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Tuesday, September 8, 2009

Few Doctors Trained For Disasters

Posted By on Tue, Sep 8, 2009 at 7:38 PM

When journalist Sheri Fink began researching for her article, “Strained by Katrina, A Hospital Faced Deadly Choices,” regarding the patient deaths at Memorial Medical Center following the levee failures, she looked closely at various methods employed by healthcare workers during disasters, when the number of patients are significantly higher than limited resources. Fink, who is also a physician and has worked in disaster areas and war zones, discovered there isn't much in terms of medical research available on patient treatment during calamities, nor is there a set standard of protocols for health workers to use in catastrophe situations. And there are few doctors who have been trained to treat patients in a disaster.

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Investigative journalist and physician Sheri Fink

Due to Hurricane Katrina and 9/11, Fink says hospitals and health systems are now trying to plan and prepare for possible disasters, but many of the nation's hospitals are still vulnerable. In some American cities and states, healthcare officials and legislators are now establishing procedures to be used in the event of the next catastrophe such as an influenza pandemic, and Fink worries that the public hasn't been engaged enough in this process. In the following interview, Fink discusses why the incidents at Memorial Medical Center remain relevant today, especially in the context of medical disaster planning.

You wrote that Pou and others “cite” the tragedy as justification for changing the standards of care during crises. What standards of care is she advocating for?

Some physicians and disaster planners are trying to create new policies or even laws that would say that during a disaster, certain standards of care that we’re used to in American medicine could or would be altered. For example, if this autumn we have a very severe influenza pandemic, there may be hospitals that cannot handle all the patients who need intensive care unit treatment. There are people who want to implement policies that would answer in advance questions like who would get a share of limited resources, or would allow doctors, nurses and therapists to work in ways they don’t normally work. Some health professionals feel that setting up these policies in advance and getting the government to recognize them would be one way to help protect doctors, nurses and hospitals from being sued if they—through no fault of their own—aren’t able to provide the expected level of care for certain people in really bad situations when the need is overwhelming. Other health professionals caution that any such policies need to be developed with input from the public, based on the best possible evidence, and with an eye to fairness and effects on society, or else following the new policies could paradoxically end up failing to contribute to the greater good of patients in a disaster, and also lead to a lot of mistrust between the medical community, patients and family members.

In your story, you write of Pou, “In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate (DNR) orders — an approach she and her colleagues used as conditions worsened after Katrina.” So now she’s advocating for this approach as a standard of care during disasters?

Dr. Pou did recently tell an audience of hospital administrators and State disaster response professionals that she believes informed consent is impossible during disasters and that there are times when doctors need to be able to evacuate the sickest last. She also told me she would like to see Do Not Resuscitate orders changed to say that such patients may have a low priority for being evacuated if there is a disaster.

As a physician who has worked in disaster areas and war zones, in your opinion, are Pou’s arguments valid, regarding evacuating the sickest and the most severely injured patients last?

Dr. Pou and her colleagues were facing a very difficult challenge, that anybody who works in a disaster faces, which is how do you do the best for a population when you don’t have all the resources you need. It’s excruciating. These were not happy decisions that these health professionals had to make.

When I was researching the article, I looked at what evidence exists for various methods of doing triage, in essence of trying to do the best for a group of sick or injured patients in an emergency. What I discovered is that there isn’t much research. There isn’t one single protocol that everyone in America uses, and relatively few doctors are trained in any method of disaster triage.

As you’d expect, most protocols call for the sickest patients to be treated or evacuated immediately, while those with minor injuries or illnesses wait. Some protocols let the healthcare worker designate a group of people who might not be able to be saved, either because it looks like they’re about to die, or because to treat them at that moment would require so many resources that it would take too much away from the care of other patients—so you might risk having several other people die while you were taking care of one of those patients. This group of patients would then be treated or evacuated after other severely sick or injured patients who seem to have a better chance of surviving. The problem is that sometimes it’s hard to predict who’s hopelessly sick and who is extremely sick but savable.

As for the idea of changing DNR orders, right now a DNR means one thing. It means, “don’t restart the patient’s heart if it stops, don’t restart the breathing if it stops.” Basically, “don’t give the patient CPR if he or she is dying.” I’ve spoken with a number of physicians who say they would be concerned that if the definition of DNR was changed to include, “don’t evacuate this patient until everybody else has been evacuated,” fewer people would request DNR orders for either themselves or a loved one.

Weren’t the doctors at Memorial Medical Center using an incorrect definition of Do Not Resuscitate?

