Staff Priority for Ventilators? ... Yes?

Today’s posting addresses the issue of providing preferential access to ventilators for health care workers in a pandemic. This is a somewhat touchy subject from an ethical point of view. Any opinions expressed here are strictly my own, but I will try to provide a rational basis for any opinions that I do express. If you disagree with my opinion, (or agree) you can leave a comment below and we can discuss it. If you think this is an important discussion, please post a link to this post ( http://panvent.blogspot.com/2008/06/staff-priority-for-ventilators-yes.html ) in other discussion forums. I should declare that I am a health care worker myself, and that could be a considered a conflict of interest in this discussion. Nevertheless, I hope you hear me out.

The May 2008 article in Chest journal DEFINITIVE CARE FOR THE CRITICALLY ILL DURING A DISASTER
(available at http://www.chestjournal.org/content/vol133/5_suppl/)
and ALLOCATION OF VENTILATORS IN A PUBLIC HEALTH DISASTER published in Disaster Medicine and Public Health Preparedness Vol 2/No1, recommends that health care workers do not receive any preferential treatment in a pandemic. Many other planning documents recommend the same. I have a great deal of respect for these documents and the people that wrote them. The authors of these documents are trying to make plans that will save as many lives as possible during a pandemic using the limited resources that they expect will be available to the health care system. They try as much as possible to stay within traditional ethical guidelines, but insist that the principle of doing the greatest good for the greatest number of people is the primary principle and this should override values based on the traditional ways of delivering health care.

The principal rationales for not providing health care workers with preferential access to ventilators are these:

1. Fundamental ethical principles demand that there is no discrimination in access except for survivability criteria. Discrimination based on age and health status is acceptable because this allows the triage team to identify which individuals are more likely to have an increase in survivability by having access to the limited supply of health care.
2. It is unlikely that a health care worker that is given preferential ventilator access during a pandemic will recover in sufficient time to be able to come back to work and help others before the pandemic is over.
3. The triage protocols demand that certain persons be given authority to decide who gets access to medical treatments in limited supply. The public must trust that these persons will make decisions based on the pre-established rules and sound ethical principles. If the public believes that the decision makers are giving preferential access to people that they personally know, it may undermine this trust.

Discussion of Point #1
I believe that the principle of non-discrimination except for areas where it improves overall survivability is very valid and should be pursued. Where the argument for not favoring health care workers may fail is that it considers the availability of healthcare in a pandemic to be a zero sum game; that whatever is available at the beginning of a pandemic is all that will be available. They state this explicitly when they say that whatever is used to help health care workers will not be available to help the general public. This is may not be entirely true, as I will outline in point 2.


Discussion of Point #2
Now it may be so that once stricken, the health care worker as an individual may not be able to contribute a positive benefit to the pandemic care effort, but it is wrong to look at health care workers strictly as individuals. Health care is a team effort. The work that must be done by health care workers during a pandemic is not the routine of the non-pandemic. Society will demand that health care workers place themselves (and possibly their families through indirect exposure) at greater personal risk than the general public, and will demand that they work under more severe and hazardous working conditions and longer hours than they normally do.

It is essential that health care workers are motivated to not only work under these conditions, but to provide the most and best quality work they can. Staffing level is one of the key issues identified as a major limiting factor in being able to provide the maximum care to save as many people as possible in a pandemic. One way to get staff to work more would be to impose stringent laws and use force to draft anyone able to provide health care to work whether they want to or not. This would not be good way to get maximum efficiency from all workers and most plans do not recommend it. The workers must be motivated to provide the very high level of performance expected from them during a pandemic.

The health care worker component of a pandemic shortage is not a zero sum game. Some conditions will encourage healthcare workers to go to greater lengths to provide the most that they possibly can, and other conditions will cause them to retreat from working into a place of self preservation. It is not as straightforward either as being that worse conditions cause more people to retreat. Many people will work very hard in poor working conditions and even in situations of great risk if they feel their cause is just. Military organizations understand this, and place a great value on maintaining morale, group cohesion and supplying a valid reason for soldiers to contribute their maximum effort.

The US military is known as being one of the finest fighting organizations in the world. They do not rely only on just having the best equipment, but also focus on getting the maximum that they can from their people. One of the ways they do this is by saving every captured or injured soldier that they can. The principle is best stated in the Ranger Creed of “No Man Left Behind”. (See http://www.yaleherald.com/article.php?Article=532 for a discussion of this.) Each soldier is willing to risk his life to save his fellow soldier, even in the face of extreme odds, because he knows that the other would do the same for him. This cohesion and dedication then translates into a high degree of effectiveness for the many other things a soldier is asked to do.

