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Potential Penalties for Health Care Professionals Who Refuse to Work During a Pandemic

by: Rex

Sat Mar 29, 2008 at 12:19:37 PM EDT

Any feedback or visibility an recent JAMA article regarding this.  Summary of article?
Rex :: Potential Penalties for Health Care Professionals Who Refuse to Work During a Pandemic
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hi, Rex
Worthy of its own diary, certainly.

Here's the concluding para:

Penalties for HCPs who refuse to work during an epidemic
have not yet been imposed. Rather than relying on
punitive measures, policy makers should develop incentives
to encourage all essential professionals to volunteer to
work during infectious disease outbreaks. For example,
governments could create funds to provide hazard pay for
individuals who volunteer to work during a pandemic.
They also could make it easier to credential individuals to
work during emergencies and adopt measures to protect
volunteers from criminal or civil liability. Professional organizations
can play a role by promoting a spirit of volunteerism,
which can be a powerful way of encouraging service
without resorting to compulsion. Threatening HCPs with
license revocations and imprisonment, even if they have
not violated any preexisting treatment obligations, is not
the solution.

Potential Penalties for Health Care Professionals Who Refuse to Work During a Pandemic

Carl H. Coleman, JD; Andreas Reis, MD

JAMA. 2008;299(12):1471-1473.

The severe acute respiratory syndrome (SARS) epidemic and the spread of avian influenza have generated renewed interest in health care professionals' (HCPs') obligations to work during a pandemic. However, most discussions of this issue have occurred on a relatively abstract level of ethical analysis, with less attention to what should actually happen to HCPs who are unwilling to work. Should HCPs who refuse to work be fired from their jobs? Should they lose their licenses? Should they go to jail?

It is a real possibility that some HCPs may refuse to work during a pandemic. Working during pandemics could place HCPs-and, by extension, their families-at significant risk of infection. Protective measures like masks may reduce the risk, but some HCPs were infected during the SARS crisis even after such measures were implemented.1 Even though most HCPs continued to work during the SARS epidemic . . .

paraphrasing some points here
Basically the article analyzes the issue systematically from several aspects.

First of all, what might be general penalties for HCW who refuse to work?  There are general contractual obligations to their employers and through them to the patients.  Even though some may say that the workplace in a pandemic would be "abnormally dangerous", this would be a difficult case to make under general labor law since it would be hard to argue that the risk of exposure to infectious diseases is not reasonably foreseeable for someone employed in clinical care.  Thus they may suffer penalties due to their violation of their employment contracts.

Secondly, there may be special penalties for refusal to work during PH emergencies.  South Carolina and Maryland are cited as specifically carrying laws that cover a wide range of activities that HCW are required to perform when ordered to do so.  Maryland in particular has made it an offense punishable by imprisonment for any HCW registered or licensed under its jurisdiction to disobey such orders during an emergency.

The authors argue that there is a difference between contractual obligations when someone has agreed as part of an employment condition to care for patients in general, such that in an emergency they would be expected to fulfill their normal roles, and others who are licensed/registered but either not working for whatever reason (retired, taking time out) or working in non-clinical jobs where they are not normally expected to provide direct patient care.  The authors believe that the latter have not willingly contracted to provide clinical care and so any clinical duty they undertake in an emergency should be voluntary, and any refusal to work in such environments should not be punishable, especially not by such severe penalties.

Some have argued that various professional associations have maintained codes of ethics and that such codes include duty to care.  However, the authors emphasize that such professional associations are voluntary organizations with no legal authority to regulate professional practice.

There is yet another school of thought that suggests the existence of some sort of 'social contract', that to the extent that societies often view HCW particularly physicians with respect, and that they are often beneficiaries of public spending eg subsidies on medical school education, there is therefore an obligation to help out society in an emergency.  Additionally, some also suggest the presence of some moral duty in that "special skills give rise to special duties".

Although there is some merit to this, to the extent that society would look negatively on a physician who refuses to care for someone say in an accident, there exists no legal responsibility to act in such altruistic manner.  Here I quote the original article which summarizes the ethical/legal balance well:

However, even the most ardent proponents of the duty to rescue generally agree that individuals should not be required to undertake rescues at significant personal peril.18  Requiring HCPs to treat patients with contagious infections, in the absence of any preexisting treatment obligations, would violate this principle. Such requirements also could conflict with HCPs' obligations to their other patients or their own families. Moreover, even if the moral obligation to assume risk is considered to be greater than usual during public health emergencies, HCPs are not the only ones whose services will be required during infectious disease outbreaks. Numerous categories of individuals will be essential during a pandemic, ranging from funeral directors to border control agents. The law should not single out HCPs for drastic penalties like license revocations or imprisonment when other individuals whose contributions are equally important are free to refuse to work without similar repercussions.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

what I find most disturbing, is the prevalence of such debates about whether HCW should be obliged to go to to work in a pandemic, but almost zero debate about whether employers should be obliged to provide protection commensurate with the dangers of working in a potentially life-threatening environment.

Any duty of care that HCWs owe to patients and employers, is equally balanced by the duty of care that employers and the government (ie states that try to ORDER HCW to go to work in an emergency) have towards HCWs.

