Yves came to IM Doc and kept sending us grim accounts from his hospital. Yesterday, he was the only doctor of medicine in the emergency room, there was a nurse, and a large influx of cases. The hospital was not overloaded, but the price was that the emergency room became a war zone.

Author: Matthew Wynia, Director of the Center for Bioethics and Humanities, University of Colorado Anschutz School of Medicine.Originally published on dialogue

As omicron variant Brought it A new wave of uncertainty and fear, I can’t help but think back to March 2020, when healthcare workers across the U.S. looked at COVID-19 in horror Flooding New York City.

The hospital is overflow Patients and dying patients, ventilators and personal protective equipment are in short supply. The patient sat in the ambulance and corridors for hours or days, waiting for the beds to open. Some people never succeed To the intensive care bed they need.

I am an infectious disease specialist and bioethicist at the Anschutz Medical School District of the University of Colorado.From March 2020 to June 2020, I worked uninterruptedly with a team to help My hospital and state Prepare for the anticipated influx of COVID-19 cases, which may overwhelm our healthcare system.

When the health system is in crisis, the first step we take is to do our best to protect and redistribute scarce resources. Hope to continue to provide high-quality care—despite the shortage of space, personnel, and things—we have done some things, such as canceling elective surgery, transferring surgical staff to inpatient wards to provide care, and keeping patients in the emergency department when the hospital is overcrowded room. These are called “emergency” measures. Although they may cause inconvenience to patients, we hope that patients will not be harmed by them.

However, when the crisis escalates to the point where we simply cannot provide the necessary services to everyone who needs it, we have to classify the crisis. At this point, the quality of care provided to some patients is indeed not high—sometimes even much lower.

The care provided in this extreme resource shortage situation is called “Crisis care standards. “The crisis standard will affect the use of any extremely scarce resources, from staff (such as nurses or respiratory therapists) to things (such as ventilators or N95 masks) to spaces (such as ICU beds).

And since the standard of care we can provide during the crisis is much lower than the normal quality of some patients, the process should be completely transparent and Officially allowed by the country.

How diversion looks in practice

In the spring of 2020, our plan assumes the worst-case scenario-we Not enough ventilators For all no one is sure to die. Therefore, we focus on how to make ethical decisions about who should get the last ventilator, as if any such decision could be ethical.

But a key fact about classification is that this is not something you decide to do or not to do. If you don’t, then you decide to act as if everything is normal, and when your ventilator runs out, the next person will be gone. This is still a form of classification.

Now imagine that all the ventilators have been taken away, and the next person who needs a ventilator is a young woman suffering from complications who is giving birth.

This is what we have to talk about at the beginning of 2020. My colleagues and I did not sleep much.

In order to avoid this situation, our hospital And many others It is recommended to use a scoring system to calculate the number and severity of a patient’s organ failure.That’s because people with multiple organ failure Unlikely to survive, Which means that if people with better opportunities also need it, they should not be given the last ventilator.

Fortunately, we got probation before we had to use this classification system that spring.Wear a mask, maintain social distancing and Business closure has taken effect, They worked. We bend the curve. A few days in Colorado in April 2020 Nearly 1,000 COVID-19 cases every day. But by the beginning of June, our daily case rate had dropped to more than 100 cases. Of course, with the relaxation of these measures, COVID-19 cases will surge in August.and Colorado surges in December 2020 Especially serious, but we suppressed these subsequent waves with the same basic public health measures.

Then it felt like a miracle happened: a safe and effective The vaccine comes out. At first it was only for those at the highest risk, but later it became available All adults By late spring of 2021. We have just entered the pandemic for more than a year, and people feel that the end is just around the corner.so Masks are eliminated.

It was too fast, and the result came out.

Memorable reminders for 2020

Now, in Colorado in December 2021, the hospital is full again.Some have even recently exceeded 100% capacity, and One-third of hospitals A shortage of ICU beds is expected in the last few weeks of 2021. The best estimate is that we will be overcrowded by the end of this month, ICU beds will be used up statewide.

But today, some citizens have little patience for wearing masks or avoiding crowds.It’s unfair for people who have been vaccinated to think they should be forced to cancel their vacation plans. More than 80% of COVID-19 hospitalized patients are not vaccinated. And those who have not been vaccinated… well, many people seem to believe that they just don’t have a risk, this Can’t be further from the truth.

Therefore, hospitals across our state face similar classification decisions again every day.

In some important respects, the situation has changed.Today, our hospital has a lot of ventilators, but Not enough staff to operate them. Stress and burnout are Pay the price.

Therefore, those of us in the healthcare system have reached our tipping point again. When the hospital was overcrowded, we were forced to make a triage decision.

Moral dilemmas and painful conversations

Our Colorado health system now assumes that by the end of December, the capacity of intensive care units and general floors in all our hospitals may exceed 10%. At the beginning of 2020, we are looking for patients who will die with or without a ventilator to protect the ventilator; today, our planning team is looking for people who may survive outside the ICU. And because these patients need beds on the main floor, we are also forced to find people on the hospital floor who can go home early, even if that might not be as safe as we hoped.

For example, suppose a patient with diabetic ketoacidosis (DKA)-hyperglycemia with fluid and electrolyte disturbances. DKA is dangerous and usually requires admission to the ICU for continuous insulin infusion. However, patients with DKA rarely require mechanical ventilation. Therefore, in the case of crisis triage, we may transfer them to hospital beds in order to free some ICU beds for severely ill COVID-19 patients.

However, since the wards of these DKA patients are also full, where do we get the regular wards? We might do this: People with severe infections caused by intravenous medications stay in the hospital regularly while receiving long-term intravenous antibiotic treatment. This is because if they use intravenous catheters to inject drugs at home, it can be very dangerous and even fatal. But under triage conditions, if they promise not to inject drugs with an intravenous tube, we may let them go home.

Obviously, this is not completely safe. This is obviously not the usual standard of care-but it is a crisis care standard.

Worse than all this is looking forward to a dialogue with patients and their families. These are what I fear most, and in the last few weeks of 2021, we have to start practicing them again. How should we reveal to patients that the care they receive is not what we want because we are overwhelmed? Here is what we might say:

“…Too many patients come to our hospital at one time, and we don’t have enough resources to take care of all the patients…

…At this point, a 48-hour trial treatment on a ventilator is reasonable to see how your father’s lungs react, but we need to reassess…

…Sorry, your father is more ill than the others in the hospital, and the treatment did not work as we hoped. “

Going back to when the vaccine came out a year ago, we hope that we will never need to have these conversations. It is difficult to accept that they are needed again now.