LA County Paramedics Told Not To Transport Some Patients With Low Chance Of Survival

Paramedics in Southern California are being told to conserve oxygen and not to bring patients to the hospital who have little chance of survival as Los Angeles County grapples with a new wave of COVID-19 patients that is expected to get worse in the coming days.

The Los Angeles County Emergency Medical Services Agency issued a directive Monday that ambulance crews should administer supplemental oxygen only to patients whose oxygen saturation levels fall below 90%.

In a separate memo from the county’s EMS Agency, paramedic crews have been told not to transfer patients who experience cardiac arrest unless spontaneous circulation can be restored on the scene.

Both measures announced Monday, which were issued by the agency’s medical director, Dr. Marianne Gausche-Hill, were taken in an attempt to get ahead of an expected surge to come following the winter holidays.

Many hospitals in the region “have reached a point of crisis and are having to make very tough decisions about patient care,” Dr. Christina Ghaly, the LA County director of health services, said at a briefing Monday.

“The volume being seen in our hospitals still represents the cases that resulted from the Thanksgiving holiday,” she said.

“We do not believe that we are yet seeing the cases that stemmed from the Christmas holiday,” Ghaly added. “This, sadly, and the cases from the recent New Year’s holiday, is still before us, and hospitals across the region are doing everything they can to prepare.”

Speaking to the CBS affiliate in Los Angeles, Gausche-Hill said personnel would continue to do everything possible to save the lives of patients, both at the scene and in the hospital.

“We are not abandoning resuscitation,” she said. “We are absolutely doing best practice resuscitation and that is do it in the field, do it right away.”

“[We] are emphasizing the fact that transporting these patients arrested leads to very poor outcomes. We knew that already and we just don’t want to impact our hospitals,” she added.

Meanwhile, the state is looking for ways to increase its supply of oxygen for use in treating COVID-19 patients, Gov. Gavin Newsom said, according to the Los Angeles Times.

We’re just looking at the panoply of oxygen support … across the spectrum and looking how we can utilize more flexibility and broader distribution of these oxygen units all up and down the state, but particularly in these areas — San Joaquin Valley and Los Angeles, the larger Southern California region — that are in particular need and are under particular stress,” Newsom said.

Los Angeles County remains the worst-hit county in the U.S. for both confirmed COVID-19 cases and deaths from the disease. Johns Hopkins University listed more than 818,000 confirmed coronavirus cases and more than 10,700 deaths from complications from the virus in Los Angeles County by late Monday.

Last week, the new highly contagious coronavirus strain from the U.K. was discovered in Southern California. Experts have said it spreads faster than the common strain.

Scripps CEO: Care rationing near if Californians ignore COVID-19 mitigation efforts

Prepare for Health Emergencies Like War Says CEO - Scripps Health

Hospitals in Southern California will need to start rationing care if more action isn’t taken by the community to mitigate the spread of COVID-19, Chris Van Gorder, president and CEO of Scripps Health, wrote in a Dec. 28 op-ed for The San Diego Union-Tribune

As of Dec. 29, 20,642 California residents were hospitalized with COVID-19. The state’s hospital bed capacity is 72,511. In San Diego County, where Scripps is headquartered, 18 intensive care unit beds were available as of Dec. 28, “not even enough to handle a single mass casualty incident,” Mr. Van Gorder wrote. Out of Scripps’ 173 ICU beds, seven staffed beds were available as of Dec. 28.

“This past weekend, one of our community hospitals ran out of room in their morgue. We are nearing the point where we have to make the decision of who gets care and who does not,” Mr. Van Gorder wrote.

He pleaded with the San Diego and California community to adhere to mask-wearing and social distancing guidelines, especially as the New Year’s Day holiday approaches. He called on residents to stay home for New Year’s, wear a mask, wash their hands, and not eat or drink with people who aren’t in their immediate family household.

Mr. Van Gorder’s commentary comes as Kaiser Permanente hospitals in Northern California are suspending elective, non-urgent procedures through Jan. 4 as they continue to face a surge in COVID-19 hospitalizations. The Oakland, Calif.-based system announced the suspension Dec. 26, days after Chair and CEO Greg Adams said during a news conference, “We simply will not be able to keep up if the COVID surge continues to increase. We’re at or near capacity everywhere.”

Los Angeles hospitals brace for care rationing

Rising Covid cases means Americans may face health care rationing. Here's  how they view that.

Several hospitals in Los Angeles County are preparing for the possibility of restrategizing care delivery in the coming weeks amid growing COVID-19 hospitalizations, according to the Los Angeles Times.

Los Angeles County reported 6,018 COVID-19 hospitalizations Dec. 20 — a 2.5 percent increase from the day prior — with 1,198 patients in ICUs, according to the state’s data dashboard. Statewide, 17,750 patients are hospitalized with COVID-19, 3,710 of them in ICUs. 