Unless and until we see massive amounts of spending on stockpiling sufficient PPE to afford reasonable protection to HCW, any discussion about penalties are to my mind unfair, unethical, and willfully negligent of the duty of employers to protect staff.  TPTB cannot and should not expect people to put their lives and their family's lives at stake without an equivalent degree of willingness to sacrifice their own budgets or careers to acquire such protection.

Anything less than that is unethical and hypocritical, IMHO.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
reciprocity is an established ethical framework
so, to be fair, if there's not much re "ethical responsibilities of employers" in a legal discussion about "existing rules for HCW/HCP", I can see that. But whether employers have a legal obligation to provide PPE is another story that should be explored.

[ Parent ]
employer's duty to the HCW-
In these United States, there are indeed mandates for employers to provide a safe working environment.  OSHA has made specific recommendations for HCWs in the context of a pandemic, and there is also the "general duty" clause which provides broad requirements for employers to meet WRT worker safety.

It is entirely appropriate for workers to bring these issues up ahead of time.  If the administration of a hospital had been put on notice that they were not prepared for a pandemic because of lack of PPE, and that unprotected workers COULD NOT LEGALLY BE COMPELLED to work during a pandemic, when the pandemic started, nobody could blame the HCWs for not showing up.  Certainly I would not.

My medical preparations include substantial respiratory protection not just for the medical team but for each member of the team.  If I can do it, so can anyone else.

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
as you said elsewhere
plenty of agreement.

[ Parent ]
employer versus state government?
This might be an unimportant distinction, but as I read the Maryland state law concerning this issue, it seemed to me it wasn't saying that a hospital could force a HCW to work in an emergency (or penalize them with fine or imprisonment if they didn't.)but that the governor/state government could.

"The Governor may order any health care provider, who does not voluntarily participate, to participate in disease surveillance, treatment, and suppression efforts or otherwise comply with the directives of the Secretary or other designated official."

Seems to me, hospitals may feel they are off the hook in the state of MD, in terms of responsibility to HCW.  THEY owuldn't be the ones requiring the HCW to work -- it would be the state government.

There's probably some law that says the state government is immune from all liability to people required to work, in an emergency, without proper protection.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
yep, Maryland is a special case
The authors of that paper certainly does not agree with their stance.

My thought on that is, particularly since their definition of healthcare providers include employers as well as individual HCWs, good luck trying to get compliance.  If the hospitals run out of resources, how the heck are you supposed to compel them to stay open?  On what?

It's one of those laws that are rather meaningless when it's time to test it, IMHO.  But then I'm generally ignorant about laws...

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
HCW's can't work miracles
I agree with Susan.  The working conditions expected to be present within the hospital and outpatient settings will rapidly deteriorate soon after the beginning of the pandemic.  Supplies will run short, beds not available and no drugs.  Forget about HCWs. Many non-professional staff will stay home especially when they see their coworkers ill or dead.  Others will be required to stay home to care for sick family members.  

While this post concerns HCWs, the truth is each HCW is supported by a legion on others who make it possible to carry out their healthcare duties.  This includes janitors, IT staff, kitchen workers, those who do the laundry and provide hospital security.  These are just a few on the non-professionals who HCWs depend on day in and out to do our jobs.  While the HCWs get all the credit and the lion's share of the money, we would be helpless without the continued support and assistance we receive from these critical workers.  

In my view, the circumstances will become dire so fast that maintaining the function of the high-tech medical center and even an office based medical practice under these conditions will be simply impossible.  HCWs can't work miracles.  The "medical miracles" seen today in the current hospital are simply an outgrowth of the combined efforts of many people, not just the HCWs.  

I expect many state legislatures will enact draconian laws in the weeks prior the the pandemic like the one in Maryland.  They will be impossible to enforce.  Even if they intended to do so, think about it.  With so many dead and disabled HCWs due to the pandemic, if a qualified HCW decided it was better to SIP or go to a retreat to ride out the pandemic and survived, what would be the use of the government deciding to punish them afterward by imprisonment and revoking their license to practice?  This would simply make the problem of recovery more difficult not better.

Grattan Woodson, MD

[ Parent ]
SusanC, I agree.
I would add this, however.

Not only is it unfair and unethical for government to attempt to coerce HCWs, it is stupid and impractical.
How are governments going to keep HCWs at work?  A 75% CFR airborne viral infection will be a powerful incentive for HCWs to absent themselves from the workplace.  Any jackbooted thug who tries to forcibly keep them at work will find it very hazardous to their health.  

This does not take into account how the families of said HCWs will react to having their family members shanghaied.  I cannot speak for big cities, but most suburban and rural HCWs have well-armed relatives who are likely to react violently to having their relations kidnapped.

Then their is the practical aspect of this situation.  In even a mild pandemic, there will be so many people taken seriously ill so quickly that the health care system will be over-run within a week of the start of a serious pandemic. There will be no vaccines, little to no anti-viral drugs, no respirators available, and nothing substantive for a doctor or a nurse to do except watch the infection run it's course.  Why kill doctors and nurses senselessly? We will need them desperately later on;  why not let them stay home?  If the infection will run it's course anyway, why not let that happen at home where most folks will have neighbors and family who can help them?  I plan to stay as far away from any hospital as possible during a pandemic;  I don't want to die!

