TRIAGE

Posted in Uncategorized on January 19th, 2010 by Ed

I need you to set aside about 30-40 minutes and read this. When I first saw it back in August I felt like I'd been punched in the stomach by the end. A second reading months later, inspired by the chaos in Haiti, had much the same effect. If you're in a hurry it is a lengthy New York Times piece about Memorial Hospital in New Orleans in the wake of Hurricane Katrina. It raises ethical issues complex enough to make abortion and the death penalty look like kindergarten topics in comparison.

Several hospital employees, particularly one doctor named Anna Pou, were charged with second-degree murder (and conspiracy to) for allegedly causing the death of a number of non-ambulatory patients with morphine and other sedatives after everyone involved had been trapped in the hospital for four days. A grand jury chosen from a community sympathetic to the doctor ("They did what they had to do! It was a tough situation!") refused to indict, and as the story stands it appears unlikely that any of them will be convicted of a crime. The reality of what happened appears to be a lot more troubling.

Triage is a pretty basic concept in emergency medicine and it originated on Europe's battlefields more than two centuries ago. It is necessary whenever the means to provide care are overwhelmed by the number of people who need it. We see that problem today in Haiti and four years ago in New Orleans. It seems like a very basic concept – do the most good with the limited resources available. But what does that mean? Does it mean treating the most severely injured, who may have little hope for survival? Treating the greatest possible number of patients? The ones with the best chance to survive? (and in whose judgment?) The youngest? The first to arrive? It's not so simple.

After the Hurricane, Memorial Hospital was without electricity or water, filling with backed-up sewage, and in a neighborhood in which gunshots were ringing out with alarming frequency. With dwindling resources (and the need to manually respire patients on ventilators) the doctors did an unorganized triage – there was no official policy in place – to make everything last until the government rescue that they soon learned was not coming. Evacuating patients to a helipad required carrying them down 7 or 8 flights of stairs in the dark, passing them through a 3'x3' hole in a concrete wall, and then carrying them up 5 more to the roof of the parking deck. This presented an obvious challenge to a staff – many of whom were older people who could add little to the manual labor effort – working on no sleep in appalling conditions. Compounding the problem was the apparent hopelessness of several of the patients; it is not hard to see how a 92 year old cancer patient with less than a week to live would seem like a wasted effort under such circumstances.

What resulted was a decision by a few doctors, given that no one seemed to be in charge, to euthanize several patients who were either nearly dead or simply too large to move. In one case that directly led to the second-degree murder charge, an otherwise healthy 350 pound patient who could not walk was euthanized for no reason other than that the doctors did not think he could be moved. Not all of the physicians agreed with these actions; several protested and others left rather than be involved.

That is the best I can do for a brief summary. Two things.

It is easy for us to revel in hindsight bias – we know that they were rescued after the fourth day – and make judgments based on information unavailable to the participants at the time. It's also easy to neglect the context. Before you come to a decision about the morality of their actions, close up the windows, turn the heat up to 90, and stay awake for three days manually pumping a ventilator bag, running from floor to floor in the dark, and caring for 100 dying people. To say that the doctors and nurses involved were not of a mindset to make good decisions is an understatement, especially in light of the paucity of information and outside help coming in.

Then again, their argument falls flat on my ears. It is essentially this: The hospital was being evacuated after several days in horrendous conditions. We could not leave these patients and we could not feasibly move them. What else could we do? It is easy for me to say, not having been present, but my answer is simple: suck it up. That's what you do. You have a moral obligation to provide health care to people regardless of the circumstances. If you have to stand there and manually ventilate people for days on end, do it. If it takes 15 people a full day to get a 350 pound man down the stairs in the dark, so be it. Spend that time suffering and thinking of the six-figure book deal and White House photo op you'll get for telling your heroic story.

The final issue, and the one most commonly ignored, is the prevalence of this kind of "passive euthanasia" in palliative care. All of the opiates they pump into terminal and elderly patients when they are near death…come on. Who is naive enough to see that as anything but what it really is? It is ostensibly about patient comfort, and to some extent it is. But it is really about convenience – about getting on with the inevitable so time and resources can be devoted to patients with some chance to survive. Even in non-emergency situations this mentality prevails. And who can blame medical professionals for that? The staff of Memorial Hospital were right to wonder why in the hell the hospital had a floor full of people in their nineties hooked up to ventilators and heart-lung machines. That is, to all but the bleedingest of hearts, a complete waste.

We comfort ourselves with advanced care directives, living wills, powers of attorney, and codes of medical ethics, believing strongly that these things will govern our end-of-life decisions. And they do, except when reality intervenes and removes us from the world in which resources are limited only by what we and our insurer will bear financially. When the capacity to provide care becomes a zero-sum game it is only natural that "turkeys" with no long-term prospects for survival will go to the bottom of the priority list. But whether triage decisions should account for doctors' convenience or their impressions, made under duress, of what is feasible is a much more troubling question.