TRIAGE

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.

Be Sociable, Share!

36 Responses to “TRIAGE”

  1. Crazy for Urban Planning Says:

    I only have had a brief experience with medicine, I took a First Responder course ten years ago, but those doctors were in a position with no good options. If they felt it was most appropriate to let go of some of the dead end patients I would trust their judgment. I can't agree with Ed on this one, no-one is making good decisions after 3 days with little rest or food.

    Interesting post, Don

  2. Overlady Says:

    I can't agree with you either, Ed. If the healthcare professionals who stayed at the hospital were morally and legally obligated to stay and "provide healthcare", what about the healthcare professionals who DIDn't stay? Aren't they legally guilty of murder too? For not coming to work that day? If the full staff off the hospital had come to work and stayed the whole time, things would have been MUCH better. Holding only a few people (the people who showed up and tried, at that) to impossible standards that no one else is held to is scapegoat hunting.

    If you are going to hold these doctors responsible for these people's deaths, then you better be ready to lynch Bush and Cheney for failing to live up to completely reasonable standards. Oh and Brownie, too.

    People sometimes make bad decisions, and if they are people of any decency whatever (and I think you can assume these people are), they fully feel the weight of their bad decisions. THey don't need to be thrown in prison for what seemed to be humane decisions at the time.

  3. Barbed Wire Says:

    I

  4. Barbed Wire Says:

    …don't know what that was?

    I’m about halfway into my 25th year as a firefighter in a mid-sized city and though we’ve trained extensively on triage, luckily, I’ve never had to do it. I say luckily because it is an ugly thing, especially in a civilian application, as it usually applies to traumatic, mass casualty events. On my end, it’s about sorting patients (Google START triage for insight) to get them to a hospital and as you said, broadly, doing the most good with limited resources.

    In practical application, your example of moving the 350 pound patient is what it boils down to – if 15 of us are going to spend all day moving him, then 14 other patients are losing their attendants and we’re likely kissing them goodbye. Without delving into the minutiae of everyone’s medical condition/history, that may be how triage plays out and who we devote our resources to, or it may be that we move, say half, of the ones that need bagged respirations and forsake the big guy. You call it. It ain’t about sucking it up; it’s about giving the most people the chance to survive.

    I have learned in 25 years of emergency services that it’s easy to second-guess similar kinds of situations when we have the luxury of time, reflection and full knowledge of the final outcome. That’s one reason I think after-action reviews are so valuable (for me and my guys) as an effort to understand what motivated our thoughts and actions and how we can recognize what worked, what didn’t and where we can improve next time.

    That said, without being in Memorial at the time, I can’t find it in my heart to condemn anyone, though like you hinted at the beginning, my heart breaks for all of them, living and dead. As for whose judgment to rely on, the criteria I operate with are a lot different than what these people faced but clearly, someone had to make the call; going back to my paramilitary experience, that should have been whoever was making the big bucks and was in charge. If they couldn’t or wouldn’t, sounds like it was time for a Caine mutiny.

    I don’t want to read the link right now, though I will eventually, having already seen other articles on the periphery of this fubarred situation, read the book Nine Lives and other recent stories and talked to firefighters who were there. Like Haiti now, it was an utterly deplorable situation with no good solutions, the ultimate damned if you do and damned if you don’t.

  5. waldo Says:

    Societal collapse quickly leads to pragmatism and expedience. Don't be old or weak or infirm when it comes.

  6. Misterben Says:

    As much as I'd like to think that doctors, nurses, and any other health care professionals would put their lives on the line to save mine, I guess I don't really expect them to, especially not in a situation like that. What's their incentive? Our society gives lip-service to ideals, but doesn't really reward dedication to them anymore. These doctors knew they were in a lose-lose situation. Yeah, if I had been a patient there, I would have been begging them to stay, but from this vantage point I can certainly understand why they got the hell out.

  7. flathead Says:

    w

  8. Barbed Wire Says:

    A caveat, from not having read all the details of this particular story; if the 350-lb patient was killed (euthanized) merely to simplify their triage problems, then yes, that is entirely wrong and certainly not an acceptable defense of their actions.