Then there is the question of how to keep hospitals open when the support staff are sick and scared, and absent.  For every doctor and nurse, there are several support staff needed to keep them at work.  Are TPTB going to draft all of those folks, too?  Send the Guard in to run the hospitals?

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
at theat point the emphasis would be on home care
something we still lag behind in terms of official recognition.

[ Parent ]
working on it.
Home care is going to be the key to this......

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
yes, that is true
Not only is it unfair and unethical for government to attempt to coerce HCWs, it is stupid and impractical.
How are governments going to keep HCWs at work?

And it doesn't even have to have a CFR of 75%.  All it takes is the first HCW death on news media, or the first child death, whichever one happens first.

The only way to get people to risk their lives to help others, is to provide them with lots of information, lots of support, and have lots of dialogue.

I'm sorry, but I always bristle when I hear senior officials speak of 'educating' HCWs.  What they need is not education, but a frank open dialogue.  They need to be ASKED what is it that they need for them to feel safe about coming to work.   NOT what the science says, about which respirators are effective or whether flu is airborne.  NOT what the law says, about their obligations.  NOT what their professional codes of ethics says.

But what THEY think will make them feel safe.  There are many, for example, who are willing to risk themselves but not their families.  One big item on planners' list should be provision of alternate housing for those who turn up for work.

It was a MAJOR issue during SARS.  I find it incredibly frustrating that no one appears to want to take those lessons seriously.  And, in case someone says they ARE taking lessons from SARS, I would suggest with all respect that they do NOT just look at Toronto, which is what most officials mean when they say that.  

It frustrates me because people ignore what was learned in Hong Kong, one of the richest economies with some of the highest standards of professional practice anywhere in the world.  Let me just share this one piece of information.  The Hong Kong government has set up detailed plans for HCW duties in a pandemic.  They include for example reassurance that if both husband and wife are HCW then only 1 will be assigned to duties that involve potential exposure.  There is also provision for alternate housing for anyone who does not want to bring the virus to their families.

These are steps that CAN be planned ahead of time.  What it takes is sensitivity and communication, not edicts from on high.

OK, end of rant.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
something else I find disturbing
is this Mass Medical Care with Scarce Resources, A Community Planning Guide published by AHRQ (Agency for Healthcare Research and Quality), part of HHS.  If you were to search for the word protection in this document, you will find only a couple of glancing references to PPE for staff, but the vast majority of the results refer to protection from liability.  

Does this indicate that tptb are more concerned with covering their backsides than protecting the people on the frontline?

In addition, as far as I can tell, in this authoritative report based on an Institute of Medicine Workshop Ethical and Legal Considerations in Mitigating Pandemic Disease, there is no reference to the ethics of asking HCW to expose themselves to potentially lethal risk, and whether special provisions are needed to stockpile extra protection for staff.  

All authorities agree that a pandemic is an extraordinary emergency and should not be treated like any other run-of-the-mill infectious disease hazard.  If that is the case, the same logic should apply to staff protection, and extra funding should be made specifically for this purpose.

This is not an area that tptb can afford to ignore.  Come a pandemic, a lot will depend on the willingness of frontline HCW to turn up despite the hazards.  Anyone who, on this day in March 08 after so much pandemic planning has been done, still believes that the issue of HCWs potentially going AWOL en mass is a far-fetched and exaggerated risk, will do well to either do lots of anonymous polls among staff, and/or to read their real voices as they speak anonymously on the internet.  

The following 2 links should be compulsory reading for all involved in such issues.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

susanC here I DO NOT agree.
HCWs will be essentially irrelevant to the immediate outcome of a pandemic, as discussed at length here-

Where HCWs will be important is during the aftermath of each pandemic wave, treating the opportunistic bacterial infections.

The message that ought to be sent out during a pandemic is-

"Stay home if you are sick! There is nothing we can do for you that you cannot do better at home!"

"Stay HOME!  All we can do if you come to the hospital is BURY YOU WHEN YOU DIE."

"STAY HOME! If you are sick don't get someone else sick!"

"STAY HOME! We have no vaccine, no medicines, no food, no water, no room, and nobody to take care of you.  STAY HOME!"


Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
well pandemics have a full range of severity
and different people may have different assessments about how much impact HCWs can make.  

Personally I'm inclined to think that the truth is always going to be somewhere in between, that while they will not be as effective as one would like, neither would they be completely useless.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
perhaps I am being somewhat boorish, but....
would you please articulate for me exactly what a HCW will do for a person who presents with fever >103, respiratory distress, and other clinical symptoms of pandemic influenza DURING a pandemic?

A week into a pandemic, there will be-
No clean sheets or lab coats;
No available beds;
No Tamiflu;
No Relenza;
No Amantadine;
No PPE for the HCW;
No oxygen;
No tubing sets for a ventilator, and no ventilator available anyway;
Shortages of every supply and staff function.

SO what exactly is a doctor or a nurse going to do to treat their patients?  

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
well I'm not here to make the case
that HCWs should go to work.  I'm just commenting on that paper, in the context of pandemic planning.  ie to the extent that they are talking about penalties, why are they not talking about other issues?

