Crisis standards of care means that a hospital or a hospital region has run out of some combination of Space, Stuff, and Staff needed to deliver care at the highest expected level to the patients who are showing up for care. This is a very bad thing. Crisis standards of care means people who normally would be treated with a plausible likelihood of recovery won’t be treated with anything and everything that could be both helpful and concordant with their care goals. Crisis standards means triage committees will be looking at their available resources and making very hard decisions as to which patient, of many, who needs that scarce and valuable resource will receive that scarce and valuable resource. That also means they decide who does not receive a scarce, valuable and needed resource.
Idaho public health leaders announced Tuesday that they activated “crisis standards of care” allowing health care rationing for the state’s northern hospitals because there are more coronavirus patients than the institutions can handle. https://t.co/7260W8E8XA
— Catherine Rampell (@crampell) September 7, 2021
Idaho public health leaders announced Tuesday that they activated “crisis standards of care” allowing health care rationing for the state’s northern hospitals because there are more coronavirus patients than the institutions can handle….
The designation includes 10 hospitals and healthcare systems in the Idaho panhandle and in north-central Idaho. The agency said its goal is to extend care to as many patients as possible and to save as many lives as possible.The move allows hospitals to allot scarce resources like intensive care unit rooms to patients most likely to survive and make other dramatic changes to the way they treat patients. Other patients will still receive care…
This is being driven by large demand for high end care for COVID patients. But it does not effect just people with COVID. Someone who is in a car accident is being placed into the same decision process to see if they get the last available ICU bed.
Normally when regions are beginning to get close to invoking crisis standards of care there are responses. The first response is to pull in the floating reserve of trained staff via travelling contract nurses and physicians. New York City relied on travelling nurses in April 2020 to give their hospital systems a chance to function while the deployment of the hospital ships also added both staff and space to the hospital system there and in Southern California. Other states have relied on the National Guard to set up and staff field hospitals. Less obvious, but quite common, hospitals will divert patients from high demand and low available capacity regions to regions with beds and capacity. Sometimes these diversions are across town. Sometimes these diversions are across time zones. Hospitals and hospital regions can increase capacity by reducing or eliminating deferrable activities as well. However, when all of these steps are taken and there is still a crunch, quality of care goes down and mortality goes up.
So what can we do?
We can keep on getting vaccinated, masking up and holding physical distance so as to decrease future demand for beds.
We can keep get surveillance testing to pick up the asymptomatic cases that are the source of many chains of transmission.
We can call Congress and tell them to take national policy action.
But until the number of cases crests and then falls rapidly for several weeks, crisis standards of care are either in action or at least on top of mind of hospital administrators in many areas of the country.
kindness
What can ‘we’ do?
That was very generous of you. They can get vaccinated and they can wear masks no matter how much it intrudes on their personal freedoms.
OzarkHillbilly
Death panels here we come. Thanx GOP.
sherparick
@OzarkHillbilly: But these are Republican Death Panels, IOKIYAR!
Booger
@OzarkHillbilly: Beat me to it. The fuckers got their death panels.
Ksmiami
Turn away Covid anti vax people- they didn’t believe in medical science before they should see it through
mali muso
@Ksmiami: Come sit by me (six feet, etc.) I vote for setting up a COVID tent ward in the parking lot and directing the unvaxxed there. Keep the beds for those who actually deserve them.
Ken
@OzarkHillbilly: I said last night, the Republicans must be cursed. Projection explains a lot of what they say but surely they didn’t want death panels.
jonas
Maybe Dave can explain in detail: what prevents a hospital from simply saying that voluntarily unvaccinated Covid patients will be sent to the back of the line for treatments like redemsvir, supplemental oxygen, respirators, and the like? Why should someone severely injured in a car accident be denied an ICU bed just because some unvaxxed idiot’s selfish ass is occupying it?
Ohio Mom
This was a headline in today’s Cincinnati paper. I know “crisis standards of care” is the proper term but if I was in charge of headlines, it would have read, “Triage starts in Idaho hospitals.”
