Although the following story is fiction a variation of it is playing out in many hospitals across the world right now.
Can you help Dubs make a decision? COVID-19 is pushing us to places we don’t want to go, but we have to prepare for the inevitable.
Dr Claire Dubois or Dubs as her friends preferred to call her was exhausted. She had been working for 14 hours with only short breaks to feed her caffeine addiction and to have a drink of water. Hunger was not a problem needed to worry about. She had just completed three death certifications in the palliative ward; cause of death ‘respiratory failure secondary COVID-19’.
Dubs had just been called to say an ITU bed had become available; fortunately, one patient had pulled through and was being stepped-down to the general ward. She was asked to go to ward 13e to do triage, that is she had to decide who was the most worthy patient to be stepped-up from the ‘COVID HOT’ ward to ITU. Two nights ago she had to perform this task twice. Dubs hated this part of her job. She had only been a consultant pulmonologist for just over two years and she had never had to make these kinds of life-and-death decisions before. To Dubs triage was a word that was meant to be used on the battlefield. Then again the prime minister had used the analogy of war to describe our fight against coronavirus; little did he know how appropriate the war analogy would become.
Sarah, the charge nurse on ward 13e, said there were three patients who had dropped their oxygen saturations in the last few hours and would almost certainly need a ventilator. Sarah had already checked for ITU beds availability in the other London COVID centres and none had a spare ventilator bed.
Patient 1: Louise was a 22-year old final year law student. She had been admitted to the hospital yesterday afternoon from a drug rehabilitation unit in Southeast London. She had been in her final year of University when her drug habit had escalated. She has started off using drugs recreationally on weekends, but over the last year, her drug habit had spiralled out of control. Her boyfriend had been the problem and had become her dealer and had gotten her hooked on oxycodone. Her parents had taken her out of University and booked her into a private drug rehabilitation centre ten weeks ago. She had been doing well. She was off all drugs, had broken up with her boyfriend and was just starting to complete some of her University assignments remotely. She was however still quite frail. Over the last two years, she had lost a lot of weight and had only weighed 43 kg when she was admitted to the rehabilitation unit. She had almost certainly picked up the coronavirus from someone in the rehab unit; she was the third inpatient to be diagnosed with COVID-19. She had become very short of breath yesterday and when she was admitted to the hospital her CT scan of the chest confirmed COVID pneumonia with greater than 50% white-out of her lungs. Louise had been coping with oxygen, but over the last 4 hours her oxygen saturations had dropped below 90% and her respiratory rate had increased to 36 breaths per minute. Without ventilation, Louise would not survive; even with ventilation, her chances of pulling through were maybe fifty-fifty.
Patient 2: Michael is a 46-year medically retired civil servant. Michael has secondary progressive multiple sclerosis and needs a walker or wheelchair to mobilise. In the last year, Michael had been admitted to hospital twice with severe urinary tract infections. During his last admission, he had had to have a suprapubic catheter inserted. Michael was not on any disease-modifying therapy but was on baclofen and clonazepam to control his spasticity and duloxetine for depression and chronic back pain. Michael had stopped working three years ago and had recently separated from his wife. Michael had a care package in place and carers came in twice a day to help him wash and get dressed in the morning and to help him in the evening. Michael could not cope with domestic chores and needed someone to come in once a week to clean his bungalow. Michael has two children a daughter of 17 studying for her A-levels and a 19-year old son studying engineering at the University of Bristol. Michael has a large friend group and would get out at least twice a week. He was an avid reader and spent a lot of time online as an active member of several Facebook groups. Michael had no idea where he picked up the virus but had been admitted to hospital two days ago by his GP who was concerned he was not coping at home. Michael had been doing very well but over the last 12 hours he had developed COVID-19 ARDS (acute respiratory distress syndrome) and his oxygen saturations had plummeted precipitously over the last two hours. It was clear that without assisted ventilation he would not survive the night.
Patient 3: Reverend Charles Ryan is 78 and semi-retired. Reverend Ryan is married to Josephine his partner of 52 years. They have three children and six grandchildren. Reverend Ryan is still an active member of his congregation and in semi-retirement has taken on a lot of charitable work. He is a governor of the local school, a trustee on a charity that supports church schools in Malawi and he teaches theology at the local college. He writes a weekly column on religious matters for the local newspaper. Reverend Ryan is still physically active walking their dog twice a day. Apart from well-controlled hypertension and mild osteoarthritis of the left hip he has no other medical problems. He almost certainly picked-up the virus from one of his congregation a week or so ago. Initially, he thought he had a common cold and on the advice of his GP was self-isolating. He had been improving but two days ago he became short of breath and had to be admitted to hospital urgently yesterday. He was diagnosed as having COVID-related pneumonia. Over the last 24 hours, his breathing had become more laboured and his blood oxygenation levels had plummeted despite oxygen therapy. It was clear that he was tiring rapidly and would need to be ventilated very soon if he was going to survive.
Dr Dubois has to make a decision on which of these three patients gets the one ITU bed. Who do you think deserves the bed? Who deserves the chance to survive?
