If we go the way of Italy, a shortage of ventilators will force our doctors to choose who lives and who dies.
The initial triage decisions will be searing, but relatively simple: those most in need of a ventilator and who have the best chances of surviving.
But there could come moments when doctors will be forced to choose from among patients who meet the same medical criteria.
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What then?
A February report by the Johns Hopkins Center for Health Security says there are approximately 160,000 ventilators in America. Some 85 percent of them are already in use at any given time. The CDC has some 8,900 ventilators stockpiled. That would still leave us tens of thousands of ventilators short of what we would need in a major pandemic.
The federal government mandates that each state have a pandemic plan. All of them provide for rationing vaccines and drugs if the need exceeds the demand. Those that also have a protocol for ventilators include Washington, Minnesota, Florida, Michigan, Massachusetts, and New York.
In 2007, and again in 2015, the New York State Task Force on Life and the Law issued lengthy and detailed Ventilator Allocation Guidelines in the event of a pandemic.
To estimate the possible demand, the task force employed software from the Centers for Disease Control and Prevention (CDC) called FluSurge 2.0. One scenario was based on data from the 1957 and 1968 influenza pandemics. The task force then applied a multiplier of 8.33 to approximate the more severe 1918 “Spanish Flu” pandemic. The projections were based on the 8,991 ventilators in New York.
FluSurge predicted that there would be a slight surplus of ventilators in the less serious pandemic. But there would be a shortage of 15,783 in the more dire scenario. That meant 15,783 instances in which there would have to be a choice between patients.
“In the event of an overwhelming burden on the health care system, New York will not have sufficient ventilators to meet critical care needs despite its emergency stockpile,” the task force concluded. “If the most severe forecast becomes a reality, New York State and the rest of the country will need to allocate ventilators and other scarce resources.”
As put forth by the task force, the procedure begins with the attending physician turning the case over to a triage officer, who has less of an immediate obligation to that particular patient. The triage officer excludes those patients who have other life-threatening illnesses.
“The medical conditions that qualify as exclusion criteria are limited to those associated with immediate or near-immediate mortality even with aggressive therapy,” the task force guidelines note.
The next step is a “Mortality Risk Assessment,” based on “Sequential Organ Failure Assessment,” also known as a “SOFA score.”
“A clinical scoring system, SOFA, is used to assess a patient’s likelihood of survival,” the guidelines say. “SOFA is simple to use, with few variables or lab parameters, and the calculation of the score is straightforward, which makes SOFA a good tool to provide a consistent, clinical approach to allocate ventilators.”
The SOFA score is based on the functioning of the lungs, liver, brain, and kidneys, as well as blood pressure and blood clotting.
“A patient’s SOFA score determines the level of access (high, intermediate, or low) to ventilator therapy,” the guidelines say.
The SOFA score is then used to assign the patient a color code.
Red—Highest—Use ventilators as available.
Yellow—Intermediate—Use ventilators as available.
Blue—No ventilation provided. Reassess if ventilators become available.
The guidelines advise, “Red code patients (highest access) are those who have the highest priority for ventilator therapy because they are most likely to recover with treatment (and likely to not recover without it) and have a moderate risk of mortality.”
During a severe shortage, the triage officers could find themselves with more than one code red patient.
“In some circumstances, a triage officer/committee must select one of many eligible red color code patients to receive ventilator therapy,” the guidelines say. “There may be a situation where multiple patients have been assigned a red color code, which indicates they all have the highest level of access to ventilator therapy, and they all have equal (or near equal) likelihoods of survival.”
Triage officer then becomes a mind-bending, heart-wrenching job like no other.
“A randomization process, such as a lottery, is used each time a ventilator becomes available because there are no other evidence-based clinical factors available to consider. Patients waiting for ventilator therapy wait in an eligible patient pool and receive alternative forms of medical intervention and/or palliative care until a ventilator becomes available.”
But once patients get a ventilator, they must pass an examination after 48 and 120 hours to determine if they should keep it.
“In order for a patient to continue with ventilator therapy, s/he must demonstrate an improvement in overall health status at each official clinical assessment,” the guidelines say. “The primary difference between the 48 and 120 hour assessment is the extent of improvement in overall health prognosis and of the trajectory of a patient’s health status required to continue to be eligible for ventilator therapy. At 48 hours, because a patient has only had two days to benefit from ventilator therapy, the progress required to justify continued ventilator use is not expected to be dramatic. However, after 120 hours, a patient must demonstrate a pattern of further significant improvement in health to continue.”
The guidelines add, “After the 120 hour clinical assessment, a patient who is eligible to continue with ventilator therapy is reassessed every 48 hours with the SOFA clinical scoring system.”
If a patient is taken off the ventilator, another patient is chosen from the pool of those whose only hope is that somebody else will be deemed to have none.