Those other issues may include your POV, about whether it is worthwhile for HCWs to go to work.  My POV is this is something that is by no means fixed.  Circumstances will differ depending not just on CFR but also on the phase of the pandemic as Dem said, and also on the preparedness of specific communities.  But for the purpose of planning we would do well to not be fixated to scenarios but cover all possibilities.

These possibilities include where it is no longer safe or no longer useful for HCWs to go to work.  But IMO they should also include where it IS relatively safe or can be made much safer by extra investments on PPE.  If we accept as of today that it is completely pointless to ask HCWs to go to work, we will at one stroke dismiss the instances where with some planning they may actually be able to save some lives.  I for one am not willing to do that, even in my mind.

I believe in informed consent.  That HCWs be assisted to make their own decisions, and that tptb should be made aware of the risks of massive absenteeism.  I also believe in saving lives, however difficult it may be.  I honor all those who are willing to risk their lives to save others.  The least we can do is to support them.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
I agree with LMWatBull Run
At my hospital the above mentioned items will not even be available for more than 3 days, we have already done this assessment on our supplies, and my hospital being aware of this has done nothing except purchase 10 1/2 face respirators (for a staff of 600+).When I read all these proposals regarding my "duty of care",I also first hand understand this is what the Government will latch onto regardless of the Employers' duty to care for their employees. Texas is a employement at will state ( I think that is how they call it), meaning I can be fired on the spot for no resaon at all, at the discretion of my employer. Being an ICU nurse who deals with vents on a daily basis, in my mind's worst case senario I see myself being dragged to work (along with my beautiful 20 yr old daughter, who is a registered pharmacy tech while attending college) This is not what I have worked for continuously the last 4+ years trying to educate the people around me at work and in my community & state. I realize my hospital has ABSOLUTELY NO REGARD for my safety, and in a high CFR pandemic all I will be accomplishing by going to work will be to die early, I will not see that happen, especially to my daughter. So coming to my house.... bullets will fly! I have looked at this from every point of view I can think of, and I think if the gov. tries some drastic measure of rounding up Dr.s & nurses first (thinking this will be top priority) they will be completely missing the boat anyway. All of the auxillary staff is what really runs a hospital, without them we can do nothing....I wonder who will get those 10 respirators!  

[ Parent ]
that is exactly my objection
When I read all these proposals regarding my "duty of care",I also first hand understand this is what the Government will latch onto regardless of the Employers' duty to care for their employees.

that the debate on duty of care by HCWs is unfair and unethical without a  corresponding debate of duty of care by employers and/or government and/or society towards HCWs.  There is no place for such a one-sided debate, IMHO.

Unless and until the day that such issues are treated seriously, ie with serious money on the table, all else is moot.  

The danger is the public whether informed or not will be in no mood for forgiveness for any known HCWs who refuse to risk their lives for others.  This issue is complex and hugely divisive, and which tptb has up to now preferred to ignore.

They place society at great peril by doing so.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Well, I have discussed this at length with my acquaintance
And we are all agreed that having the HCWs die during a pandemic serves nobody.

And I will explain that to my neighbors when the time comes.

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
this discussion has been sent
to various tptb.  I hope they take notice.  

I know many of you no longer believe that government can do anything useful.  My POV is that at least they have been given notice, of what is being expressed here.  Whether they can or will do anything that will make a major difference cannot be determined, but at least it won't be for want of trying from this end.  Just my very humble opinion.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
i'm starting to think
there are two key questions to ask of planners:

- what level of CFR are you folks planning against?
- what level of HCW absenteesim are you planning for?

The answer to those two questions tells a lot about where they stand on this pandemic preparedness issue.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Saving SOME lives, anyway...
It won't require HCWs, just willing people to save some lives.And I agree this is better done in the HOME. I think you can legislate all you want, there will still be a big shortage just because of sick workers and workers with sick family members. How would you ever prove someone wasn't sick when they called in/ didn't show for a while anyway?
Sick people will still need care.A person with a fever of 103 may be unable to get water. Or they may not be able to show good judgement (I am thinking of preventing accidents, especially).  
Rather than appealing to sick people to "stay home, we can't help you" maybe rephrase the message to "take care of each other at home, the hospital is the worst place for you right now," then back it up with PSA s and phone support.

[ Parent ]
I am not saying stay home and die, I am saying stay home and live!  

And anyone that has to be told that they may need help from their friends and neighbors during a pandemic is probably too stupid to heed the message!  Such PSAs are self defeating.

It will be too late at that point to encourage preparation or food storage, but some advise on water disinfection might be useful.

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
there's also early and late
with different responses at different times.

As a HCW, I am planning on going to work, but that may mean I don't come home for weeks.

Your mileage may vary.

[ Parent ]
Can employees refuse to come to work?
I hadn't seen this updates in the FAQ section of pandemicflu.gov before.  I am posting it on this thread because it seems to be related to the discussion.


"During an influenza pandemic, can a healthy employee refuse to come to work, travel, or perform other job duties because of a belief that by doing so, he or she would be at an increased risk of catching pandemic influenza?"