Again, the doctors at Memorial Medical Center were put in the horrible position of having to decide which patients, visitors and staff members would get access to evacuation helicopters and boats first and who would have to wait. Their decisions took on the importance they did because of the utter breakdown in city communications and the chaos of the evacuation efforts across the city. One of the doctors told me he decided to prioritize the DNR patients at Memorial last for evacuation because they had terminal or irreversible conditions, and therefore, would have “the least to lose.” But actually not all patients with DNR orders are terminally or irreversibly ill. The definition of DNR in Louisiana merely amounts to: do not restart a patient’s heart if it stops; do not restart a patient’s breathing.

You posed some difficult questions in your article, including: “Which patients should get a share of limited resources, and who decides? What does it mean to do the greatest good for the greatest number, and does that end justify all means? Where is the line between appropriate comfort care and mercy killing?” “How, if at all, should doctors and nurses be held accountable for their actions in the most desperate of circumstances, especially when their government fails them?” After writing this article how do you answer those questions?

These are tough questions, and I hope after reading the article, each reader will be better prepared to make his or her own decisions. In writing this article, I am trying to inform the discussion.

Understanding what happened at Memorial Medical Center during Katrina is important because the events have been part of the basis for new laws and policies. For example, many health workers are concerned about being sued for their actions in a disaster when they literally can’t provide for everybody in the way they normally would. Dr. Pou promoted several Louisiana laws (e.g. Act 538: “Immunity for Evacuation or Treatment,” signed into law by Gov. Jindal 6/30/08) that help protect health professionals against these types of lawsuits. Some experts argue that the laws should go further and, for example, that health institutions like hospitals merit a similar kind of protection during a disaster. Of course, there are also people who argue that it’s important to protect the right of patients or their families to bring action if there’s been true wrongdoing.

What lessons have been learned from this tragedy, and are there others that aren’t getting across to government officials or the public?

I was down in New Orleans when Hurricane Gustav hit last year, and I think New Orleans has learned a lot more than the rest of America has. A lot of the hospitals had done things like improving backup generators systems; they had closed some hospitals in advance; and quite a number of very ill patients were evacuated out of town before the hurricane hit. Unfortunately, some of these patients were transferred to Baton Rouge, which ended up taking a harder hit from Gustav, and some of those patients had to be transferred a second time when Baton Rouge hospitals lost power. That just goes to show you never have perfect knowledge of what is going to happen, and real tough choices get made.

There are persistent vulnerabilities in other hospitals around America. For example, in many other hospitals in flood plains, parts of their backup power systems are below the flood level. In many areas, auxiliary power systems aren’t set up to operate air conditioning systems, which becomes a huge problem in a hot climate for modern hospitals that are sealed in design. Many hospitals operate on very thin profit margins and there aren’t, as far as I know, a lot of resources for them—say government grants—to reduce those vulnerabilities.

On the positive side, there has been a lot more focus on planning and preparedness in the years since 9/11, and the major hospital accrediting body, the Joint Commission, has changed its disaster standards since the time of Katrina, for example focusing on community preparedness and how hospitals fit into that. But even if a hospital fully follows those, they wouldn’t necessarily be able to handle a situation like Katrina. So I guess the bag is mixed. There is certainly a lot more recognition of the importance of preparedness, even on a larger scale, such as interoperable communications for first responders, governments and hospitals. However, there’s still a lot of vulnerability, particularly in places that haven’t been hit by disasters like New Orleans has.

You write how currently, “health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again.” Where is this happening? Why isn’t the public involved?

This is happening community by community. It’s happening, for instance, in my city, New York City. There is a draft protocol for how to use ventilators in an influenza pandemic, in a very severe one. This is an extremely well thought out protocol aimed at benefitting the population. It calls for some patients who are faring poorly to be taken off ventilators to make way for other patients who would be expected to benefit more from them. The problem is that much of the public is not aware of the details. What we saw with the Memorial case is that if patients and their family members don’t understand why resources are put toward certain patients and not others, then mistrust can grow up between family members and patients and health professionals. For example, at Memorial, doctors were quite certain it made sense to put patients with DNR orders last for evacuation, but when family members found out, they opposed that. Some tried to rescind those orders. So that’s just one example of why it’s important that the public at the very least be educated about what these decisions are, and, hopefully, be part of those decisions being made before a disaster ever occurs.

Why isn’t there enough scientific evidence?

Not enough research has been done looking the effects of different methods of splitting up limited resources in different kinds of emergencies. The good news is that there has recently been more interest in doing this challenging type of research.

Do any of the triage protocols call for palliative care, or more precisely, injecting drugs such as morphine and Versed into the sickest and least likely to survive?

It is entirely appropriate for doctors to treat patients for pain, anxiety or other symptoms in a disaster, whether or not more definitive types of treatment are possible for the moment. That’s a truly important point. None of the protocols—military or civilian—calls for intentionally hastening death.

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