March 2, 2008
By Dorsey Griffith - dgriffith@sacbee.com
Sacramento Bee
Older, sicker patients could be allowed to die in order to save the lives of patients more likely to survive a massive disaster, bioterror attack or influenza pandemic in California.
It's not how nurses and doctors are accustomed to doing things, nor how Californians expect to be treated. But it is part of a sweeping statewide plan being praised for its breadth, even as it rankles providers who will have to carry it out.
The new "surge capacity guidelines" released by the state Department of Public Health, depict a post-disaster health care environment that looks and feels nothing like the system most Californians depend on.
It provides for scenarios in which patients could be herded into school gymnasiums for life-saving care or animal doctors could stitch up the human wounded and set their broken bones.
The 1,900-page document lays the practical – and ethical – groundwork for local and county health departments, hospitals, emergency responders and any able-bodied health care worker likely to be called upon in a catastrophe.
Striking in its specificity and its frank focus on the need to suspend or flex established laws and to ration health care, the plan is being hailed as a model for the rest of the nation.
"I don't know of any state that has taken it to this level of detail in outlining a surge plan for everyone who needs to respond to an emergency of this magnitude," said Jeff Levi, executive director of Trust for America's Health, a nonprofit group that has criticized the nation's emergency preparedness. "It's exactly the kind of dialogue that has to happen."
The conversations emerging from the plan will be very painful, especially for professionals trained to save a life at almost any cost, said Betsey Lyman, deputy director for public health emergency preparedness at the state Department of Public Health.
"Today, the practice of medicine is do everything you can for an individual patient," Lyman said. "This is, 'OK, we have limited resources. How do we best save the greatest number of lives?' That can mean saying to an individual patient, I can't give you a ventilator because I don't have enough for everybody."
The $5 million plan was developed as a result of Gov. Arnold Schwarzenegger's 2006 health care surge initiative. That $172 million effort included the stockpiling of millions of doses of antiviral medications, thousands of ventilators, mobile field hospitals and extra hospital beds.
But health care officials acknowledge that when and if a global pandemic or major disaster strikes, no amount of extra drugs or supplies will be sufficient to manage the impact on an already strained health care system.
That's why the state assembled public health professionals, hospitals, ethicists, nurses and others to hash out guidelines for procedures they hope will minimize red tape and maximize survival rates.
The plan lists, for example, which responsibilities and patient protections can be waived if the governor declares a state of emergency.
Hospitals will not have to report births, deaths, infectious disease outbreaks, medication errors, and suspected child or elder abuse. Existing rules that protect patients' privacy also can be tossed out.
Dr. Ron Chapman, Solano County health officer and a key surge plan participant, cited as an example the bare-bones approach to caring for people in the wake of Hurricane Katrina. There, he said, a friend's leg was sliced open by a piece of glass while he was helping haul away debris.
"They took him to a Wal-Mart parking lot. He stood in line, walked in, they sewed him up, gave him a pack of antibiotics and sent him on his way," Chapman said. "They never asked his name or his insurance status."
The guidelines say California's strict nurse-patient ratios can be ignored, and nurses can be assigned to jobs for which they have no experience.
The scenarios worry nursing leaders. "If you are going to throw out regulations … we know the consequences can be very bad," said Donna Gerber, government regulations director for the California Nurses Association. "(The regulations) wouldn't be there except to protect the public."
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PLANNING TO BE PREPARED
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Here's a look at the key elements of California's emergency health care capacity guidelines:
• Many state statutes and regulations that govern hospital and health care operations can be flexed or suspended by the governor during a surge.
• Retired and other unlicensed volunteers will be given emergency credentials to provide certain types of care during a surge.
• Alternate care sites, including school gymnasiums, sports venues and parking lots, can be used to care for ill and injured patients.
• Scarce medical supplies such as ventilators will be rationed under a system in which those patients who have a critical need for treatment and are likely to survive will be treated before those who are sick or critically injured and less likely to survive.
• Additional guidelines will be released for community clinics, long-term care facilities and licensed health care professionals.
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During a health care surge, even nonlicensed, or retired health care providers whose licenses have lapsed, will be recruited to provide emergency care.
National surveys indicate that more than 40 percent of health care employees would not come to work during a massive disaster or pandemic, either because of fear or because of their own household demands.
"It means that people are going to be volunteering and coming in and helping who may not be properly credentialed," said Duane Dauner, president of the California Hospital Association.
A hospital janitor, for example, could get an emergency credential to stitch up wounds or start intravenous lines if that janitor had experience as a military medic.
It means, Dauner said, that a volunteer veterinarian could be asked to mend broken bones, stanch bleeding or jump-start a patient's heart.
"In times when there is nobody else, getting someone like a vet to help out is better than not treating a patient," Dauner said.
It also means that a pharmacist will be able to dole out drugs even without a doctor's prescription.
"It's not what we are used to, but when someone with diabetes comes in and they need insulin but they can't get in to see their doctor because the doctor is sick, why can't a pharmacist give it to them?" Chapman asked. "It's all about saving lives."
Such practice stands in stark contrast to the normal workings of any hospital, where restricting the provision of medical treatments to authorized individuals is serious business.
Even though he is a licensed primary care doctor, Chapman, for example, is not authorized to operate a ventilator, even in hospitals where he has privileges to otherwise treat patients.
Under surge guidelines, he said, even a patient's family member could be trained to maintain the machine.
"Right now, ventilators are considered a high-level technical piece of equipment," Chapman said. "But in that scenario, we won't have nearly enough intensive care nurses and doctors to run them."
Perhaps the most jarring aspect of the guidelines, though, is the seemingly hard-hearted treatment of some kinds of needy patients.
The plan will allow hospitals to empty beds for higher priority patients, sending ill patients into hallways, make-shift hospitals in tents, nursing homes or even back home.
"Everybody will have to think differently," Dauner said. "Radio, TV and police will direct patients where to go. People will be herded like cats."
Scarce life-saving resources will be rationed under a radically different system of care that puts the good of the larger population over that of the individual patient.
That means that instead of starting with the sickest or most critically injured, treatment will go first to those more likely to survive with immediate intervention. A patient's kidney disease or congestive heart failure could diminish their chances of getting life-saving treatment in such an emergency.
The plan emphasizes that treatment decisions must not be based on a patient's ability to pay for care, their perceived worth to society, or whether their past behaviors contributed to their health status.
These will be very difficult decisions to make, particularly for nurses who – by their training and nature – are patient advocates, said the CNA's Gerber.
"The nurse is usually the one who says 'Excuse me, but I don't think that's the right dose, or I really don't think my patient is ready to be discharged," she said. "These are very draconian kinds of situations and … that is not what we are trained to do."
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