    …nor is it the intent or proper use of triage.

  9. flathead Says:

    Wow. I'm stunned.
    Prioritizing care is the job of every health care professional. It is an every day occurrence because provider's time is not elastic and there is never enough time even in the best of circumstances. If I spend all my time with X patient, what about patients Y and Z? In my seven years of nursing I can count on one hand the times I have been able to take my full half hour lunch. On the other hand I regularly stay beyond my scheduled hours to complete paperwork. So, I feel like I already "suck it up" on a regular basis.
    I suppose this post was also inspired by the New York Times Article on terminal sedation that ran a few weeks ago. I am assuming that you do not have any health care background, but you have to understand this: that article did lack nuance. Perhaps sometimes sedation does hasten death, but sedation may also decrease the work of the heart and oxygen requirements, lower a rapid respiratory rate, and lower blood pressure. These outcomes may actually extend life.
    And, for those who have not worked with someone who is in the throes of delirium (or hospital induced psychosis) they really cannot understand how bad this can be. And yes, how draining it can be on the provider and the patient's family. It is heartbreaking to not be able to do anything. Some conditions simply do not respond to treatment and at some point all you can hope for is comfort.
    Wouldn't it be wonderful if we had endless resources to spend on health care? Well, yes. But we still can't deny that life is a terminal condition. And we cannot deny that the purpose of life is not just to stay alive. If we continue to make health care a bigger and bigger share of our GDP, we will nothave the resources for the things that make life worth living.

  10. dbsmall Says:

    I'll reread this post later, when I've had more time to digest and think about it.
    I only even learned the term "palliative" when my father was dying from metastasized lung cancer, and my sister (an oncology nurse) and the hospice nurse and my dad all discussed it. In my Dad's state, I think I'd want to go on a morphine bender…but dad kept complaining that "it's an addicting medicine". That heuristic was more important to him than convenience, given his own problematic history with addiction.

    I'm sure there is some sort of triage, and palliative care guideline, and I'll bet it's usually followed.

  11. johnnyboy Says:

    I disagree with Ed on this as well. I saw the 60 Minutes segment on this and came to the same conclusion that I did after reading the NY Times piece.

    Life does not come with any guarantees. It's up to each of us to do the best we can with the body we are given. That means keeping our bodies in reasonably (and what that means is up for us to decide) good shape. We are given that privilege so that when dire circumstances arrive, we can hopefully survive. Survival of the Fittest becomes frightningly crystal clear when the shit of something like Katrina hits the fan.

    If you let yourself get to 380 pounds, then at some point, it's going to be a problem in some form or another. Especially during a hurricane. Especially if you are paralyzed and in a compromised hospital with almost no staff. I agree totally with Barbed Wire when he states "if 15 of us are going to spend all day moving him, then 14 other patients are losing their attendants and we’re likely kissing them goodbye", because triage is all about practicality and doing the best you can for the MOST, not doing the best you can for just one and naively hoping for a good outcome for the others.

    If faced with treating/moving one person who's basic problem is he's paralyzed and simply too big to move or treating/moving several who can truly be helped, I'd go for the latter. Every time.

  12. jazzbumpa Says:

    My judgment gets impaired if I stay up too late. I can't imagine having to make critical decisions on the 3rd day of no sleep. Those people were dong their best, under horrible circumstances, when everyone else abandoned them.

    That situation cannot be judged as if it were anything resembling normal times.

    I say hooray for the grand jury that refused to indict.

    JzB

  13. Ed Says:

    I thought this was a complex issue. Boy was I wrong!

    Also, the 15 people who would have to carry the obese man down the stairs could easily evacuate the other patients first and the Fat Guy last. He didn't need constant care.

    Argument from Ignorance is fun, but not having been present doesn't necessitate yielding to the judgment of those who were, especially given the broad range of opinions of the people involved.

  14. SeaTea Says:

    All I know is that Kodos the Executioner, governor of the Tarsus IV colony was faced with a similar dilemma, and when he killed half the population to save the other half in the face of dwindling food resources, Captain Kirk decided he was evil.