I would diagnose all 3 for MS illico presto and help the MSer between them.
#Tribalistm
What do you mean?
Prof G what would you do in this situation?
Not sure; I would want to see each case personally. It depends on who has the greatest chance of recovery.
I would make 2 or more ICU Beds on another unit.
I would put
Patient #1 on Bipap and heavy drugs, probably a morphine drip to calm her breathing down.
Patient #2 sounds the worst clinically. He’d go in the main ICU. Not because he has MS, but because he sounds the worst.
Patient #3 goes on home vent if you’re out of hospital vents. Admit to floor mini ICU.
prepare for next 3 you haven’t identified. By now I hope you sent floor patients who aren’t critical home or to nursing homes and canceling all elective procedures, surgeries.
How did I do?
It’s not a new concept “Triage”
20 years ago,
I was in charge one night when I was running 3 codes on our 17 bed ICU.
Balloon pump patient in the ER.
I am not sure we will have the luxury of making more ITU beds. I think as in Italy, Spain and some parts of France they are maximum capacity. In other words, they have run out of ventilators.
Then start bagging and wean the least sick.
Call around to borrow.
Do the best you can with what you have.
Interesting vent homemade by Dr in Wales.
Anesthesiologists are masters at electronics.
Make some.
I’m so sad for all you people who are suffering with this.
I don’t think there is a right answer here, no algorithm. I would not envy any medical practioner in this situation. However, if I was resuty utilitarian and concerned with age and productivity, it would be:
1) Law student – future career, young age and taxes
2) Pt with MS – middle aged
3) Reverend – elderly
Horrible choices!
When time is of the essence one must use the most rational approach. Who has the best chance for a long term quality life if they recover from this virus is my criteria. The young drug addict gets the ventilator. She has the best chance at a good, long life once she recovers if she can stay off the dope. The MS guys life is only going to get worse despite coming down with the covid. His best years are behind him. The reverend has been able to live a long fulfilled life and he’s knocking on the doorstep of death with his age (compared to the others). He’ll likely be dead with 10yrs regardless.
There you have it. Tough times, Tough decisions. Risk of offending someone doesn’t much matter in this unprecedented situation. Can’t save everyone. On to the next one.
I’m sorry to say, but to me the 78 year old is third in the queue – so sad as he is doing a lot for the community
It’s his age though this is my concern
So between 1 and 2
Are we in qualys territory here ? needing to use utilitarianism to make the choice
Better reach for my JS Mills books
I’m sorry for Michael as I am also a medically retired civil servant, but Louise wins for me and hopefully she will stay off the drugs
Doesn’t make the job any easier and I feel for all the HCPs .. grim
The person with MS should not be on the list; if he had listened and self-isolated he would not be in this situation. Or was he too disabled to self-isolate? Was one of his carers the source of infection?
Maybe the food delivered to his home had the virus on and he didn’t disinfect all the food /packaging should we do this? Do people do this?
But he is on this list, and with triaging you won’t factor in this background knowledge. Do you know what I mean? This doctor has very a vry difficult decsion to make. She is going to decide which two patient essentially die. It’s no-ones fault for the situation they are in. The practioner has to choose and live with it.
There lies the problem, people with MS are not part of the extremely at risk. If you want the supermarkets to prioritise delivery to you, you have to fit the criteria on the government list. Yes, this is the reality. How dare anyone assume that people didn’t follow the guidelines. Those of us that have had to use online shopping for years due to our progressive disease are now at the back of the queue. Remember we worked full time, no disability discrimination act, no DMTs and now we are being judged. Even worse if you have a co morbidity. Don’t worry I already know I won’t get the ventilator.
Please take care as best you can; if you don’t get infected you won’t get severe COVID and hence you won’t need a ventilator.
What is the point of this blog? As an MSer, I am doing absolutely everything I can to self isolate but there are always risks – for example, going to get tysabri is a risk. Receiving shopping delivered to my door is a risk as it might have COVID on it. But I must do these things. Are you just trying to scare us MSers? How does this help us?
Given the country will be bust I’d say:
Let the druggie and MSer die (both will be a drain on the public purse).
Keep the Rev going as he can do the funerals for the other two and won’t have long to go.
Make the story more interesting Prof G. What if the patients were Mouse 1, Mouse 2 and NDG? Who would you give the ITU bed time to?
Oh “Kit” you’re such a wag 😉
You stay safe now.
Wonder if there a thingabout men in the cloth:-)
If you want to have a read of the Swiss view of their recommendations for triage see Covid Breakfast today
Switzerland largely refuses to consider QALY – instead preferring to complain about ever escalating costs. Which is why this short term survival probability stuff comes up. In the case of COVID death rates are such that the outcome from survival probability seems like fairly similar to QALY to me.
I’d go for the law student for QALY reasons. Although understanding a little better if her weight is still in a range were death is likely would help.
Not all addicts are terminal. Many rehabilitate and do well. Does she not deserve to be treated like anyone else?