The LA Times obtained a document recently circulated among physicians at the four county-run hospitals that outlines resource allocation in crisis situations. The guidelines call for physicians to save as many patients as possible versus trying everything to save a patient, meaning those less likely to survive will not receive the level of care they would have otherwise. L.A. County Health Services Director Christina Ghaly, MD, told the LA Times that the guidelines were not in place as of Friday night.

California activated its “mass fatality” program last week, which coordinates mutual aid across several government agencies when more deaths take place in a period of time than can be handled by local coroner or medical emergency personnel, NPR reports. 

Nearly all of the state is under stay-at-home orders, with residents prohibited from gathering with anyone outside their immediate household.

“I have yet to see any clear signals that things are slowing down, and I’m very concerned about the next two months,” Timothy Brewer, MD, an epidemiologist with UCLA Health, told the LA Times. He said UCLA Health is scheduling several infectious disease specialists to be on call at any time, and the biggest issue is that hospitals may quickly run out of providers who can administer ICU-level care.

Hospitals consider universal do-not-resuscitate orders for coronavirus patients

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Worry that ‘all hands’ responses may expose doctors and nurses to infection prompts debate about prioritizing the survival of the many over the one.

Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation few have encountered in their lifetimes — how to weigh the “save at all costs” approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.

The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient “codes,” and their heart or breathing stops.

Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.

Richard Wunderink, one of Northwestern’s intensive-care medical directors, said hospital administrators would have to ask Illinois Gov. J.B. Pritzker for help in clarifying state law and whether it permits the policy shift.

“It’s a major concern for everyone,” he said. “This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances.”

Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country’s major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

Several large hospital systems — Atrium Health in the Carolinas, Geisinger in Pennsylvania and regional Kaiser Permanente networks — are looking at guidelines that would allow doctors to override the wishes of the coronavirus patient or family members on a case-by-case basis due to the risk to doctors and nurses, or a shortage of protective equipment, say ethicists and doctors involved in those conversations. But they would stop short of imposing a do-not-resuscitate order on every coronavirus patient. The companies declined to comment.

Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

“We are now on crisis footing,” he said. “What you take as first-come, first-served, no-holds-barred, everything-that-is-available-should-be-applied medicine is not where we are. We are now facing some difficult choices in how we apply medical resources — including staff.”

The new protocols are part of a larger rationing of lifesaving procedures and equipment — including ventilators — that is quickly becoming a reality here as in other parts of the world battling the virus. The concerns are not just about health-care workers getting sick but also about them potentially carrying the virus to other patients in the hospital.

R. Alta Charo, a University of Wisconsin-Madison bioethicist, said that while the idea of withholding treatments may be unsettling, especially in a country as wealthy as ours, it is pragmatic. “It doesn’t help anybody if our doctors and nurses are felled by this virus and not able to care for us,” she said. “The code process is one that puts them at an enhanced risk.”

Wunderink said all of the most critically ill patients in the 12 days since they had their first coronavirus case have experienced steady declines rather than a sudden crash. That allowed medical staff to talk with families about the risk to workers and how having to put on protective gear delays a response and decreases the chance of saving someone’s life.

A consequence of those conversations, he said, is that many family members are making the difficult choice to sign do-not-resuscitate orders.

Code blue

Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient’s life, absent an order, such as a DNR, to do otherwise. But as cases mount amid a national shortage of personal protective equipment, or PPE, hospitals are beginning to implement emergency measures that will either minimize, modify or completely stop the use of certain procedures on patients with covid-19.

Some of the most anxiety-provoking minutes in a health-care worker’s day involve participating in procedures that send virus-laced droplets from a patient’s airways all over the room.

These include endoscopies, bronchoscopies and other procedures in which tubes or cameras are sent down the throat and are routine in ICUs to look for bleeds or examine the inside of the lungs.

Changing or eliminating those protocols is likely to decrease some patients’ chances for survival. But hospital administrators and doctors say the measures are necessary to save the most lives.

The most extreme of these situations is when a patient, in hospital lingo, “codes.”

When a code blue alarm is activated, it signals that a patient has gone into cardiopulmonary arrest and typically all available personnel — usually somewhere around eight but sometimes as many as 30 people — rush into the room to begin live-saving procedures without which the person would almost certainly perish.

“It’s extremely dangerous in terms of infection risk because it involves multiple bodily fluids,” explained one ICU physician in the Midwest, who did not want her name used because she was not authorized to speak by her hospital.