The circumstances under which employees have a right to refuse to work are very limited.  Refusing to do a job because of potentially unsafe workplace conditions is not ordinarily an employee right under the Occupational Safety and Health Act (OSH Act).  (A union contract or state law may, however, provide for such rights.)  Employees may refuse an assignment only if: (1) they reasonably believe that doing the work would put them in serious and immediate danger; (2) they have asked their employer to fix the hazard; (3) there is no time to call the Department of Labor's Occupational Safety and Health Administration (OSHA); and (4) there is no other way to do the job safely.  Employees are not protected for simply walking off the job.

An employer can impose disciplinary action for refusing to work.  However, employees do have the right to refuse to do a job if they believe in good faith that they are exposed to an imminent danger.  "Good faith" means that even if an imminent danger is not found to exist, the worker had reasonable grounds to believe that it did exist.

In addition, employers should be aware that an employee's inability to attend work or perform certain duties could be related to a disability.  In this instance, the employer may need to consider the implications of its actions under the Americans with Disabilities Act1 before proceeding.  For example, if an employee with a disability could safely perform the essential functions of the job with a reasonable accommodation (e.g., telework, changes in shift times), then an employer would need to provide the accommodation, in lieu of termination, unless it would pose an undue hardship.  (See the U.S. Equal Employment Opportunity Commission's Enforcement Guidance: Reasonable Accommodation and Undue Hardship under the Americans with Disabilities Act for additional information.)

We would encourage employers to prepare a plan of action specific to your workplace.  As a practical matter, employers will likely want to be flexible regarding attendance during a pandemic.  It would also be prudent to notify employees and, if applicable, their bargaining unit representatives about decisions made at the earliest feasible time.

Is it just me, or does this response not really answer the question?

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

no, it doesn't answer the question
as to whether those who will refuse to come to work will suffer consequences, and what those consequences will be.

It does however appear to make the case that workers should seek clarity through their 'bargaining unit representatives' (which btw I think is a very quaint phrase for 'union' or similar bodies!  LOL)

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
HCW's do have an ethical duty to the public
As a HCW, I am have enjoyed many privileges and advantages.  One of the most significant is the satisfaction of this work and the ability to help others.  This is why I am a HCW and why I continue to practice medicine despite the well-known problems plaguing healthcare today.

It is my best judgement that it will be impossible to provide meaningful healthcare in the hospital or office during the pandemic within the urban environment.  There are many reasons for this concern and believe me I have really thought about it.  This does not mean that I would consider for a moment not providing healthcare in some setting if I could.  

The setting where I think healthcare will be able to be provided best under these conditions is within the home and small rural communities.  Many of you know that I have spent considerable time writing about how non-HCWs can provide good home care.  As a doctor, I know I can provide advanced care outside the current system in the home of patients or other ad hoc medical settings but not when the zombies are crashing through the door with guns and knifes.  Security is critical to providing good healthcare.  I simply do not see anyway that TPTB will be able to maintain security within the urban environment during a severe pandemic.  This is why I am going to decamp to the countryside and ply my medical arts there.

I am prepared to do this and have obtained a number of low tech medical supplies and some basic pharmaceuticals to accomplish this task.  This is how I am going to honor my ethical duty to the public and society.  I see no good coming from becoming a city-sacrifice in a fruitless attempt to man the hospital barricades.  

What I think is different from my view and that of Demfromct is that I have no faith in the ability of the hospital system and organized medicine to cope with this crisis.  Dem, assuming that I am correct in my view, do you have a fallback plan?  If not, why not?  Don't you think every HCW should have a fallback plan even if they intend to remain at their current job at least until that becomes untenable?

Grattan Woodson, MD

personally I'd like to see more
efforts at setting up what I would call 'astute intermediate care' for moderately ill persons delivered on a large scale.  Like using school halls or such places.

Assuming you have good rapid diagnostics, we are likely to have in my view large numbers of people who are moderately ill (ie too ill for homecare to be effective) who can benefit from IV fluids and meds and oxygen but not requiring more sophisticated care such as CPAP or vents.  For many, timely intervention at the most critical period of their illness, say for 24-48 hours, may make the difference between recovery and deterioration.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Yes, good intermediate care
This is the type of advanced community-based low tech approach that seems most appropriate for the set of circumstances I think likely.  However, the bulk of care must and can only be done at home by non-HCWs.  The biggest impediment is getting the basics of how to provide this care in the hands of the consumer and to provide them with some very basic but needed medical supplies, oral drugs, and other supplies (food, clean water, heat, and survivable and safe shelter) they will need for the duration of a pandemic emergency (9 to 12 months?).

My approach for fluid administration is even more basic than yours Susan.  For instance, while we use IVs every day in the hospital, these medical devices will not be available for long once the pandemic starts. Also, a whole range of other items required for IV fluid administration will be in short supply and since the administration of IV fluids requires a relatively high tech system, like all complex systems, the loss of one critical element results in the failure of the whole.  For instance, to administer IVF consider the following: 1) you need a trained person to start the IV and manage the entire process from deciding how fast the fluids run, how much to give and what fluid to administer, 2) the IV catheters will be in short supply or unavailable soon (a just in time item), 3) the IV tubing will be in short supply (same as #2), 3) the bags and of sterile IVF will also be in short supply quickly as well as the selection of the appropriate IVF solution (ibid #2), 4) Use of IVF has a high probability of complications (sepsis, infiltration, phlebitis etc) all of which occur regularly today despite the use of sterile technique in the hospital setting.  The rates of these in the ad hoc setting will surely be much higher.  Also, the cost of providing or stockpiling these items will be high and prohibitive.  IVF bags also expire like all drugs and their use after expiration raises lots of issues even though they might still be safe.  

