If it’s not them that’s personally affected, some people just don’t care.
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Yeah, triage sucks bricks. OTOH, it’s a lot easier to blame triage protocols than to come up with something better. Even people who have been trained and train others can lose it when confronted with making calls.
I set up an exercise once that I’m really proud of more than a decade later. Simulated head-on between an SUV and a subcompact. SUV had father, mother, and baby in it. Baby was screaming [1], mother was stuck in the shotgun seat and freaking out, and dad was quietly bleeding from a lacerated arm out the driver’s window. Subcompact had a pair of busted legs (femurs) in the passenger side and the unresponsive driver had the steering wheel pinning her to the seat with a crushed chest. The challenge was to get them all assessed and sorted in very little time.
Most of the group did theirs pretty well but oddly enough the one who completely blew it was an ex-Army MD who absolutely could NOT get past the subcompact’s driver. In retrospect I wonder if the scene triggered a nasty PTSD memory. I should ask him.
Thing is, the baby was fine and just angry. She was the #2 priority because NOBODY can think clearly with a baby screaming. Mom was #3, because once she got the door open and had baby in hand, she was fine too. The two solved each other. The broken-legged subcompact passenger was OK where she was and should not have been moved until proper equipment arrived because until then movement could nick a femoral artery and good night Irene. The subcompact driver was dead already for practical purposes because without immediate Level 1 trauma care there was no way to prevent brain death – you can’t do CPR on a crushed chest and no breathing means death PDQ. The #1 priority was, deceptively, the SUV driver who had an arterial bleed that would kill him rather soon but would take very little time to address. Get that bleeding stopped and leave him with the woman and kid, then figure out how to safely extricate the passenger in the subcompact.
This was just a drill. We knew going in what it was about. It was out in the bright sun on a lovely clear November afternoon. And our best-trained and most experienced member totally lost his shit. I cannot overstate the fact that when the shit well and truly hits the fan with lives at stake, you absolutely MUST be able to fall back on training and let that training handle the (relatively) routine things so that your frontal lobes can spare at least a little bit of capacity to watch out for the things that aren’t part of the script. In a real overworked ER or ICU when the world turns into MASH, guidelines and checklists will get you through when what you really deep down want to collapse in a gibbering sobbing puddle in a corner.
In case anyone has gotten the wrong impression, BTW: I am absolutely terrible at this myself. I have been next thing to useless in a couple of scenes, one fatal, where I was outside of my own training and unprepared.
[1] that little girl wasn’t a baby but deserves an award for genuinely nerve-shredding screaming cries and acting.
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I lived there for two years. Leaving was the best thing in a long time to happen – and this was Huntsville, which is almost civilized thanks the Army and NASA.
If anyone has a 3D printer, laser cutter, relationship with any manufacturers anywhere, a phone to help organize, or anything else that could help reduce this horrible triage problem, maybe the links and resources here can help you connect to the highest-impact efforts https://medium.com/@brucefenton/we-need-ventilators-we-need-you-to-help-build-them-30805e5ee2ea
Stay safe and love fiercely, this is not forever.
I spent almost 25 years married to a NICU nurse. I saw what it did to her, so I may not understand but at least have seen it up close.
Now I can worry about $HERSELF’s nephew: resident in pediatric neurosurgery, has the PhD and hopes to do research. Great “kid” and apparently has his head pretty steady, I hope he can deal. He’s also an amazing pianist, that may help.
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Seems like in some cases this could be harder for people with more medical training since they have more knowledge of what they could do with better resources at their disposal.
That sim, or the real thing, would freak me out. But if I could think straight (a big if) I might be able to make the right call because my only training is CPR and a Stop the Bleed class, so the father bleeding out from his arm is the only person I know anything I can do about, and CPR alone doesn’t help most of the time - and CERT disaster response doesn’t even do CPR because people who need it don’t fit the triage protocol for disasters 
Triage sucks in all its forms.
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Those triage decisions need to be made based on medical ethics board guidelines, not political appointees.
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The standard should not be to those that do best without care, nor worst without care. Nor best with care, nor worst with care.
The standard needs to be who will improve the most with care.
If they’ll do well with or without care, there’s no need to supply care. If they’ll die with or without care, there’s no use in supplying care.