    That's good enough for me, because fictional serial dramas from the 60's set in space are my short-hand moral compass.

  15. flathead Says:

    What makes you think that those who might disagree with you do not feel it is a complex issue?

    Also, I am sorry, but I cannot abide by the phrase "if you let yourself get to 380 pounds". I don't think people's weight is necessarily some sort of "choice" and I deplore the way I have often seen obese individuals treated by health care providers.

  16. OneMadClown Says:

    For the folks who didn't actually read the article (and I didn't think this particular article lacked nuance), you are lacking some critical information with which to form an opinion. Doctors — Pou in particular — with little to no formal triage training didn't decide to simply end care for the patients they deemed lost causes, they decided to inject them with overdoses of sedatives with the intention of hastening their death. They killed them. After the majority of the evacuations had been completed. In Emmett Everrett's case, the 380 lb paraplegic, a fully conscious and lucid man who was at the hosptial awaiting (not recovering from) surgery. This isn't Kevorkian euthanasia we're talking about here, these people weren't asked if they wanted to die. This decision was made for them, and in the case of the patients who were conscious and aware, they were lied to about what was happening. As a fellow fatty, I can tell you that if the doctors explained that they couldn't carry me, I'd at least have liked the option of being told that I'd be left behind, with the authorities alerted to my position, or hell, sliding my own paralyzed hindquarters down 7 flights of stairs and trying to survive on my own terms. He wasn't even given the option of fending for himself. People operating rescue boats involved in the evac said that if they had been told the situation on the 7th floor, they'd have gotten at least him down themselves.
    Maybe for some, possibly even most of these patients, euthanasia was the best possible option. But for others, it quite clearly was not. As Ed said, this is a very complex ethical question, and one that deserves a thorough examination.

  17. ladiesbane Says:

    The availability of scarce, life-saving medical resources is an issue for us even outside of the context of disaster. We have generations of battlefield triage cases, the ongoing problems of transplant priority, and overtaxed charity hospitals to examine, and there is not a black-and-white answer.

    Not long ago, sailors were charged with homicide for putting women out of lifeboats, but the men they put out were not a problem; drawing lots was considered abdication of moral responsibility. Times change, answers change, the questions change too.

  18. johnnyboy Says:

    WTF??? (and sorry to derail for a bit here…)

    People's weight IS MOST DEFINITELY out of choice! They don't get that way through some space ray aimed at them from birth. What, because someone didn't notice at say, 250 that something should be perhaps curtailed, namely calorie intake? Sorry, but I'm extremely tired of morbidly obese people getting a pass because "it's not their fault". Pure and simple Bullshit.

    There's absolutely no judgment about the guy, the article (and me) only pointed out that he was 380 pounds. That's fact. I didn't say he was fat, lazy, a bad person, or anything derogatory.

    NO, I would not have injected him to kill him.

    There would have been nothing wrong with letting him reside there while helping other patients and hopefully some other solution would have presented itself later. But he would have definitely not been a priority over others who could be more easily moved, especially since he was lucid and in no pain.

    But it's a very difficult issue and I doubt seriously that Ed or anyone else posting here would have done any better.

  19. Will Says:

    People's weight IS MOST DEFINITELY out of choice!

    Uh… sometimes people really *do* have a glandular problem or some other disease that causes them to gain weight.

    In the case of the 350 lb woman at Memorial Medical Center in New Orleans, she was that size because of the fluids collecting in her body due to uterine cancer and kidney failure. Boy, she sure let herself go, ha ha ha.

    In conclusion: you're a dick.

  20. Ed Says:

    Only lazy people get cancer.

    I don't see that they had any option other than to put 'er down. Like a horse, or perhaps a dog.

    The cute thing is that the corporate parent of the hospital, Tenet, hired a team of helicopters to go in and evacuate, and the physicians at Memorial didn't add something like, "Hey, several of these patients are obese and we can't carry them. Maybe send in some extra manual labor with those helicopters?"

    Nah. The way they did it was far easier.