Fred Wyese, an ICU nurse in Muskegon, Mich., describes it like a storm:

A team of nurses and doctors, trading off every two minutes, begin the chest compressions that are part of cardiopulmonary resuscitation or CPR. Someone punctures the neck and arms to access blood vessels to put in new intravenous lines. Someone else grabs a “crash cart” stocked with a variety of lifesaving medications and equipment ranging from epinephrine injectors to a defibrillator to restart the heart.

As soon as possible, a breathing tube will be placed down the throat and the person will be hooked up to a mechanical ventilator. Even in the best of times, a patient who is coding presents an ethical maze; there’s often no clear cut answer for when there’s still hope and when it’s too late.

In the process, heaps of protective equipment is used — often many dozens of gloves, gowns, masks, and more.

Bruno Petinaux, chief medical officer at George Washington University Hospital, said the hospital has had a lot of discussion about how — and whether — to resuscitate covid-19 patients who are coding.

“From a safety perspective you can make the argument that the safest thing is to do nothing,” he said. “I don’t believe that is necessarily the right approach. So we have decided not to go in that direction. What we are doing is what can be done safely.”

However, he said, the decision comes down to a hospital’s resources and “every hospital has to assess and evaluate for themselves.” It’s still early in the outbreak in the Washington area, and GW still has sufficient equipment and manpower. Petinaux said he cannot rule out a change in protocol if things get worse.

GW’s procedure for responding to coronavirus patients who are coding includes using a machine called a Lucas device, which looks like a bumper, to deliver chest compressions. But the hospital has only two. If the Lucas devices are not readily accessible, doctors and nurses have been told to drape plastic sheeting — the 7-mil kind available at Home Depot or Lowe’s — over the patient’s body to minimize the spread of droplets and then proceed with chest compressions. Because the patient would presumably be on a ventilator, there is no risk of suffocation.

In Washington state which had the nation’s first covid-19 cases, UW Medicine’s chief medical officer, Tim Dellit, said the decision to send in fewer doctors and nurses to help a coding patient is about “minimizing use of PPE as we go into the surge.” He said the hospital is monitoring health-care workers’ health closely. So far, the percentage of infections among those tested is less than in the general population, which, he hopes, means their precautions are working.

‘It is a nightmare’

Bioethicist Scott Halpern at the University of Pennsylvania is the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a blanket stop to resuscitations for infected patients is too “draconian” and may end up sacrificing a young person who is otherwise in good health. However, health-care workers and limited protective equipment cannot be ignored.

“If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” he said.

Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.

Wyese, the Michigan ICU nurse, said his own hospital has been thinking about these issues for years but still is unprepared.

“They made us do all kinds of mandatory education and fittings and made it sound like they are prepared,” he said. “But when it hits the fan, they don’t have the supplies so the plans they had in place aren’t working.”

Over the weekend, Wyese said, a suspected covid-19 patient was rushed in and put into a negative pressure room to prevent the virus spread. In normal times, a nurse in full hazmat-type gear would sit with the patient to care for him, but there was little equipment to spare. So Wyese had to monitor him from the outside. Before he walked inside, he said, he would have to put on a face shield, N95 mask, and other equipment and slather antibacterial foam on his bald head as the hospital did not have any more head coverings. Only one powered air-purifying respirator or PAPR was available for the room and others nearby that could be used when performing an invasive procedure — but it was 150 feet away.

While he said his hospital’s policy still called for a full response to patients whose heart or breathing stopped, he worried any efforts would be challenging, if not futile.

“By the time you get all gowned up and double-gloved the patient is going to be dead,” he said. “We are going to be coding dead people. It is a nightmare.”





COVID-19 threatens to overwhelm hospitals. They’re weighing how best to ration care.

The coronavirus outbreak is forcing the U.S., a nation largely unaccustomed to scarcity, to have tough conversations about how to allocate limited medical resources as hospitals warn its only a matter of time before they’re inundated with COVID-19 patients.

Across the country, hospital officials are discussing ethical dilemmas and attempting to draft policies about rationing care when patients needing ventilators and other resources dwarf the supply, several hospital ethicists told Healthcare Dive. In addition to issues of mortality, questions also are being raised about whether medical workers can opt out of treating patients with COVID-19, particularly if they don’t have the right personal protective equipment.

“They are having these conversations at the policy level,” Kelly Dineen, director of the health law program at Creighton University and a member of COVID-19 Ethics Advisory Committee at the University of Nebraska Medical Center​, told Healthcare Dive.

Ethical dilemmas are usually tackled by a hospital’s ethics committee, which, in an ideal scenario, encompasses a variety of workers from across the hospital, including clinicians, ethicists and social workers. 

No federal mandate exists requiring hospitals to have such committees. However, many do to meet accreditation standards that require facilities to have some sort of mechanism for ethics conflicts and decision making. Many choose to meet that standard by having an ethics committee, though not all do, according to one expert.

