated and who won't, Pesik said. "Essentially what I'm saying is that we have to develop exclusionary criteria. What's the minimal basis of survival, based on the morbidity and mortality of certain diseases, so that we know how much use of resources is reasonable, given the situation?"
She said she is one of several people who are studying potential exclusionary criteria. One possible example, she said, is cardiac arrest, because advanced cardiac life support is very resource-intensive and the prognosis for affected patients is poor. But she also noted that patients excluded from full treatment should still receive "compassionate care" to reduce suffering.
Lotteries may have a place in the rationing of care when the patients involved "have no major disparities in medical utility," that is, when all have the same apparent prognosis or level of risk, Pesik said. An example might be a large group of patients who are all asymptomatic and awaiting antibiotic treatment or vaccination. Lotteries "allow people to be treated as absolute equals," she said. "They're random, and they surely provide a lot less stress for individuals who are involved in triage, because you're picking numbers out of a hat."
However, she added, lotteries are not problem-free, because "some people do not enter the lottery at the same point as others." People who don't speak English or people who don't have transportation to the hospital might not have an equal chance.
Protection of healthcare providers is another principle of the efficient use of medical resources in a bioterrorism scenario, Pesik asserted. To ensure that they will come to work, "Physicians and nurses must be afforded some sort of protection against falling ill themselves. . . . I believe that they should have priority for prophylaxis, personal protective equipment, or treatment, because it's critical to preserve this resource." Such an approach says nothing about the "social worth" of healthcare providers but simply recognizes the need for their skills, she said.
Pesik stressed that any rationing plan should be based on objective criteria that are developed in advance and open to public review. Individual physicians will not be able to make such decisions on their own, especially in the heat of an emergency, she asserted. "We need the support of our legislatures, our hospital legal staff, our ethicists, to give us the basis and the guidelines for triage and protocols in this type of situation." Moreover, she said, "I truly believe the public is going to have a great deal of mistrust in any kind of rationing or triage unless we explain the rationale behind it and why we believe it's going to occur."
Rationing crtieria should be flexible for use in different kinds of emergencies and should undergo peer review, the speaker said. In addition, the allocation and treatment functions should be separate: the person who conducts triage or determines which patients get treatment should not also be treating those patients.
Pesik concluded that, if triage is practiced well, "We can save lives by using resources the best way we know. And it can be a tool to manage a seemingly overwhelming situation."
A panel that followed Pesik's presentation offered a variety of comments. More than one commentator emphasized the importance of maintaining the public's trust and good public communication.
John Hick, MD, said it is essential to have statutes protecting physicians from legal liability for decisions they might have to make in a bioterrorism event. "The immunity and indemnity clauses for physicians that are applying these rules have to be in place or you won't have a single healthcare practitioner who's willing to go out on that limb to follow those principles," he said. Hick is a faculty physician at Hennepin County Medical Center and an associate professor of emergency medicine at the University of Minnesota.
Susan Craddock, PhD, said history teaches that no matter what public health laws are on the books, medical care during epidemics is usually marked by discrimination. "In history there is virtually no chapter of responses to infectious diseases where there has not been some degree of differential application or targeting of particular populations," she said.
Craddock, an assistant professor in the University of Minnesota Department of Women's Studies and Institute for Global Studies, said there is little to suggest that things would be different now, especially in the political landscape created by the Sep 11 attacks. In a public health crisis, the combination of public fear and public health laws with vague wording would probably create "the potential for misapplications of the law, no matter what the letter of the law might be."
As a remedy, she suggested building in some grass-roots checks and balances to govern the application of public health laws in emergencies. Such checks and balances, she said, might include citizens' councils representing all groups, or panels of judges and physicians to review decisions about isolation and quarantine of patients and appropriation of private properties. "We need this so that we can learn from history and have a departure from previous instances of responding to public health emergencies," she said.
Related story from Jan 29 symposium, State health emergency laws aren't ready for bioterrorism, says expert