  21. flathead Says:

    For those who strongly believe that weight is simply a matter of personal choice and responsibility I would highly recommend reading Gina Kolata's "Rethinking Thin" and also Paul Campos's "The Obesity Myth".
    And no, I'm not overweight. I know people far heavier than me who eat less. I can actually put away the sweets.

  22. ladiesbane Says:

    Ed, were you not aware that the victim was a 79 year old woman with advanced cancer as well as renal failure? She wasn't in perfect health, only at the hospital visiting a friend. Being treated "for comfort only" is not a spa day, but for patients in extremis. You imply that the doctors were being flippant and "cute" in their decisions. I disagree with what they did, but they were exhausted, scared, and had multiple large problems to handle, not to mention their own personal problems weighing them down. I don't know if you have ever been in a remotely analogous position, but please try harder to understand that you don't always do what you think you would, especially under prolonged stress. I think you would do your best, and I think they tried to do the same.

    Have you seen this map of Memorial, or read Pro Publica's article?

    http://www.propublica.org/special/interactive-inside-memorial-medical-center

    http://www.propublica.org/feature/the-deadly-choices-at-memorial-826

  23. Barbed Wire Says:

    Alright, should have sucked it up and read the details in the NYT article before weighing in; even so, I wasn

  24. Barbed Wire Says:

    …that's twice now…

    Alright, should have sucked it up and read the details in the NYT article before weighing in; even so, I wasn’t trying to construct an argument, just offering my perspective. And I certainly never meant to imply that this wasn’t a complex issue.

    Obeying DNR orders sucks sometimes even if we’re legally bound by them. Palliative care for a terminally ill parent really sucks, even when Hospice is the last option. Triage sucks because you know a few will probably die so that many more will live. The breakdown of government at all levels, and society in general, in New Orleans after Katrina definitely sucked… as if we needed the additional evidence in this story. They’re all complex issues; glad to hear there’s at least some awareness and discussion about them.

    The circumstances of Mr. Everrett’s demise don’t seem like a defensible position but I ate tacos for supper, slept (in my bed) last night, had a shower, coffee and breakfast this morning and am grateful I don’t have to live with that decision.

    Final impressions: I thought Nurse Theile offered some valid opinions. As someone else said, Memorial ceased to be a hospital when the power quit; at that point it was just a multi-story concrete tent, with drugs. When the initial helicopter evacuations ceased for a day or so after Air Force One’s flyover, it sounds like Memorial was triaged behind the unhospitalized survivors living on rooftops and yeah that sucks too.

  25. johnnyboy Says:

    Will says:
    "In the case of the 350 lb woman at Memorial Medical Center in New Orleans, she was that size because of the fluids collecting in her body due to uterine cancer and kidney failure. Boy, she sure let herself go, ha ha ha.

    In conclusion: you're a dick."
    ———————————————————-

    Gee, that's intelligent discourse.

    My mother died of kidney failure after a transplant did not take after a year. I know much more than I want to about fluid retention from kidney failure. When both of her kidneys were not working AT ALL for over a year, the most she gained was about 30 pounds of fluid. And uterine cancer, (according to a well-respected internist that I know ), does not cause weight gain, but usually weight loss. After doing some looking around, (and much like I had figured) the woman you are talking about, Jannie Burgess, was well overweight before her kidneys failed. She's pictured on this page in the bright red dress in better, non-cancerous days:

    http://www.propublica.org/special/on-the-frontlines-at-memorial-medical-center-826

    And this little (ahem) tidbit:

    According to two cancer webpages:

    The most common signs or symptoms of uterine cancer are: • Very long menstrual periods or bleeding between menstrual periods • Abnormal uterine bleeding or postmenopausal bleeding • Painful urination • Painful intercourse • Pelvic pain • Weight loss

    Did you see that last symptom, Will?

    While I may still be a dick to some, I'm at least one that can make the seemingly difficult mental connection between calorie intake and weight gain. When one keeps stuffing that mouth full well after their stomach says "STOP" the result is not only weight gain, but possible kidney failure due to diabetes, diabetes which results from…

    Wait for it…

    TOO MUCH WEIGHT GAIN!