Hospitals are at risk of not having the capacity to care for a surge of COVID-19 patients if an outbreak similar to Wuhan or Italy occurs here. New York Gov. Andrew Cuomo has pleaded with the federal government to allow the Army Corps of Engineers to build back-up facilities as the COVID-19 rapidly spreads through areas of the hard-hit state. Similarly, California Gov. Gavin Newsom has requested a Navy hospital ship and two mobile hospitals to address a surge in patients.

Federal officials are urging Americans to do their part by retreating to their homes to socially distance themselves from others in an effort to hamper the disease’s reach. CMS also last week urged hospitals to put off non-essential elective surgeries to prepare for an onslaught of cases. Years of culling hospital beds in a shift to outpatient care has the nation’s facilities short of meeting expected demand under some prediction models.

The concern about scarce resources is not unfounded. Italy’s healthcare system has been pushed to the brink and many see parallels in terms of the trajectory of the spread. Overwhelmed with sick patients, Italy’s society of anesthesiology and intensive care published recommendations on how to prioritize patients and not just serve the first in the door.

China, the first country to report cases of the disease, feverishly began building hospitals to meet demand.

And the U.S. has far fewer hospital beds per 1,000 residents than China or Italy.

It’s important facilities across the country start having conversations about allocating resources now before clinicians are pushed to their limits, ethicists said.

“Any time you have that kind of pressure and load … it’s going to be hard to also be thinking about all of the ethical implications and what that means in a way that might otherwise not be so hard,” Dineen said.

The struggle will be effectively communicating those policies throughout a system or hospital, Erica Salter, associate professor and program director of the doctorate program for healthcare ethics at St. Louis University, told Healthcare Dive.

“It’s wise to anticipate failures of communication and protect against those,” Salter said.

Ultimately, those policies will vary by institution, though ethicists said it’s important to be proactive rather than reactive. And hospitals should also be prepared to be held to account for decisions that are made, Dineen said.

Patients and their loved ones will want to know there was a process and that it was fair, not arbitrary. 

“There’s no reason we can’t be prepared with a process, even if we don’t necessarily have a better answer,” she said.

Still, despite the most well-intentioned plans it will always be the doctor’s call, Arthur Caplan, head of the division of medical ethics at NYU School of Medicine, told Healthcare Dive.  

“You’re going to see variation in what is decided floor to floor, doctor to doctor, hospital to hospital,” Caplan said.

Still, some hospitals are hesitant to issue overly broad guidance because of the liabilities that might come later. However, depending on the state, emergency orders issued during a pandemic may help shield providers or systems from liability as standard of care decisions were made during a unique situation.

And, though Americans may struggle to talk about the end of life and mortality, the medical profession is used to tough conversations about scarce resources.

For example, when dialysis machines were first developed, the technology was not widely available for everyone with end-stage kidney failure. A decision had to be made about which patients were granted access to the lifesaving treatment and which ones were not. It’s a conversation that continues today for those needing transplants.

“The principles guiding these decisions are not new,” Salter said. “We’ve been dealing with issues of scarce resources for many decades.”





Coronavirus will radically alter the U.S.

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Here’s what may lie ahead based on math models, hospital projections and past pandemics.

When Jason Christie, chief of pulmonary medicine at Penn Medicine, got projections on how many coronavirus patients might soon be flocking to his Philadelphia hospital, he said he felt physically ill.

“My front-line providers — we were speaking about it in the situation report that night, and their voices cracked,” Christie said on Wednesday. They saw how quickly the surge would overwhelm the system, forcing doctors to make impossible choices — which patients would get ventilators and beds, and which would die.

“They were terrified. And that was the best-case scenario.”

Experts around the country have been churning out model after model — marshaling every tool from math, medicine, science and history — to try to predict the coming chaos unleashed by the new coronavirus and to make preparations.

At the heart of their algorithms is a scary but empowering truth: What happens next depends largely on us — our government, politicians, health institutions and, in particular, 327 million inhabitants of this country — all making tiny decisions on an daily basis with outsize consequences for our collective future.

In the worst-case scenario, America is on a trajectory toward 1.1 million deaths. That model envisions the sick pouring into hospitals, overwhelming even makeshift beds in parking lot tents. Doctors would have to make agonizing decisions about who gets scarce resources. Shortages of front-line clinicians would worsen as they get infected, some dying alongside their patients. Trust in government, already tenuous, would erode further.

That grim scenario is by no means a foregone conclusion — as demonstrated by countries like South Korea which has reduced its new cases a day from hundreds to dozens with aggressive steps to bolster their health system.

If Americans embrace drastic restrictions and school closures, for instance, we could see a death toll closer to thousands and a national sigh of relief as we prepare for a grueling but surmountable road ahead.

