During disasters and other crises, the scarcity of resources facing emergency physicians can escalate rapidly. The luxury of taking a structured, proactive approach is rarely afforded to emergency physicians in disaster situations. Understanding how to prioritize actions and triage decisions is critical. Unfortunately, consideration is often not given to how decision making or resource use should be modified to allow for the greatest good for the greatest number of patients. “We need to have a mindset in which we are prepared to make ethically appropriate, relevant, best-informed triage decisions when faced with a disaster situation,” says John L. Hick, MD.
Analyzing the Spectrum of Emergency Care
Dr. Hick was lead author of a review on allocating scarce resources in disasters that was published in Annals of Emergency Medicine. He says that care in the ED occurs across a spectrum, from conventional care to contingency care (Figure 1). “Contingency care involves providing usual care, but also adapting the staffing, supplies, or environment slightly from conventional care practices. Institutions that are better prepared can delay transition to crisis care longer than those that are not as prepared. In crisis care, the medical care provided changes to reflect resource limitations. Decisions about how to prioritize resources to benefit the most people have to be made.” Six key strategies have been established in published literature to help ED providers when anticipating or faced with a resource shortfall:
1. Prepare: Stockpiling some reasonably inexpensive items, like morphine, can make a big difference when faced with any kind of mass casualty situation.
2. Substitute: Many medications, such as antibiotics that cover the same basic spectrums, can be used in place of one another.
3. Conserve: Oxygen supplies, for example, can be maintained by only using oxygen when saturations are below 90%.
4. Adapt: Thinking outside the box can be helpful during a crisis. For example, an anesthesia machine could be used instead of a ventilator in some situations.
5. Reuse: Most medical devices, including tracheal and nasogastric tubes, can be disinfected and used in multiple patients. Some items (eg, central lines) need to be sterilized, but some medical equipment that normally gets discarded can be reused with some foresight.
6. Reallocate: Some items, like blood products, cannot be reused. During a crisis, ED physicians should determine how much of a particular resource is left and how it will be used to the best advantage of the population.
See Figure 2 to view a sample prioritization of the most critical intervention in a mass casualty setting — hemorrhage control.
Making Decisions During Disasters
When mass casualty events occur, emergency physicians are often forced into reactive situations, particularly when these events cause infrastructure damage. “When it’s unknown what’s going on at other hospitals, ethical choices must be made on the fly,” Dr. Hick explains. “Clinicians need to know how to activate their facility’s plans to get in touch with other facilities, if possible, to find out where there are sufficient resources and then begin making proactive decisions. Thinking ahead, having a good framework for making these decisions, and understanding the factors that should and shouldn’t be considered can put physicians in a good place to defend decisions.”
Among the key factors to consider when allocating resources is prognosis (Figure 3). “Physicians should ask themselves what the benefit is by offering particular resources to patients and the duration of the expected benefit,” says Dr. Hick. “For example, patients with acute respiratory distress syndrome may need a ventilator for 10 days, whereas those with pulmonary contusions will likely only need it for a few days. During those 10 days, the ventilator could benefit several people versus one.” Dr. Hick adds that it is important to avoid considering the contribution of patient behavior to conditions, the cost of providing resources, and other more obvious factors (eg, gender and race) when allocating resources.
Ongoing Efforts Among Emergency Physicians
“With inventories, emergency physicians must be vigilant about trying to keep some degree of flexibility and responsiveness in hospital and vendor supplies,” Dr. Hick says. “This is especially true when deciding on and maintaining stocks of items and pharmaceuticals that are likely to be needed in all disaster situations. With the clinical and administrative skills that make them adaptable to unique situations, emergency physicians should be able—with practice and preparation— to manage resources and make ethical decisions when resource shortages occur in disasters.”
Readings & Resources (click to view)
Hick J, Hanfling D, Cantrill S. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59:177-187.
Klein K, Pepe P, Burkle F, et al. Evolving need for alternative triage management in public health emergencies: a Hurricane Katrina case study. Disaster Med Public Health Prep. 2008;(suppl 1):S40-S44.
Merin O, Ash N, Levy G, et al. The Israeli field hospital in Haiti: ethical dilemmas in early disaster response. N Engl J Med. 2010;e38.
Hick J, Barbera J, Kelen G. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3:S59-S67.
Chaffee M. Willingness of health care personnel to work in a disaster: an integrative review of the literature. Disaster Med Public Health Prep. 2009;3:42-56.
Sasser S, Hunt R, Sullivent E, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep. 2009;58:1-35.
Powell T, Christ K, Birkhead G. Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep. 2008;2:20-26.
Bogucki S, Jubanyik K. Triage, rationing, and palliative care in disaster planning. Biosecur Bioterror. 2009;7:221-224.