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?