My solution to the need to provide advanced hydration to ill flu patients unable to drink is also less than perfect but much more low tech than IVF.  This solution is to resort to naso-gastric feeding through a 1/4 inch plastic tubing that is similar to IV tubing but sold for a fraction of the cost in hardware stores for as a water feed for refrigerator freezers. The placement of this make-shift NG tube is something that requires a trained HCW but the remains a good option to consider for those have these skills.  While there are several possible containers that could be used to hold the fluid administered through the NG tube, my favorite is a kit sold in drug store for use as a combination enema or douche kit.   Don't laugh, this will really work and work well :~). The fluid bladder holds a liter of more of fluids has a hanger attachment built in and also a fluid meter to control the flow rate.  

There are risks using NG rehydration but many many advantages of IVF.  The potential complications include improper placement into the trachea rather than the stomach resulting in aspiration (Susan I know you are well aware of these but others who read this might not).  Good clinical exam post placement will be needed as post-placement x-ray will not be (as an intern in 1980 we didn't use post-tube CXR routinely as is done today and rarely caused aspiration).  Second is proper tube placement but the patient aspirates anyway (the patient's head needs to be elevated and the admin rate needs to be right).  Third is trauma to the nose, throat or esophagus during tube placement.  Fourth is excessive or too rapid NG fluid replacement.  Avoiding all these complications requires expertise and attention to detail but is cheep, low tech, and can be done in almost any setting safely and at low cost using non-medical supplies. The shelf life of these items is infinite as long as they are stored properly.  Boiled water with electrolytes or elemental nutrients (meat broth, dissolved rice CHO, sugar) can be added and their acceptance by the patient is more physiologic than IVF.  Risk of infection is very low to nil.  

I have purchased yards of this tubing and a number of administration sets and pounds of salt and sugar to make rehydration solution for administration in the ad hoc facility I plan to work in.  I have a source of clean well water at the facility with a solar powered pump to obtain the water and a backup hand pump to boot.  I am ready to deliver this low tech approach too sick to stay at home with flu now.  

Lets keep planning and preparing.  It is critical that we put our plans into action rather than just talk, talk, talk but do nothing.  

Grattan Woodson, MD

[ Parent ]
i recall another way to do rehydration but i'm not sure :-?
it's good to have a menu of options if at all possible

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Do you mean the French Method?
Rectal rehydration aka the "French Method" ;~> Just kidding.  No offense meant.

All kidding aside, this is a viable option.  The WHO recommends it in some instances when IVF or NG fluids can't be given.  It is more complex and the patient acceptance is an issue especially if the fluids are given too quickly.  I have never used it clinically but have studied it and worked out some of the issues surrounding it like fluid composition, administration volume, rectal tube placement and how to secure the tube, and most important, patient placement.

I think I put an article about this on the BridFluManual.com web site under Treatment, Advanced Treatment.  I will need to check.  Anyway here is a summary

The colon can only absorb about 1.5L per day in adults.

Also, it can't absorb sugars so they must not be added to the solution.
The patient needs to be in the left later Sims position so the fluid can get through the sigmoid then rolled over into the right lateral Sims position where is will flow by gravity to the right colon where fluid absorption is best.  

A really interesting think I learned about this method of rehydration is that it may be the preferred way to deliver fluids to people subject to CHF.  Apparently, the colon "knows" when the intravascular volume is adequate and will no longer absorb fluids under these conditions.  This of course is not the case with IVF or NG fluids.  I found that pretty interesting.  

If anyone has used this technique clinically, please get in touch with me at gwoodson@mindspring.com.  I would like to learn more about it, when to use it, complications, and how to really do it.  Thanks,  GW

[ Parent ]
eh, I was talking about
anybody who is beyond the kind of help you are suggesting!  ;-)

Basic homecare and innovation will be what we need most, no doubt about that.  While you keep working on those, I would still pursue (yes PURSUE lol) whoever will listen to turn their attention from vaccines which won't be available for way too long and for which at least the US has already ploughed in boatloads of dollars, to some low-cost community care that may make the difference between life and death to masses of people.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
NG Tubes
I talked about NG tubes sometime ago last year, didn't get many replies because non HCW's I just think really didn't get it, but I believe these will be an excellent way to deliever fluids and crushed meds. I think an even easier way to deliver the fluids instead of enema bags would be a 60cc catheter tipped syringe attached to the end of NG tube and held up to deliever fluids in moderate amounts by gravity, and would be safer to prevent large amounts of fluid at one time and possible aspiration. And as stated xrays for placement would not be available.....we rarely use xrays solely for NG tube placements anyway (usually only when we are getting one for endotrachial tube placement, and see the OG or NG placement). We still pretty much rely on ascultation over the stomach with a stethoscope, really very fool-proof with a little training. 60cc cath tip syringes can usually be purchased in any Farm/Feed store where they sell other products for livestock. Putting in an NGT is also fairly easy with alittle training. When I participated in the HHS blog last summer the point I really tried to get over to TPTB was a series of maybe 30 min. instructional videos every week on TV/computer/whatever else that would reach people, each video would cover a different aspect of pandemic preparedness, especially HOME CARE, seeing something visually is an excellent way to teach...we are getting nowhere with these random 30 sec. commercials that most people don't even know what they are about. Maybe we could start some simple teaching techniques here...at least we have interested people.

