What's Up Doc? Planning for disaster

Dr. Jeff Hersh

According to a recent article, Gov. Deval Patrick is going to improve the disaster readiness of Massachusetts. One of the issues that is under-addressed, or not addressed at all, in many disaster plans is the ethical demands of such situations.

A Mass Casualty Event, or MCE, by definition, overwhelms the normal health care system. This could be an ongoing crisis, such as a major and severe influenza pandemic, or it could be an acute event such as a terrorist attack.

The common thread for an MCE is that the number of people requiring medical care is too large for the existing health care infrastructure to treat. Let me use Hurricane Katrina as an example: Despite superhuman attempts by many Louisiana health providers, the loss of so much of the infrastructure - including hospitals, clinics, pharmacies and more - made it impossible for the system that was left intact to respond to the needs of the many victims of the disaster.

It may surprise people to know that the overall capacity of our health care system, in terms of available in-hospital patient care, has been shrinking over the last 10 to 20 years. For example, from 1993 to 2003 the number of hospitals in the U.S. decreased by 703, the number of emergency rooms decreased by 425 and the number of hospital beds decreased by almost 200,000. However, during this same time period the number of ER visits increased from 90 million to 114 million visits.

The decrease in the health system capacity has been driven by increased outpatient care for many conditions, increased day surgeries that don't require admission to the hospital, shorter length of hospital stays, and many other factors. Amazingly, all this has occurred despite an increase in our population and an overall aging of the population.

We have all already seen some of the implications of this: overcrowded hospitals and ERs have made long waits and hospital diversions commonplace.

With all this said, I do not think anyone should be surprised to find out that we are not as prepared as we want to be for an Mass Casualty Event. So what will happen to our health system in a disaster? The answer can only be that things will not be ``business as usual.''

So, if it will not be ``the usual,'' what will it be? I think the answer is to be found in the philosophy of Jeremy Bentham (1748-1832) and his Principle of Utility: ``Act so as to produce the greatest good for the greatest number.''

This concept is translated to our health care response to an MCE in the Agency for Healthcare Research and Quality report (AHRQ 07-0001) as: ``The overall goal of hospital and acute care response to an MCE is to maximize care across the greatest number of people while meeting at least minimal obligations for care to all who are in need.''

This means the standard of care for health care delivery must change in response to an MCE. In order for this to happen we must have ethical considerations addressed during our planning for such an event. To do this, we need to (as noted in the AHRQ report) ``use expert panels or planning groups to develop decision-making protocols or guidance for allocating scarce resources.'' This must include, the report continues, ``clinical changes to usual care.''

For example, the threshold to admit a patient with chest pain but with a normal ECG will need to be different during an MCE than in a ``usual'' circumstance, even knowing that there is increased patient risk with this approach. This cannot happen unless there are ethical policies in place before an MCE, and these policies include protection for health care providers against litigation (a huge issue that must be addressed).

We all expect our health providers to be willing and able to provide care in response to an MCE, even if the MCE is due to a contagious disease. Yet we must realize that the providers have families they will wish to care for, and they will also be concerned about their own health. There may, therefore, be reason to utilize a portion of the limited health care resources (such as vaccines and prophylactic medications) to treat our health care workers and their families. Again, the ethical considerations of this need to be worked out before an MCE, being sure to address the principles of fairness and absolute equity (providing some level of protection for all).

Another ethical issue that must be addressed is that of personal liberty. Freedom of travel may need to be limited to contain an infectious disease outbreak. This may include quarantine of some people against their will. On the other hand, forced evacuations may be needed in some MCEs, again for the benefit of the ``greater good.'' Personal privacy may also have to be limited for the overall public good. All these are ethical issues that should be addressed as part of the preparation for an MCE.

One of the most difficult issues to address in an MCE is allocation of limited resources. If there are not enough ventilators (breathing assist machines) to treat everyone that has a serious pneumonia during a flu pandemic, how will the decisions be made for who is placed on a machine and who is not? Who will make these decisions? Understand that not making such a decision is a decision in itself, since limited resources mean that there is not enough for everyone in need.

There are many other issues, but due to space limitations I will mention just one more. Adequate preparation to respond to an MCE must include training to an operational level (actually doing) not just to an awareness level (just putting plans on paper or just having a mock training exercise which is not realistic). This means conducting training drills that will interrupt normal health care delivery, even though an MCE has not yet occurred. The ethical considerations of, for example, increasing waiting times in the ER in order to run a realistic training exercise need to be considered.

So, what needs to be done? Our state MCE preparedness plan must address the ethical considerations that can arise during an MCE. Hospitals, clinics, nursing homes and all other components of the health care delivery system need to be given guidelines and be required to address these ethical issues as well. Putting our heads in the sand and not addressing these difficult issues during the preparation and planning phase for an MCE will only make the negative impact of an MCE greater. It is also clear that difficult decisions will need to be made, and that there will not be universal agreement on any decision.

E-mail me with your ideas of how the guiding principles (from the ARHQ report) of providing ``acceptable quality of care to preserve as many lives as possible'' within an ``adequate legal framework for providing health and medical care in an MCE'' can be accomplished. The decisions that must be made will affect everyone, so your opinions and input really matter.

Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., can be reached at DrHersh@juno.com.