Now look at two scenarios, handled in different ways and what could be the possible outcomes. Both scenarios start the same way. A pandemic strikes; workers are worried for their safety, but feel a sense of duty and commitment to work. Most show up for work, but are not sure about volunteering for extra work. Some are distrustful that their employers are doing everything they can to protect them and stay away from work. They talk about this a lot at breaks. One of the nurses gets sick and needs a ventilator. The other staff believes she got sick from caring for a pandemic patient.

In the first scenario the nurse is refused a ventilator so that it can be given to another person. The other staff worries that they too may get sick and believe that not enough will be done for them. More staff now stays home from work. The hospital can now care for less patients than they could before due to staff shortage.

In the second scenario the nurse is put on a ventilator. Other workers volunteer extra hours to make sure she is well looked after. Some workers that initially stayed home now also come to work. They have greater trust that they will be looked after if they get sick and also wish to be available if any more of their coworkers get sick and need help. The hospital can now care for more patients than they could before.

It is interesting that the second scenario works even if the nurse does not survive. It is the fact that they were able to try to save her that is important.

Discussion of Point #3
The public may accept that health care workers will go to great lengths to care for their own. We accept this from other groups that put themselves in danger in order to protect us. Two examples are police and firefighters. When they go to great lengths to save one of their own, or in the case of police to obtain justice for the death of one of their own, the public does not complain that they are now providing a lower level of service to the rest of us. We accept this, and even demand it. When it was found out by the public that many injured Iraqi war veterans were poorly treated the public demanded that conditions improve. The same happened for many police and firefighters injured in 9/11. The public respects the risks that people place themselves in for the public good and demand that they receive the best care possible when they are hurt in the line of duty.


Conclusion
I would like to believe that I would do everything I can to help in a pandemic crisis regardless of risk to myself, and I think most people feel this way. I just can’t be sure that everyone will actually act so magnanimously when a crisis actually occurs. A lot can be learned from studying staff reactions during the SARS crisis in Toronto when some people felt that the hospitals involved did not provide adequate information and protection to staff working with SARS patients. I understand that the critical care system is a public trust and that the health care workers cannot arbitrarily use these resources preferentially for themselves. The triage plans that have been published take a much more pragmatic approach to the allocation of scarce resources such as ventilators in a crisis such as a pandemic. These plans are willing to forgo systems that are currently used such as first come, first served, in favor of allocation systems that will save the most people possible. Perhaps they should study how staff will actually behave in a pandemic system, and adjust the plans accordingly if it could in fact save more total lives.

Clarence Graansma



P.S.
Maybe this is the place for the Pandemic Ventilator. Maybe if healthcare workers volunteer extra hours to look after their own in a pandemic and even build their own ventilators…

Quick Review of “Definitive Care for the Critically Ill During a Disaster”

This week the report from the “Task Force for Mass Critical Care Summit, January 26–27, 2007” was published in CHEST. The series is titled “Definitive Care for the Critically Ill During a Disaster”. It consists of five separate articles subtitled:

• Summary of Suggestions From the Task Force for Mass Critical Care Summit
• Current Capabilities and Limitations
• A Framework for Optimizing Critical Care Surge Capacity
• Medical Resources for Surge Capacity
• A Framework for Allocation of Scarce Resources in Mass Critical Care

I quickly read through all these papers this week. I will review each of them in more detail in upcoming postings. You can get all five of the published articles for free at this location. Thank you CHEST for supplying these articles for free. If you are involved in pandemic planning, I urge you to download these papers and read them. They offer many suggestions and solid frameworks for planning your response to a mass critical care incident.

The publishing of these papers has generated a few news reports this week. Most of the newspaper articles were sensational, focusing mainly on the list of classes of people that would be excluded from care. Here are a couple of news links. AP, Globe and Mail.

When you read these news articles you would think that the summit meeting was all about denying care. When you read the actual papers you will see that the summit was really about providing the best care possible under various worsening and even the nearly hopeless conditions that could possibly occur. The sensational articles referred to the list of recommendations of who would be refused care in the most severe crisis. This list was merely a suggestion, and the authors state in the papers that there must be an ethical discussion of these issues by non medical professional people to determine whether society will accept these criteria.