[ Parent ]
60cc syringes
I like this idea TX.  It will be safer too than hanging a liter enema bag and walking away.  You can give 60 cc all at once and come back every hour or so and give more, or train a lay person to do the same.

I agree with the use of auscultation for determining proper placement.  I don't think we can expect lay-persons to ever be able to confidently pass the tube or ensure proper placement though.


[ Parent ]
This might be ridiculous for humans, but when my cat was dehydrated,
the vet injected a solution under her skin.  It made a bulge of 3 or 4 square inches, which slowly went away.  If this works, wouldn't under-the-skin injection be less hazardous than threading a nasal tube?  I suppose the solution would have to be sterile, and syringes would have to be available (aren't they a controlled item because of drug addicts?).

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]
Not at all
Subcutaneous fluid replacement is an option.  It is just not as nice as IV or NG replacement because is does damage the tissue and hurts.  Never the less, it would work in a pinch.  


[ Parent ]
does "astute intermediate care" deserve its own diary?
Is it being done somewhere?  I think afludiary's 3 newsitems are exactly about what you suggest, no?




(it's on the right column of said blog)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
argh, wrong word,
austere, not astute!


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
:-( "astute" sounded quite apropriate ... LOL!

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
that too lol
but the word austere has special meaning - very basic, with minimal bells and whistles, focused most importantly on treating as many people as possible with available resources.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
it deserves an austere diary, then
and i guess many people would contribute to it fast

Ok, here it is: http://newfluwiki2.com/showDia...

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
sorry, typo
austere intermediate care.

Not, 'astute' intermediate care!!

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
didn't see the comment until now
early next week, I will write up a report on an austere "flu triage" low tech care unit that we are setting up in the region where I live. We're actually going to run the first field test this weekend with assistance from the state and outside observers, though it's not ready for prime time yet as far "as opening for business" if it needed to.

it will fail at some things, succeed at others, but from it we hope to learn what works and what does not.

The fact that we are doing it at all is a story in itself. There are many community organizations cooperating to make this happen, including but not limited to local public health.

Should that not work, we will try something else. But the emphasis will be on home care. every one who comes through will be given materian now from getpandenic ready.com

So as far as a plan B, right now I am working on plan A. But i have a duty to serve and will likely do so at the local hospital where I have responsibilities. Something will be happening there, no doubt, to keep me busy.

[ Parent ]
possible penalties
I don't think that penalties will necessarily be confined to civil penalties or threats of imprisonment.  The New Orleans city goverment has shown us a little of what those in power can do when sufficiently frightened, and how little respect for law and freedom they can display.  If a pandemic is severe enough, it is very likely that any identifiable health care worker will be made to work by armed force.  A politician in fear for his own life will have no respect at all for yours.

 Sorry about that.

forcing doctors and nurses to work
during a pandemic is wrong, stupid, and impractical.

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
Hear! Hear! n/t

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
But it WILL happen, if not as a decree by officialdom then by desperate parents out-and-out kidnapping someone to come save their child.  

[ Parent ]
it's very sobering
and a matter of practical importance, if you're a known HCW in your neighborhood.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
how quickly can you knock back a can of cream-of-mushroom soup and a dose of ipecac?  they might not be as fond of kidnapping a doc that is projectile vomiting sticky white stuff with chunks everywhere..  :-)

[ Parent ]
Known HCW in your neighorhood
We live rurally, and over the years I have been called in the middle of the night for kids with asthma attacks, people show up on my door or call me during the day for broken limbs, lacerations, one attempted suicide, and other such ailments. Mostly you end up calming the families, stoppping the bleeding and taking them to the ER, or calling EMS if necessary. In my neighborhood during a pandemic I'm sure I will get lots of calls and show-ups, and will do what I can, which may not be much, even reassurance for families at this time will be difficult most likely due to the extreme illnesses....and I know by this time hospitals will be out of the question....how do you calm very desperate families?? Especially when they they will out of their minds with fear and grief,I really do believe the governments could lessen these senarios from happening all over the world with a little honesty and a lot of basic medical info & training....but money and greed rule our world and our politicians. I think if you are a known HCW you may become the object of that grief and anger, they may look to us for answers that we will not have. My sister who is also nurse (retired) lives next store, and she gets calls & show ups also.

[ Parent ]
Some practical advise for HCWs who may be in harms way-
1) consider getting trained in effective self defence.  By this I mean firearms training.  In deference to the stated policy here I will not go further into this topic; there are many resources available.