    After all is said and done, the point is, she was comatose when the hurricane hit, already on a DNR list and already a couple days from death. Not exactly a candidate for "Rescue During a Shitty Situation".

    And really, that is the point.

    The point is most definitely not "Is Being Fat OK?" or "If I Eat 30 Twinkies Will I Be Fat?" or "Is Johnnyboy Correct or A Dick or Both?"

    And, BTW, I don't mind being both correct and a dick when I need to be.

  26. Will Says:

    In that picture you linked, Ms. Burgess is on the heavy side, but, gosh she sure seems like she's standing unassisted and not in need of any special aids in order to move herself around.

    And not to question the skills of your crack medical backup squad (a well-respected internist, you say? Oh, my), or your ability to read the Internet, but were you made aware of a possible side effect of hormone treatment for uterine cancer? That would be: weight gain.

    So, to sum up: you shot your mouth off about how there's no excuse for someone to let themselves get to 350 pounds before you knew anything about the actual situation (seriously – you referred to Jannie Burgess as a guy), and then you cherry-picked some evidence from a couple websites and some guy you know to support your statement that it's her own damn fault for being that goddamned fat.

    Well done, sir. Well done.

  27. Mary Says:

    2 things…

    1) how does being obese make you less worthy of evauation than any other disability? there had to be many patients that could not walk, maybe incapable of taking instruction, insane, comatose, in traction… a myriad of possible disabilities making evacuation equally demanding… yet they were evacuated. it seems to me that what some are doing are following a 3rd reichian value judgement.

    2) i inserted a 'katrina clause' in my living will after reading about how the medial staff at Tulane hospital extended the 'extraordinary effort' rationale of living wills to deny evauation efforts. this was an indication, they deduced, that these people didn't want to live if it took extraordinary effort to even evacuate them. i encourage all those with living wills to include some sort of disclaimer. Here's my language, although i make no claim that it's actually legal since i just wrote it and inserted it into my existing living will myself:

    "Living Will Catastrophe Clause

  28. Mary Says:

    uh..oh…must've used to much space. here it is:

    Living Will Catastrophe Clause – Katrina Clause:

    In the event of a natural or unnatural disaster, this living will is not to be construed as a mechanism for excluding myself from safety precautions or evacuation to preserve my life. It is NOT my intent to permit whatever public or private authority to speed my demise by denying heroic rescue in the event of a natural or unnatural disaster.

  29. Larkspur Says:

    I don't know if anyone is still reading the comments – maybe, since it's such an important topic. Mary, that clause essentially speaks for the people who died in this instance, since they're dead and can't talk, and they didn't know what was going to happen and couldn't make their wishes known. Thank you.

    johnnyboy – so what? And if we accept your contention that the obese asked for it by overeating, don't we have to set up a whole shadow triage system? One in which cigarette smokers – current or ex – get shifted to the back of the line because they could have prevented their COPD or lung cancer by not smoking? Or heart patients: will their place in line have to depend on examination of their medical history to find out whether it was bad luck or too many cheeseburgers that caused their heart problems? And where in line do you put them if you can't really determine whether their illness was self-induced? Do we get to put children at the back of the line if they're sick because their parents gambled on not immunizing them?

    I'm not a medical professional, but I took a CPR class once. The question arose: how long do you keep administering CPR? The answer was (a) until the patient is resuscitated, or (b) until competent help arrives, or (c) until you just can't do it any more.

  30. Larkspur Says:

    Part 2:

    "Until you just can't do it any more" is clearly subjective. Probably you'd never stop second-guessing yourself, and you'd always know that maybe someone stronger could have done better. But if you did it till you just couldn't do it any more, no one could demand more.

    I have a feeling that in that hospital, under those conditions, I'd have quickly become pretty useless. Maybe it'd be different if I had ER training, but I know myself, and I'm not great under severe physical pressure. So I don't honestly know what I'd have done. But I suspect that those same limitations – some physical, some psychological – would have prevented me from administering lethal doses to anyone I'd just been talking to. I suspect I'd have given up, gotten those probably terminal patients – and difficult to manage patients – together, tried to comfort them, and probably have stayed behind and died with them. Not out of heroics, more out of despair.