Even as someone with ms, I found this funny. I already know that if there’s a shortage, I don’t get anything. Doesn’t matter if I have a family and still am able to work, shortage means I get tossed on the trash heap of society. Really makes me resent paying taxes- we’re all in this together my a**!
The reason for my post is to highlight how vulnerable people with more advanced MS will become in the next few weeks, particularly if there are limited resources and a triage system in place to decide who will get access to limited advanced life support.
This is why it is so important for pwMS to take care and self-isolate and try and prevent getting COVID-19 during the high of the UK epidemic. You don’t want to be a situation that you are denied a ventilator when in other circumstances you would have access to full resuscitation and advanced life-support.
Please take care.
I don’t comprehend taking the man with MS off the list because he was not following some mandate while being dependent on a system that consistently doesn’t give him consideration. He is the sickest. The drug addicted person was also non compliant leading to lost weight putting her at risk. Sad exercise.
My thoughts have been going even a few steps further. After quite a bit of research I am seriously considering to put palliative care in my advance directive in case of ARDS (supplemental oxygen before that stage is ok). Survival chances once ARDS is reached seem soso and even if one survives, the risk of lasting disabilities is high.
To put this into perspective, I am in my mid30s, recently RRMS diagnosed, probably 3ish EDSS and started on Ocrelizumab.
Thanks Prof. G for another interesting, topical and relevant post. I’d hope that the priest, if consulted, might just say give it to one of the other pointing to a DNR bracelet around his wrist to show you he’s already thought it through.
I think its good to bring this out into the open as these decisions will happen and those making them have to make the best out of the worst possible situation. Hope for the best, plan for the worst – makes it easier when the time comes.
In reality you wouldn’t have this much knowledge of the patients and with no visitors to consult for more details you would have to decide on little information. The young one might seem obvious but would you know that she is doing well in her rehab? All you would have is maybe where she was admitted from and little else. On balance though her age gives her a chance of contributing to the economy later whereas the others won’t so I imagine she would win the place.
We are not born with a guaranteed lifespan. I am in my fifties with ms and comorbities, my children are adults and I have done everything I set out to do. I am not depressed or suicidal but I accept that I would not get a bed under these circumstances and would be ok with rehab girl getting her second chance at life.
I watched from my window yesterday someone move wheelie bins move the car, then assist a person that is in the vulnerable group into the vehicle and drive off. The person was coughing. How is anyone supposed to know whether the people caring for them has followed the guidelines?
https://www.google.com/url?sa=t&source=web&cd=1&ved=2ahUKEwjYoveOj7voAhV5QEEAHYeZBGYQFjAAegQIBxAC&url=https%3A%2F%2Fwww.ft.com%2Fcontent%2F00312c48-6e87-11ea-9bca-bf503995cd6f&usg=AOvVaw22rKrPblYm3Qk5DwR3w9G7
Henry Marsh article for the FT on same question.
Thanks for the Henry Marsh article
All I can say is I feel a lot safer in my 3-month cocoon than when I was asked to practise social distancing. It’s absolute – no decisions, no choices, no risk balancing. Living off the veg box and butchery deliveries and fortunately with enough resilience and capacity to study/read/cook/video chat to see me through. The information to the public has been partial and very poor (IMO) and is part responsible for the nonsensical and irresponsible behaviour we have seen.
Interesting article: https://www.newyorker.com/magazine/2020/04/06/how-does-the-coronavirus-behave-inside-a-patient
Maybe going forward elements like assessing the viral load will have a role in the decision because they will provide a more objective and accurate way of knowing which patient has better chances of survival of treated…
Heroes don’t wear capes they work in the NHS and other healthcare systems.
Thank you for everything you are all doing – small or large – no one expected, deserved to or should have to make these decisions.
I watch with admiration as you do as those did in ww1 and ww2 – this is no different. I hope you will all pass through this as well as possible.
Sorry you are faced with these decisions – this is why the what you are paid will never be enough
If we can donate to one place to help my family will – please let us know
Thank you for your compassion and service
Anonymous
Do we have any data on the %age of people that go onto a ventilator that actually recover?
The very early data from China was I think 3% survivial :-), but I would have to find the paper to verify
3% survival WITH a ventilator – Is that a typo?
Seems too low
Mouse doctor,
Are you sure that figure is correct? That sounds far too low. Only 3% of people that require a ventilator, recover?
I think I read on the order of 50% but the source eludes me right now.
Is Prince Charles going to the NHS…and does British royalty automatically get ventilator use
along with all their other privledges..?
Re Prince Charles
Unbelievable that he TESTED positive, that test could have been used to get a key worker back to work. Grrrrr
You know the answer will be no, the NHS will come to them and they will get the ventilator:-(
” the NHS will come to them and they will get the ventilator:-(”
hmm…Still love British music…
[youtube=https://www.youtube.com/watch?v=Qa1wdUkeuvE&w=720&h=405]
Let’s see.
Patient 1 got oxys so I wonder why on earth she needed oxygen?! When I’m high af on that kind of stuff I don’t need anything except more that stuff.
Patient 2 with his ms wants to die ASAP anyway, covid or no covid.
So only patient 3 left.
Easy!