An alarming new model

Doing that will require Americans to “flatten the curve” — slowing the spread of the contagion so it doesn’t overwhelm a health-care system with finite resources. That phrase has become ubiquitous in our national conversation. But what experts have not always made clear is that by applying all that downward pressure on the curve — by canceling public gatherings, closing schools, quarantining the sick and enforcing social distancing — you elongate the curve, stretching it out over a longer period of time.

Success means a longer — though less catastrophic — fight against the coronavirus. And it is unclear whether Americans — who built this country on ideals of independence and individual rights — would be willing to endure such harsh restrictions on their lives for months, let alone for a year or more.

This month began with U.S. officials recommending actions such as hand-washing and social distancing. By Sunday, the Centers for Disease Control and Prevention was warning against gatherings of 50-plus people. By Monday, President Trump had made an abrupt turn from encouraging Americans to go on with their lives, to urging them to work from home, not meet in groups of more than 10, and calling on local officials to close schools, bars and restaurants. (Getting the public to comply has been alarmingly difficult. Young revelers from Bourbon Street to Miami have ignored those pleas, as have some elderly, who are at highest risk.)

Trump’s sudden shift was driven by an alarming new scientific model, developed by British epidemiologists and shared with the White House. The scientists bluntly stated the coronavirus is the most serious respiratory virus threat since the Spanish Flu of 1918. If no action to limit the viral spread were taken, as many as 2.2 million people in the United States could die over the course of the pandemic, according to epidemiologist Neil Ferguson and others at the Imperial College Covid-19 Response Team.

Adopting some mitigation strategies to slow the pandemic — such as isolating those suspected of being infected and social distancing of the elderly — only cuts the death toll in half to 1.1 million, although it would reduce demand for health services by two-thirds.

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Only by enacting an entire series of drastic, severe restrictions could America shrink its death toll further, the study found. That strategy would require, at minimum, the nationwide practice of social distancing, home isolation, and school and university closures. Such restrictions would have to be maintained, at least intermittently, until a working vaccine is developed, which could take 12 to 18 months at best.

The report’s conclusion: This is “the only viable strategy.”

What hospital planning tells us

Here is another thing that hasn’t been spelled out in our national conversation about flattening the curve: There will probably be more than one curve.

If we’re lucky, the coming months will probably look more like string of hilly bumps, say epidemiologists. If authorities ease some measures in coming months or if we start letting them slip ourselves, that hill could easily turn right back into the exponential curve that has cratered Italy’s health system and that U.S. officials are desperately trying to avoid replicating.

Climbing this first bump is in many ways the most challenging because it involves persuading people to change their individual behaviors for an abstract larger good — and because no one knows how far we actually are from the peak.

On Tuesday morning, New York Gov. Andrew M. Cuomo (D) said infections in his state are expected to peak in 45 days — at the start of May. The state has roughly 53,000 hospital beds, including 3,000 intensive-care beds — way short of the projected need for as many as twice that number of beds and as many as 11 times the number of ICU beds.

A day earlier, Northwell Health — whose 23 hospitals and 800 outpatient centers make up New York’s largest health system — canceled all elective surgeries in its hospitals to free up staff and space. It has 5,500 beds.

“We’re looking at Italy, which is currently 10 days ahead of us, and what they’ve had to do,” said Maria Carney, Northwell’s chief of geriatrics. Carney was health commissioner for New York’s Nassau County during the 2009 H1N1 outbreak and has worked furiously on Northwell’s plans to prepare for the coming tsunami.

One reason she and others are alarmed: In China, the fatality rate in Wuhan, the raging epicenter, was 5.8 percent. But in all other areas of the country it was 0.7 percent — a signal that most deaths were driven by an overwhelmed health system.

And U.S. hospitals are pinched as it is, with some already running at 95 percent capacity pre-coronavirus, Carney noted. As cases surge, Northwell plans to place multiple beds in single rooms. Its ambulances will also shuttle patients to less crowded satellite sites. Those suffering from ordinary emergencies — strokes, heart attacks, car accidents — may find themselves routed to other facilities away from ERs to avoid transmission.

But it’s unclear if it will be anywhere near enough.

Staffing shortages are already developing: As of Tuesday, 18 Northwell employees had already tested positive for the coronavirus. More than 200 were self-quarantined as a result of potential exposures, foreshadowing what is likely to come.

If the numbers next month get truly crazy, cities may look to convert stadiums into isolation wards, as in Wuhan. Cuomo has talked of turning the six-block-long Javits Convention Center on New York City’s west side into a medical surge facility. Others might take Italy’s approach and split hospitals into those treating coronavirus and those treating all other medical problems, to reduce transmission.