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I agree, though such boards can be biased, too. Is there any information on whether or not an ethics board created the list? Or, if so, if there were any political overrides in the list?
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I don’t think Fascist is the right word because it doesn’t necessarily have any of the other hallmarks of Fascism, but it certainly is authoritarian overreach.
Those two paragraphs are contradictory. Improve the most isn’t a viable standard because “the most” from a bad state might still not include surviving.
I’m not medically trained, nor I’m am I fully versed in triage, though the local CERT disaster response training does have it’s own harsh form of triage based on limited resources. Anyway, I’m assuming the standard is who’s most likely to die without treatment, but can be saved with the least treatment. That is, what allows you to save the most people with the your fixed resources. It is harshly utilitarian. We could toss a coin for each person to be fair to individuals. But I’m also assuming that treating the sickest people will take the most resources and lead to the most death. But I don’t know.
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They’re only contradictory for some measures of improvement. I suppose I should have spelled out that you need to cash out improvement as “change in chance of survival”.
EDIT: And yes, excellent point, that it has to be “per unit of resources used”. Though you often have a bunch of resources that different people need differently and you’re simultaneously short on all of them.
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You’ve got five ventilators and ten patients. You do triage - you have no choice in that, it’s inevitable. You can’t not do triage. Only question is: are you going to aim to save as many lives as possible, or aim for some other criteria? (It’s a weird definition of fascism that’s trying to save as many lives as possible).
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I go through drills like this every year. I hate the sadistic psychopaths that design them, and simultaneously am grateful for them. The debriefs frequently lead to near fist-fights. This year’s scenario was a construction scaffold collapse with a range of horrible injuries to workers and passers by. I’m still pissed off by the guy that bled out on me cuz my check wasn’t as thorough as it should have been and I triaged him too low.
The very few times I’ve had to deal with anything close to the real thing, the answers were much more obvious, and while I didn’t seize up, I didn’t perform quite as well as I had hoped I would.
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If you’d read my comments, you’d see I want to have had pre-emptive planning, which the federal government dismally planned on.
You might still end up in a triage situation, but it would not be as extreme as it’s going to be…
I know that you’ll do all you can under the circumstances and I’m sorry for that. It’s criminal that we have a government that refuses to plan ahead right now, because you’d be in a much better position. It’s also criminal that we have a political party that claims to be pro-life but clearly is not.
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I posted this a few days ago, but I’ll repost it here as it’s directly relevant:
These discussions aren’t theoretical anymore. The avalanche has already started. It is too late for the pebbles to vote.
If politicians start deciding who lives and who dies, it is too late. It is also too late if these decisions are made ad-hoc, bedside. These discussions need to happen now with qualified folks who can make these touch decisions before it’s too late.
If the trajectory goes the way the medical professionals claim, instead of how a large part of the US political machine claims, and these guidelines aren’t hammered out, IMHO, we are going to see some very, very atrocious behaviour, vs yet more heroic defiance and stepping up by bedside staff - who, as I said, should not have to be put in that position .
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Right idea, metric is slightly off. How about, “what allocation of resources will save the greatest number of people?”
I’m an OK emergency field medic. I take pride in being a pretty damn good sadistic psychopath. And who knows? That SOB who bled out on you may save someone’s life some day. It’s not terribly likely but if it happens it will justify a lot.
Train hard, fight easy. Of course the whole idea is to have you perform less than your best – that’s how your best gets better. BTW: to the lurkers, there’s always room for volunteer “victims.” It’s a serious public service, you learn a lot, and I confess it’s a hoot as well.
I know you don’t need to be told the above, but I figure some others will benefit.
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There was a good article 1-2 days ago in Ars Technica on the topic of rationed care. It was in response to this article in the New England Journal of Medicine:
https://www.nejm.org/doi/full/10.1056/NEJMsb2005114
Under ethics, the authors write:
Previous proposals for allocation of resources in pandemics and other settings of absolute scarcity, including our own prior research and analysis, converge on four fundamental values: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off. Consensus exists that an individual person’s wealth should not determine who lives or dies. Although medical treatment in the United States outside pandemic contexts is often restricted to those able to pay, no proposal endorses ability-to-pay allocation in a pandemic.
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