The guidelines note that more machines—such as President Trump has promised—is not the answer when there is no extra trained staff to operate them. And existing staff can dwindle as medical personnel themselves become ill.
“Purchasing additional ventilators beyond a threshold will not save additional lives, because there will not be a sufficient number of trained staff to operate them,” the guidelines say.
What can be done, what we all can do, is follow the guidelines set by the CDC for minimizing the spread of the virus. That includes keeping “social distance” and avoiding shaking hands, as Trump and his team did repeatedly while declaring a national emergency in the Rose Garden on Friday afternoon.
One person who did not shake hands was Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. He did raise his right hand in a sharp upward curve to describe the trajectory of the disease in countries that failed to act quickly and effectively. His hand indicated a much lower curve as he described what can happen if containment and mitigation are applied in time.
The American health care system could possibly handle the lower curve. The higher curve would likely translate into doctors making decisions that no doctor wants to make.
One person who figures she would be in the “no ventilation provided” category is Laura Baker, a 45-year-old nurse practitioner and mother of three who worked at an upstate New York urgent care center until last week.
Laura Baker.
Courtesy of Laura BakerThen, on Wednesday, there came a transformative day that might be called 3/11. The world took a scary turn for many of us when over the course of a few hours the World Health Organization declared a pandemic and President Trump finally acknowledged the seriousness of the threat, a reality that was quickly drilled home when Tom Hanks made it known that he and his wife had tested positive for the virus. Obliviousness turned to panic.
That same day, her county, Monroe, reported its first coronavirus case. Her doctor called her at her clinic.
“I’m an immunosuppressed nurse,” she said. “My doctor said, ‘Go home.’”
Her heart was attacked by a virus of another kind when she was a 20-year-old nursing student. The eventual result was a heart transplant in 2014 that continues to require her to take immunosuppressive drugs. She therefore took particular note of something an Italian doctor posted in describing the overwhelmed health care system there.
“One of the things he said was if you’re old or have had any kind of transplant you might not be able to get a ventilator,” she recalled. “And those words were chilling.”
Baker understood that her condition not only increased her chances of getting infected but also decreased her chances of survival.
“I would be in the category of a person unlikely to get a ventilator,” she told The Daily Beast.
She figured that she might already have been exposed to COVID-19 at her Monroe County clinic. She had started reading everything she could about the new virus when it emerged, and some of the symptoms seemed to fit several of her patients.
“I started realizing I’d probably seen it for at least a couple of weeks, but because we didn’t have any tests, we couldn’t prove that.”
That was a number of weeks ago, and she shares the opinion of many national and international experts that America has lost its opportunity to contain the virus.
All it could do now was mitigate.
“It’s so obvious the storm is coming, and it’s really scary,” she said. “It absolutely terrifies me.”
One way we can reduce the threat is social distancing, yet she sees continues to see people frequent public places as if there were nothing amiss.
“My gym is still open, and they don’t just see the problem,” she said. “They think they’re healthy, under 30, and it’s fine and they’re not going to pass it on. They’re like, ‘If you’re staying home, what do you care if we go? Exercising is healthy.’”
One man she knows told her, “I’m not going to live in fear.”
She told The Daily Beast, “Two weeks from now, he’s probably going to have a very different tune. I just hope it doesn’t come to anybody he loves.”
She added, “The amount of selfishness and lack of understanding of the real real risk, I’m horrified, honestly.”
And she notes that there are many more people at particular risk than you might expect.
“You would think I was one of the healthy ones if you looked at me,” she said. “There’s plenty of us walking around who will be seriously ill.”
Baker has been in need of intensive care for reasons unrelated to the coronavirus. She suggests that the young also consider that there are many more reasons than COVID-19 why someone of whatever age might need it. A serious mishap or a dire illness of another kind could leave a twenty-something facing a question.
“If the ICU is full of corona patients, what the hell are you going to do?” she asked.
As a longtime nurse practitioner, Baker knows the hospitals are doing all they can to meet the coronavirus threat.
“I know the hospitals are preparing,” she said. “But the thing is, I know we’re not prepared.”
She fears for many more people than herself.
“I feel like there’s a tsunami that is about to attack the American health care system, and it’s going to collapse,’” she said. “It absolutely terrifies me.”
She is in favor of a national quarantine.
“I don’t think we should be doing anything except going to the grocery and the pharmacy,” she said.
And she believes everybody has to do their part in reducing the curve that Dr. Fauci traced with his right hand.
“It’s a war we’re fighting,” she said.
In the meantime, Baker must keep taking immunosuppressive drugs that keep her body from rejecting her heart but also make her more vulnerable to the coronavirus.
“All I can do is hide in my house and hope that it misses me,” she said.
And if the worst comes to pass, New York has ready its Ventilator Allocation Guidelines.
