Israel Matzav

Ethical dilemnas in disaster scenarios

I don't envy the kinds of decisions these people had to make, but it's fascinating to read how they make them.

The New England Journal of Medicine carries an article by some of the doctors who ran the IDF hospital in Haiti about how they decided whom to treat and when.

Under normal circumstances, triage involves setting priorities among patients with conditions of various degrees of clinical urgency, to determine the order in which care will be delivered, presuming that it will ultimately be delivered to all. After the Haitian earthquake, however, it was impossible to treat everyone who needed care, and thus the first triage decision we often had to make was which patients we would accept and which would be denied treatment. We were forced to recognize that persons with the most urgent need for care are often the same ones who require the greatest expenditure of resources. Therefore, we first had to determine whether these patients' lives could be saved.

Our triage algorithm consisted of three questions: How urgent is this patient's condition? Do we have adequate resources to meet this patient's needs? And assuming we admit this patient and provide the level of care required, can the patient's life be saved?

In the first days of our deployment, most of the patients we saw had recently been removed from the rubble. The majority had limbs that were compromised by open, infected wounds. Untreated, open fractures meant infection, gas gangrene, and ultimately death. Clearly, the sooner after injury the patient received medical attention, the better his or her chances of survival. Late-arriving patients who already had sepsis had a poor chance of survival. But there was no clear cutoff time beyond which patients could not be saved; each case had to be evaluated individually.

One of the dilemmas we had to confront repeatedly was whether to accept a patient with a crush injury. In such patients, rhabdomyolysis often develops, with resulting impairment of renal function. Given the absence of functioning dialysis facilities, the chances of survival in this scenario were low.

The potential for rehabilitation was an additional consideration in the triage process. Patients who arrived with brain injuries, paraplegia secondary to spinal injuries, or a low score on the Glasgow Coma Scale were referred to other facilities. Since we had neither a neurosurgical service nor computed tomography, we believed it would be incorrect to use our limited resources to treat patients with such a minimal chance of ultimate rehabilitation at the expense of others whom we could help. But denying care to some patients for the benefit of others was not a course of action that came readily to physicians accustomed to treating all who seek care.

Patients who had just been rescued presented another dilemma. We believed it would be inappropriate to deny treatment to a patient who had survived days under the rubble before a heroic rescue, even though this policy meant potentially diverting resources from other patients with a better chance of a positive outcome. Indeed, one patient who was rescued a week after the quake was brought to us in dire condition. She was admitted, was intubated, and underwent surgery but ultimately did not survive.

Read the whole thing (it's not long).

Curiously, they don't even mention that the same kind of analysis regarding whom to treat first is done on the scenes of terror attacks (God forbid), although ultimately having the facilities to treat everyone is less of an issue in a terror attack in Israel than it was in an earthquake in Haiti.

posted by Carl in Jerusalem @ 2:53 PM