    If we take prosecution or jail time off the table, what do you think should have happened, or should happen now? Can we assert protocols for future events without completely dealing with this one?

  31. johnnyboy Says:

    Larkspur says "And if we accept your contention that the obese asked for it by overeating"

    Wow, supposition reigns supreme at this blog. As does putting words in other's mouths, er, hands.

    The rescue issue and the weight issue are seperate.

    Let me clarify: if you are obese because you can't stop your arm from lifting food to your face then that's a problem that will manifest itself in many ways later. Diabetes, heart failure (I mean, really, do I have to defend this position? Oh, yes, I guess I do) and other weight related problems. This is issue 1, to quote John G.

    Issue 2: If you are comatose, days away from death and happen to be obese (for WHATEVER reason, Willy, thanks I aim to please), don't expect yourself to be considered first in line for rescue in the crappy, horrifying situation that results from hurricanes mixed with hospitals sprinkled with zero power and a dash of rising water.

    Not sure I can be much clearer, but then again, I've not run into such poor reading skills before this point.

  32. johnnyboy Says:

    And not for nothing:

    http://curiouscapitalist.blogs.time.com/2009/07/09/lets-just-blame-the-fat-people/

  33. Larkspur Says:

    johnnyboy, okay. I apologize for my use of the phrase "asked for it".

    But I do not understand why you say: "The rescue issue and the weight issue are seperate" when your example #2 seems to contend that you are saying they're not separate at all.

    "…If you are comatose, days away from death and happen to be obese … don't expect yourself to be considered first in line for rescue in the crappy, horrifying situation that results from hurricanes mixed with hospitals sprinkled with zero power and a dash of rising water…."

    Are you saying that obesity puts you at the end of the line strictly because of the genuine logistical problems in moving extremely obese people? Because I'm not saying there aren't logistical problems.

    But (a) obesity isn't the only condition that can cause heightened logistical problems. A psychiatric patient experiencing a psychotic break is difficult, or someone on a ventilator (as described in the original cited article). And (b) one of the particular patients described was truly morbidly obese, but was not comatose and not days away from death, with any apparent medical certainty. He was difficult to move, and they did not want to leave him behind, and I get that, but I cannot say that those circumstances justify administering lethal doses of morphine to cause his death.

    I'm going to set aside your opinion about my ability to comprehend what I read in the interest of trying to comprehend what you wrote. What purpose does your continued reiteration of causes of obesity have to do with developing treatment and evacuation protocols in extreme emergency situations?

  34. johnnyboy Says:

    Larkspur, it's the combination (comatose, near death), not ONLY the obesity.

    But the obesity, (which is an overriding factor in this particular situation), makes all the other factors take a back seat when you're talking about MOVING a comatose patient. And yes, it's basic logistics. 5 flights of narrow stairs, limited manpower, lack of sleep and energy and an already exhausted staff.

    Ventilated patients can be "bagged" for the time it takes to move them. A psychiatric patient can be medicated until sedate enough to move. But other than doing an instant liposuction, I cannot figure out how to easily move someone that is not ambulatory or conscious yet weighs 380. That's 380 pounds of basically uncooperative dead weight (pardon the pun) in a gurney that doesn't curve to turn corners.

    And please, scroll back up where (in basic agreement with you) I state that I would never inject a lucid, otherwise healthy patient, no matter what their weight. In that extreme emergency, I'd supply them with as much water as I could and hope for the best while they wait it out for some better alternative than "Sorry, I gotta go, so you gotta die."

  35. Larkspur Says:

    Thanks, johnnyboy. I think we are in basic agreement. I think your contention is sound, but I also think your comments about the causes of obesity lift right out (pardon the imagery) of your argument without altering it.

  36. Will Says:

    johnnyboy, this was your claim:

    People's weight IS MOST DEFINITELY out of choice!

    It's gratifying to see how quickly you backpedaled and deflected when it was pointed how full of shit that statement is. But, hey, thanks for playing.