Rationing Patient Care in a Pandemic

Physicians in general are not trained to think this way, but may be forced to do so in the very near future.

During the early part of this month, the U.S. has been averaging nearly 200,000 new cases each day, a 15-percent increase from the average two weeks prior. Whether this has been caused by the lack of precaution compliance around the holidays, the new surge, or other factors, there is an unfortunate expectation that these statistics will continue to change for the worse.

How Did We Get to this Point?

Hospitals and healthcare systems are preparing for increased usage of hospital beds, especially ICU beds, as families gather for the holidays and activities move increasingly indoors, with the onset of colder weather across much of the country. Lockdowns and restrictions on gatherings are on the rise in an attempt to diminish this trend. The point that is being made in this writing is that there are considerations and decisions being made that might be considered radical and far-reaching. As an example, as outlined in a Dec. 7 article in Becker’s Hospital Review, the Governor of New Mexico will probably implement a measure that will allow hospitals to move toward “crisis standards” and ration care based on patients’ chances of survival. New Mexico has 1.8 hospital beds per 1,000 residents, one of the lowest ratios in the U.S. 

Such a policy would allow hospitals to implement a uniform guide for triaging care, as the availability of all beds, ICU beds, ventilators, and other hospital equipment may need to be rationed based on the acuity of each patient. This can and will have a significant effect on routine non-emergent and urgent care not being available to many people. That’s what is frightening.

Even though the COVID-19 statistics will change with every passing day, the principles proposed will not. We have entered a time in which drastic scenarios demand drastic measures. We all look forward to the time when we can look back on these challenging times as a unique response to a fairly unique medical emergency.

This type of rationing suggested is unprecedented for hospitals, but it is not uncommon in the military and disaster scenarios. As the chairman of our hospital’s Disaster Committee, I remember utilizing this process back in 1983, when there was a gas explosion in a pizzeria that demolished the building and took many lives, also resulting in multiple injuries. We set up a triage area and were prepared to ration care based on those disaster standards that will be detailed below.

Physicians may have a hard time making these rationing decisions, because we feel obligated, and appropriately so, to save every salvageable life, according to our Hippocratic Oath. It is often said that the exact phrase “first, do no harm” (Latin: Primum non nocere) is a part of the original Hippocratic Oath. Although the phrase does not appear in the 245 A.D. version of the oath, similar intentions are vowed by, “I will abstain from all intentional wrongdoing and harm.” The phrase primum non nocere is believed to date from the 17th century.

In addition to the rise in COVID-19 cases, there have been profound effects on hospitals and healthcare systems during this past year. Some of those effects are the following:

• Shrinking volumes
• Profit margins falling as expenses rise
• Flattening gross operating revenue
  • Decline in outpatient visits
  • Decline in emergency room visits
  • Suspension of elective surgeries
  • Let’s face it, patients are afraid of contracting the virus in hospital settings

Military Mass Casualty Rationing Care Protocols

The principles or goals for rationing care in the military/combat world can be summarized here as follows:

• Accomplish the greatest good for the greatest number of casualties
• Employ the most efficient use of available resources
• Return personnel to duty as soon as possible

There are distinct categories, designated by color:

Green

• These are simply the walking wounded, and require very minimal care

Yellow

• These patients are more seriously injured and may eventually need intervention, but it can be delayed without danger to life or limb, and will suffice with medical treatment for the time being, as they are hemodynamically stable

Red

• These patients require immediate lifesaving intervention. They need to be recognized as such quickly, as if there is a delay, they may die

Black

• These patients have a survival that would be highly unlikely, and comfort measures, including pain medication, are typically the extent of their treatment

Non-Military Mass Casualty Care Rationing

A mass casualty incident (often shortened to MCI, and sometimes called a multiple-casualty incident or multiple-casualty situation) describes an incident within the United States in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties. We typically associate this response with natural disasters such as earthquakes or events such as massive explosions, fires, etc., but not what we see now, with a pandemic. This is what we saw months ago and seem to be experiencing again, but very possibly in differing quantities.

Pre-hospital crews are well-trained for this type of rationing, and they essentially use the same protocol for triaging as in the military. Civilian physicians in general are not trained to think this way, but may be forced to do so in the very near future.

Our world is irreversibly changing, and we need to adjust for survival.