The papers do not focus only on pandemic planning, but stress that plans must be flexible enough to account for many different types of mass casualty incidents. The included charts list nearly every type of incident and the appropriate responses. Still the main focus is on pandemic preparedness. Short of a nuclear war, a severe pandemic is probably the incident that would most stress the existing critical care infrastructure.

Some of the papers I have read before these on pandemic planning were very complex and tedious to follow. Many other papers focus on the numerous problems, give many “what if “ scenarios and concentrate a lot on how little we know. These papers focus more on how to get to a solution rather than moaning about the hopelessness of it all. The planning goals are focussed on three main areas; stuff, staff, and space. Essentially they say you have to have enough of each. If you are well prepared in two areas and short in the third, you are still limited by that area. They focus less on trying to predict the severity of any incident and more on how hospitals can maximize their ability to respond.

Stuff is things like ventilators, medications, PPE and other medical supplies. Staff is the number of staff that are not affected by the event plus the number of addition personnel that can be trained and used as well as how much you can increase the number of patients existing staff can care for. Space is the suitable areas that can be used to provide complex critical care.

In a nutshell, they recommend that facilities aim to increase by a factor of 3, the amount of critical care (including ventilators) they can provide, and also stockpile enough supplies to last about 10 days, with perhaps some additional buffer, and to ensure they can maximize their staffing and space to make this possible. I think these are very good recommendations. They are very similar to the recommendations I posted on the BMG website last year. I also suggested that facilities try to increase their ability to manage ventilated patients by up to a factor of 3 in one of my posts last year.

They warn that manual ventilation will not work. They are very skeptical that sharing ventilators among several patients will work with real patients that have ARDS. They provide an extensive list of requirements that facilities should look for when purchasing ventilators for surge capacity, but acknowledge that is unlikely that anyone will actually buy that many ventilators ahead of time. They also provide a much shorter list of the minimum requirements for a ventilator in suggestion 3.2:

(1) be able to oxygenate and ventilate most pediatric and adult patients with either significant airflow obstruction or ARDS
(2) be able to function with low-flow oxygen and without high-pressure medical gas
(3) accurately deliver a prescribed minute ventilation when patients are not breathing spontaneously
(4) have sufficient alarms to alert the operator to apnea, circuit disconnect, low gas source, low battery, and high peak airway pressures

The pandemic ventilator should be able to meet those short list minimum requirements.



P.S.
My son Jeff is taking his own pandemic ventilator design “Norman” to the Canada Wide Science Fair in Ottawa this week. I will have a more detailed report on “Norman” next week. I think you will be impressed with the work Jeff has done. I am.

WWSEF Science Fair Results

Below is the pandemic ventilator prototype "Norman". Norman was built by one of our developers in his automation and robotics class.

This prototype is named “Norman” after Norman Burn. Norman Burn was the Chief Technician at the Department of Anesthesia at Newcastle. Norman Burn built many of the very first positive pressure ventilators. Some of his “home made” ventilators were used during the polio epidemic in Britain in 1947. (link here)

This developer is a high school student and has contributed to the Pandemic Ventilator Project right from the beginning. He has added many insights to the design of the project and did all the PLC programming for "Max" as well as his current prototype. He entered "Norman" in the Waterloo Wellington Science and Engineering Fair.


The Pandemic Ventilator at the Science Fair


He won 3 awards at this Science Fair:

• Silver Medal in the Senior Engineering Division

• The University of Ontario Institute of Technology Innovation Award for demonstrating the most innovative development, adaptation or use of technology in a science project.

• An Award of Merit
  

In addition to the awards, his project has been accepted to participate in the National Canada Wide Science Fair to be held in Ottawa Canada from May 10 to May 18th 2008.

We congratulate him on his hard work and dedication.


Receiving the Silver Medal Award
for Senior Engineering



Receiving the University of Ontario Institute of Technology
Innovation Award for Demonstrating the Most Innovative Development,
Adaptation or Use of Technology in a Science Project




Receiving the Award of Merit

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Correction

It seems there was an error made at the awards ceremony. Instead of the silver medal he was awarded, he was supposed to have received a gold medal and several university and college scholarships. So, we congratulate Jeff on his gold medal award. Here is a link to the official site.

Here are the awards he was supposed to have received:

• Award of Merit,
• Gold Medal, Senior Engineering,
• University of Ontario Institute of Technology Innovation Award,
• Conestoga College Entrance Scholarship,
• University of Guelph Entrance Scholarship,
• University of Waterloo Entrance Scholarship.
• Wilfrid Laurier University Entrance Scholarship.
  

His project is also entered in the Canada-Wide Science Fair