2) Buy a good bullet resistant vest, and get a number of sweat wicking undershirts to go with it.  I strongly recommend that you get the type of vest with removable carriers so that you can remove the kevlar inserts and wash the carrier.  Vests are hot and you sweat underneath them.  After a few days, you will not want to be downwind of yourself if you cannot wash the carrier easily.  Getting shot is not fun, and vests are neither bullet PROOF nor infallible, but if you have a reasonable expectation that you may someday find yourself being shot at, they do give you an edge that may help you to survive the experience.  Especially if you are the only medical are around, you do NOT want to need treatment for a GSW of any sort.  Besides, getting shot really hurts!
One source is www.bulletproofme.com;  local police supply stores may also sell to HCWs if you say something like-  "I am a nurse and sometimes work late at night in a bad area and I wanted some protection..."  Note:  possession of an unlicensed bullet resistant vest in New Jersey is a felony.

3) Get a good supply of pepper spray, but read the fine print, and be prepared to cope with someone who is not affected by the spray.  (Hint, see recommendation #1)

In closing, I will say this:  I have trained a number of HCWs and I tell them that the Hippocratic Oath is not a suicide pact, and that a person who is attempting to kidnap, rape or murder you is not a patient, but someone who must be stopped to prevent human misery.  Their reasons or lack thereof for their behavior is NOT your problem;  Their felonious conduct is!

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
Kidnapping a HCW?
I'd guess that'd be like stealing a horsein the old days out west. Leaving a man on foot was tantamount to a death sentence, so horse theives got hung.

Kidnapping a HCW during a pandemic is useless and risks killing someone we will all need later on.  If we do not defend individual rights we lose our civilized values.  The goods and technology of today are the result of the philosophy of the Enlightenment, of the idea that people have rights and that all must respect those rights.  No rights, no goods.  If we want the trappings of civilization, we must protect the foundations of civilized behavior

I have a suggestion for what to do with somebody that kidnaps a HCW during a pandemic.  Get a rope!  In spite of what any politician says, nobody was born entitled to health care, and no HCW is obligated to treat you if they don't want to.  Period.  Freedom of choice means the right to say "NO!"

Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]

Sir, I agree entirely.  I am awe-struck that HCW's would even consider working through the kind of event that this forum discusses.  However, it does seem sometimes as though their own virtue blinds them to others' complete lack therof.  

[ Parent ]
this topic is also being discussed
at Effect Measure over here

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

Not related to the JAMA article
but from our nurse friends down under:

"So, something to reflect on yourself. How might you have responded to having to work during the SARS outbreak?
Are you prepared to put your life on the line for your patients?
Thousands of nurses do so every day in war zones all over the globe.
But what of other scenarios?
Currently the simmering H5N1 (avian influenza) virus has a mortality rate of around 61%. The emergence of a rapidly spreading, highly infective ( think: how many patients have I treated with the flu this year? ) disease would place nurses under incredible ethical and moral stressors.
Would you be prepared to expose yourself to the very real risk of becoming infected with avian influenza in your workplace?
What of your duty of care to your family?
And the public?
And what of your duty of care to make sure you stick around to provide an ongoing duty of care to your patients after a pandemic?
For me it would be very difficult. Could it be that the public (and governments) perception that nurses will simply step up to fulfill their duty of care during times of exceptional risk may be somewhat overestimated?

What say you? Is duty of care in the eye of the beholder?"


It is better to look ahead and prepare than to look back and regret.

Medicine is still a profession, at least I hope it is
Being a doctor or nurse is not like other types of jobs.  It is a caring profession where we have an ethic of putting the interests of those we treat above our own interests.  

Believe it or not, it is not the virus that scars me or that would cause me to abandon my office practice and move the to country.  I think it is very likely that I will get the pandemic flu.  I know I might die from pandemic flu but I also think that I probably won't.  It is likely that I will get very sick but I have been sick before.  In fact I got the 1957 pandemic flu and was very ill from this infection for two weeks.  Ironically, it was my father, a doctor who ran a temporary mass influenza vaccination clinic in Atlanta that brought it home to me.  

For some reason I am confident that I will survive the flu and that the vast majority of people who contract it will too.  I have my scientific reasons for this but to be honest the most influential reason I think this way is based on intuition.  I am sure this sounds pretty weird for a medical man to talk about his faith in intuition but not me.  I have learned to listen to it and more often than not I have found this to be a very reliable source.  Laugh if you want.  I care not.

I think that trying to practice in the city where my current office is will be suicide.  My intuition confirms my thoughts about this.  My concern is not about dying from infection bur rather being caught up in murderous civil disorder.  Since I both think and feel that this will happen and medical practice under these conditions will not be possible, I plan to leave the city and go to my farm in the country about an hour NE of Atlanta.  In this rural area, I plan to establish an ad hoc medical clinic.  In the clinic we will take care of people too sick with flu to be cared for at home.  I am hoping to be joined there by other HCWs who feel the same way as I do about taking care of people but are not able due to the above or other circumstances.  I am confident that this will be of help to a lot of folks and that I will be able to serve best in this way.  My intuition confirms this thought, which gives me confidence in its reliability.  

The Doctor


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