In San Francisco, we may see coronavirus patients put into RVs. In Takoma Park, Md., the old Washington Adventist Hospital site, which shuttered in 2019, could suddenly find its doors reopened.

‘Pandemics aren’t just physical’

As America enters this utterly unfamiliar territory, some experts have turned to history for glimpses of what to expect in the months ahead.

Initially leery of alarming the public, they have increasingly compared this pandemic to the 1918 Spanish flu, the deadliest in modern history. It infected roughly a third of the world’s population and killed at least 50 million people, including at least 675,000 in the United States.

Like the hilly bumps experts foresee in coming months, the 1918 pandemic hit America in three waves — a mild one that spring, the deadliest wave in fall and a final one that winter.

With each wave came a cycle of denial, devastation, community response finally kicking into overdrive — always followed by finger-pointing and blame among leaders and the public.

“Every outbreak is different,” said medical anthropologist Monica Schoch-Spana, who spent months digging through archives to study how Spanish flu played out in Baltimore.

Like coronavirus is likely to do, the 1918 flu overwhelmed hospitals. Unable to get help, desperate families waited outside to beg and try to bribe doctors for treatment. In a three-week period, 2,000 died in Baltimore alone. Mortuaries ran out of caskets. When the bodies finally reached cemeteries, the gravediggers were so ill, no one could bury the dead.

Economic pressure on business owners and workers caused public resistance to adopt — and stick with restrictions. The crisis brought out the best in Baltimoreans — with sewing circles churning out gauze masks and hospital bedding, and neighbors donating food and services.

But it also brought out the worst — xenophobic conspiracy theories that nurses of “German extraction” were deliberately infecting people. African American patients were kept out of most hospitals under Jim Crow-era segregation.

“Pandemics aren’t just physical,” said Schoch-Spana. “They bring with them an almost shadow pandemic of psychological and societal injuries as well.”

The power of the individual

Stanford virologist Karla Kirkegaard said she has tried to stave off dread from the projected U.S. death toll with a case study she teaches in her classes:

Amid a cholera outbreak in mid-19th century London, as panicked residents fled one hard-hit neighborhood, a doctor named John Snow calmly entered the breach. He deduced that the source of hundreds of deaths was a single contaminated water pump and persuaded authorities to remove the pump’s handle — a strategy that ended the outbreak.

Controlling the covid-19 pandemic will take much more than a single water pump, Kirkegaard acknowledged as she sheltered in place at her Bay Area home.

But the story, she said, reminds her how powerful the simple act of one individual can be.




There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.


Rationing of care for novel coronavirus patients has been reported in China and Italy.

Medical utility based on scientific patient profiles should guide decisions to ration critical care resources such as ventilators, medical ethicist James Tabery says.

In a pandemic, public health considerations should drive decisions on prioritizing who is tested for disease, he says.

The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.

In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.

The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. “Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn’t enough of these resources than what we anticipate needing,” says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.

He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.


In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. “The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can.”

The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.

“But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility,” Tabery says.

Medical utility is based on scientific assessments, he says. “You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient’s condition quickly.”

Rationing of critical care resources would be jarring for U.S. clinical staff.

Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.

However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.

“When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn’t look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck,” he says.


There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.

While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.

“The primary purpose of the test is pure public health epidemiology. It’s about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn’t so much about who is at greatest risk. It’s about who is more likely to interact with lots of people, or who is more likely to have interacted with more people.”

A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.

“For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street.”


The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. “On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don’t want to get sick, which can incline them not to work,” he says.

“The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work,” he says.

However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. “If hospitals don’t have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem.”


When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.

“When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups,” he says.





Doctors Fear Bringing Coronavirus Home: ‘I Am Sort of a Pariah in My Family’

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One doctor dreamed he was surrounded by coughing patients. “Most physicians have never seen this level of angst and anxiety in their careers,” a veteran emergency room doctor said.

SEATTLE — After her shifts in the emergency room, one doctor in Utah strips naked on her porch and runs straight to a shower, trying not to contaminate her home. In Oregon, an emergency physician talks of how he was recently bent over a drunk teenager, stapling a head wound, when he realized with a sudden chill that the patient had a fever and a cough. A doctor in Washington State woke up one night not long ago with nightmares of being surrounded by coughing patients.

“Most physicians have never seen this level of angst and anxiety in their careers,” said Dr. Stephen Anderson, a 35-year veteran of emergency rooms in a suburb south of Seattle. “I am sort of a pariah in my family. I am dipping myself into the swamp every day.”

As the coronavirus expands around the country, doctors and nurses working in emergency rooms are suddenly wary of everyone walking in the door with a cough, forced to make quick, harrowing decisions to help save not only their patients’ lives, but their own.

