A funny kind of anniversary

pogge — Sat, 10 May 2008 01:32:57 GMT

It was a year ago this past Wednesday that I had an unfortunate disagreement with the driver of an SUV. She seemed to think it was perfectly natural for her vehicle to occupy exactly the same space as my Honda Civic at exactly the same moment in time. I was always taught that was a violation of the laws of physics. Turns out I was taught correctly. That Civic has long since gone where Hondas go to die and I woke up in the hospital.
A year ago today I was more or less conscious, lying in the ICU of a Toronto hospital and beginning to understand, at least dimly, what had happened to me.

A few days later, one of my cobloggers turned up with a big, fat envelope for me. It was pages and pages of well wishes from a thread here on the forum and from comments at the blog. In case I didn't say it properly along the way since then, a big thanks to everyone for the kind thoughts. It was much appreciated.

As you can see, I'm still around. I may not be as visible around here as I was on the old forum but that's because this one requires less of the kind of care and feeding I used to provide at Old Yeller. But know that I still cruise through every day. You can't get rid of me that easily. Even an SUV wasn't up to the job.

Oh, and from the Dept. of Silver Linings: when I came to in that hospital and realized it was going to be a while before I'd be able to slip out for a smoke I decided I may never get a chance like that again. It's been a year and two days since I had a cigarette. At least something good came out of the experience.

Okay, as you were.

Disasters, Surge and Pandemics

DemFromCT — Sun, 11 May 2008 15:22:28 GMT

So here are some cheery headlines to catch your eye:

US: Hospital ERs overwhelmed, one-day study finds (May 5)
A one-day snapshot of emergency room conditions at 34 U.S. hospitals shows they are all overwhelmed and none is prepared to handle a big event like a disaster or attack.
Bird flu pandemic risk just as real and probably growing (May 8)
Experts are warning that the risk of a human bird flu pandemic remains just as real and is in fact probably growing.
Doctors debate who would be allowed to die in pandemic (May 5)
Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding who to let die.

Together, they illustrate a dilemma. On the one hand, US hospitals are already strained, and can't really handle any more stress (see Medical Crisis: The Shape Of Things To Come). On the other hand, any kind of major disaster, be it a Katrina-size storm or a pandemic, will add more patients and more demands to a medical system already maxed out, particularly when it comes to emergency departments and intensive care units (see Pandemic Challenges For Hospitals.) From the WaPo back in February:

The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say.

It's a problem. After all, from wildfires to tornadoes, natural disasters happen. So what does one do? A relatively new approach to major disasters after Katrina is to realistically appraise the numbers and try and figure out how hospitals can cope... see Hospital Surge, Exercises and Pandemics. And when they can't, well, at that point, when patients outnumber the available beds and equipment to take care of them, tough decisions need to be made.

...an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.
The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and U.S. government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.
The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health-care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

For anyone interested in the details, the medical journal CHEST has made the task force report available (in several parts) for free.

Now, whenever we talk about hospital surge and rationing, there's bound to be people that get upset. But in reality, it's much better to talk about these things in advance rather than avoiding the topic, having no plan and having a disaster hit. And limited beds, limited supplies and limited personnel (shortages of space, staff and stuff) will force these unpleasant rationing choices upon us, like it or not. That's why California and New York have both looked at versions of this. In addition, the nature of infectious disease outbreaks, with the possibility of quarantine and isolation, have raised civil liberties issues of a different sort (see The ACLU, Pandemic Preparedness, and You).

So, step back and look at the big picture. The sheer size and scope of disasters require a completely different approach than medical 'business as usual', yet that means bringing in ethical and legal issues (e.g., rationing) that our political candidates like to avoid (except when they are accusing the other guy of advocating it). But don't let the politicians fool you. As illustrated in today's post, looking at rationing is now a mainstream part of evaluating hospital disaster care, and an arguably appropriate response to shortages.

The California Department of Public Health recently released the first comprehensive surge guidelines for health care during a catastrophic emergency.
The new "surge capacity guidelines" - which authorities hope will serve as guidlines for hospitals nationwide, especially in the event of a pandemic - calls for letting older, sicker patients be allowed to die in order to save the lives of patients more likely to survive a catastrophic public health crisis.

By the way, this is a topic (health reform, disaster preparedness and the state of disrepair of public health infrastructure) the Presidential candidates need to address. At the same time, looking at "gut-wrenching dilemmas" needs to be done openly and with the input and participation of the public. You certainly don't want decisions like these to be made without you, do you?

Flu Wiki Forum - Recommended Diaries

A funny kind of anniversary

Disasters, Surge and Pandemics