The stress only grew on Sunday, when the American College of Emergency Physicians revealed that two emergency medicine doctors, in New Jersey and Washington State, were hospitalized in critical condition as a result of the coronavirus. Though the virus is spreading in the community and there was no way of ascertaining whether they were exposed at work or somewhere else, the two cases prompted urgent new questions among doctors about how many precautions are enough.

“Now that we see front-line providers that are on ventilators, it is really driving it home,” Dr. Anderson said.

Doctors, nurses and other staff members in a variety of hospital departments face new uncertainty. In intensive care units, for example, health care providers must have extended exposure to people who have contracted the virus. But they know in advance of the risk they face.

In emergency departments, the danger comes from the unknown.

Patients arrive with symptoms but no diagnosis, and staff members must sometimes tend to urgent needs, such as gaping wounds, before they have time to screen a patient for Covid-19, the disease caused by the virus. At times, the protocols they must follow are changing every few hours.

“Many of us have trained for disasters, like Ebola and hurricanes,” said Dr. Adam Brown, the president of emergency medicine for Envision Healthcare, the largest provider of contract physicians to emergency rooms. “This is different because of the scale and scope of the disease.”

Add to that the shortage of protective gear and delays in testing, and health care workers fear they are flying blind.

Though the numbers are still low, Envision, which employs 11,000 emergency clinicians across the United States, has five times as many doctors under quarantine as it did a week ago, Dr. Brown said.

Several providers spoke on the condition of anonymity because their employers have told them not to talk to the news media.

The personal strain is cascading as the virus reaches new parts of the country. “Everybody feels the stress, but everybody is pulling together,” said Dr. K. Kay Moody, an emergency room doctor in Olympia, Wash., who runs a Facebook group with 22,000 emergency physicians. “That is what is keeping us OK.”

A few doctors said they were talking about bunking up in Airbnbs to create “dirty doc” living quarters to avoid endangering their children when they go home. Some are showing their partners where to find their passwords and insurance, should they end up in intensive care. Dr. Moody said she knew of at least one doctor whose former spouse was threatening to take their children away if the doctor went to work.

Many emergency physicians work as contractors, not hospital staff, so they will not necessarily be paid if they are quarantined. “As it stands, that is one of the most anxiety-provoking things,” Dr. Moody said, “on top of fear for your life.”

Nurses face similar challenges, though with less pay and support. An emergency nurse in Milwaukee said she bought her own goggles after hearing that protective gear was running low. A nurse at a rural hospital near Lake Tahoe in California said that the hospital was providing physicians with shower facilities as well as clean scrubs to wear, but that nurses had to wash their work clothes at home. She said that the physicians she worked with lobbied the hospital to provide clean scrubs for the nurses, but that the hospital concluded it would cost too much.

One doctor, who spoke on condition that the identity of the veterans hospital where she worked was not revealed, said the protocols have not kept up with the changing reality on the ground. When determining if a patient should get a separate room, she said, the emergency department still asks patients if they have been to high-risk countries, like China and Italy, even though community transmission of the virus has been well established.

Doctors have begun building plans for how they will ration supplies when there are more patients than their hospitals can handle. Emergency room doctors have experience sitting families down to advise discontinuing care because it would be futile. But in the United States, they are not used to making such calls based on resources alone.

Some said they were looking to Italy, where doctors on the front line have sometimes had to ration care in favor of younger patients, or those without other complicating conditions, who are more likely to benefit from it.

“If we get it all at once, we don’t have the resources, we don’t have the ventilators,” said Dr. William Jaquis, chair of the American College of Emergency Physicians.

Last week, Italian media reported that Bergamo, a city northeast of Milan, saw roughly 50 doctors test positive for the virus. In the region of Puglia in the south, local media reported that 76 employees had been quarantined after being exposed to patients who contracted Covid-19.

After the coronavirus broke out at a nursing facility near Seattle, Dr. Anderson sat with the leaders of his hospital, MultiCare Auburn Medical Center, to talk about how urgently they should prepare. Their hospital is ringed by nursing homes and other care facilities, and he rattled off those most at risk for fatal cases of the virus: males over 60, and those with cardiac and pulmonary problems. “I literally stopped what I was saying and realized that that was me,” he said.

He said his hospital was down to a two-day supply of surgical masks — he wears one per shift. “Those are supposed to be disposable,” he said. Now he must carefully remove and clean the mask each time he takes it off and on. “That may sound just like a nuisance, but when you’re potentially touching something that has the virus that could kill you on it, and you’re doing it 25 times a shift, it’s kind of nerve-racking,” he said.

His wife has moved to their mountain cabin, and they have given up on their retirement cruise in Europe. “I haven’t slept for longer than three hours in the past two weeks,” he said.

In the early hours of Monday morning, he could not sleep. More than 200 emails had come into his inbox since he went to bed, including news that three other health care providers had been admitted to a hospital overnight, he said.

But he plans to be at his next shift nonetheless.

“I have been doing this for 35 years,” he said, “and I’m not going to stop now.”





Does the United States Ration Health Care?

MRI taking place in the U.S.

As recent congressional hearings on Medicare for All proposals have illustrated, members of Congress and presidential candidates are looking outside the United States to find ways to achieve universal coverage. Some have suggested that other countries are able to provide universal coverage because they “ration” care — a term rife with negative connotations. This post examines the extent to which health care is rationed in Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom — as compared to the U.S.

Examples of health care rationing tend to focus on long wait times for procedures —such as hip replacements, or MRIs — or limited access to the newest drugs. This happens in some (but not all) countries and can be a challenge for policymakers. But there are other ways in which health systems engage in rationing, by restricting access to insurance, through insurance benefit design, or by imposing high patient cost-sharing. While other countries may ration because of national budget constraints and supply-side factors, the United States’ lack of access to comprehensive insurance and affordable care represent a de facto form of rationing that leads people to delay getting care or going without it entirely.

Getting in the Door

In the five European countries we examined, all residents are entitled to health care through the national system. These range from tax-funded systems in Sweden or the U.K. to private insurance-based systems in Germany, the Netherlands, and Switzerland. In the latter, governments regulate premiums to be affordable and provide income-related subsidies to low-income families, which include 27 percent of Swiss and 30 percent of Dutch residents. Governments also mandate generous benefit packages that typically guarantee a minimum set of services: primary, specialty, and hospital care; prescription drugs; mental health; maternity; and palliative care.

In comparison, there are 30.4 million uninsured people in the U.S. Not having affordable, comprehensive insurance coverage often means that sick Americans do not even get in the door to see a doctor. For those who do have coverage, new rules that allow states to circumvent the Affordable Care Act’s mandated essential health benefits may mean skimpy coverage for some.

Waiting to Be Seen

Patients in some countries face longer wait times for specialty care than in the U.S., where only 25 percent of Americans need to wait longer than one month for a specialist appointment. Patients in Germany and Switzerland get in just as fast (27% and 26%, respectively) as their U.S. counterparts, but those in Sweden and the U.K. do not (45% and 43%, respectively). Similarly, very few U.S., Dutch, and Swiss patients (4% to 7%) who need elective surgery face wait times longer than four months, while 12 percent of Swedish and British patients do. It should be noted that in Sweden and the U.K., where wait times for specialty care are longer, people can buy supplemental insurance to gain quicker access to private specialists.

While Americans overall enjoy shorter wait times for specialty care, wait times for same- or next-day appointments when sick are around average compared to other countries. U.S. adults are among the most frequent users of emergency departments. Nearly half who do report doing so because they couldn’t get an appointment with their regular doctor.

Weighing Health Against Your Wallet

In a recent Commonwealth Fund survey, fewer than one of 10 patients in the U.K., Germany, the Netherlands, or Sweden reported skipping needed care or treatments because of cost. This contrasts sharply with the U.S., where one of three Americans reported the same. This is partly because of the rise in high deductibles, unpredictable and opaque copayments, and higher health care prices in the U.S. than in other countries. An estimated 44 million Americans who have insurance are effectively underinsured because their out-of-pocket costs and deductibles are very high relative to their incomes.

Other countries are more protective. In the U.K., Germany, and the Netherlands, patients have no out-of-pocket costs when they visit a primary care doctor, and Brits never pay for hospital care. In Germany, out-of-pocket costs are capped at 2 percent of annual household income and 1 percent for chronically ill people. In Sweden, out-of-pocket costs for physician visits and drugs are capped at $370 annually. No one in these five countries declares bankruptcy because of medical debt.

Paying for Value

A commitment to providing universal coverage means that other countries have to make hard choices to ensure that each health care dollar is spent effectively.

Countries aim to give patients access to the most clinically meaningful and cost-effective drugs. In the U.K., only drugs that are deemed cost-effective are covered, while in Germany, manufacturers have to demonstrate that their new drug adds clinical benefit to negotiate a higher price than other existing drugs. This doesn’t mean that new technologies aren’t available; in fact, 79 percent of new cancer drugs are approved for routine use in the U.K.

These kind of controls, coupled with fixed copayments and annual caps on patient drug spending, translate into better access. While nearly one of five U.S. adults skip doses or do not fill a prescription because of costs, just 2 percent to 9 percent of patients do so in the other countries discussed here.


It would be a missed opportunity for America to ignore lessons about universal coverage from other countries out of a fear that they ration health care more than we do. In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.