Because the average reader has probably heard of the word “triage” and associates it with war and other extreme conditions. Which is what this is, an extreme condition.
Nobody knows what “crisis standards of care” is except people in the medical field. So it isn’t scary to the average old dolt reading the morning paper in Red America. And they need a fire lit under them.
Rocks
@Ken: No, quite the contrary, the Republicans actively wanted death panels. They just never imagined that they would be the ones on the receiving end.
lee
Woah I actually have something interesting to contribute to a thread!!!
My wife and I just spent 5 days in N Idaho (Couer d’Arlene) for a conference (Continuing Education requirements for her job). Both of us are fully vaccinated.
Outside of the conference NO ONE was masked up and no social distancing at all (conference had both requirements). Even the waitstaff at restaurants typically didn’t have masks. The local hospital’s (Kootenai Health) parking lot was typically full every time we drove past it.
We both wondered what the vaccination rate was for the area. I guess I now have an answer to that question.
Saturday there was a ‘Trump Won’ parade both on the water and up and down the main street.
lee
@jonas: Just in the last week or so there was a hospital that announced that very policy. They quickly backtracked publicly but I’m guessing the policy is still (quietly) in place.
David Anderson
@jonas: that is unethical as hell.
OzarkHillbilly
@sherparick:
@Booger:
Low hanging fruit for sure.
I wish I could be sure, but their eagerness for wars and fondness for the Bible gives me pause.
bbleh
No, see, this is just a big hoax perpetrated by the hospitals so they can get more gummint money. Why, there isn’t any real problem, I don’t know anyone who’s had any problems! And we never heard about this sort of thing when Trump was president. [Narrator: yes we did.] Anyway, if *I* need something at a hospital, I’m not letting any bureaucrat stand in my way! I pay my taxes, and I deserve every bit of the care I need!
Barry
@Ken: “Projection explains a lot of what they say but surely they didn’t want death panels.”
IMHO, they were fine with death panels. For those people, ifyouknowwhatimeanandithinkyoudo.
Tony Gerace
This is a good argument in favor of those scary “vaccine passports”, and, in times of extreme scarcity of medical resources giving priority to those patients who have valid “vaccine passports”. Triage. That will never happen though.
White & Gold Purgatorian
Since last week the local news has been reporting that Alabama hospitals have more — over a hundred more yesterday — ICU patients than they have staffed ICU beds. They have not explained what that means for standard of care or whether it means staff has to decide who gets “actual” ICU bed vs. something less. We are all vaccinated and are trying to be more careful than normal so as not to need hospitalization for an accident or fall. Of course, no one ever plans to have an accident or fall … or a heart attack or stroke. What an eye opener this has been. I never would have believed so many here would be this foolish about vaccination.
dr. bloor
@Ohio Mom:
Mine would be “Idahoans opt to put their Meemaws on ice floes, shove them out to sea.”
Enhanced Voting Techniques
Northern Idaho. That’s seriously messed up that some of the worst hit areas in the country are the rural areas. The low population density alone should be enough to slow things down, sounds like a social behavior thing that’s causing this.
dr. bloor
@Enhanced Voting Techniques: What’s that old saying? “You’re not just screwing that sheep, you’re screwing everyone who’s ever screwed that sheep.”
Ken
Do medical ethics apply to the whole of a health-care corporation, or just to the doctors and nurses? Asking for a friend in the insurance and billing department.
White & Gold Purgatorian
@David Anderson: Is likelihood of survival the only ethical discriminator once care has to be rationed? This is not a question I have ever pondered, but as someone with a 93 year old parent, I worry that she would automatically be put at the back of the line, just because of her age.
WereBear
@mali muso: I do believe such a strategy would, at least, get their attention in a new way.
dr. luba
@lee: I spent the weekend, with family, at my brother’s hunting camp in mid-MIchigan (Gladwin area).
When we went out, wearing KN-95 masks, I noticed that we were the only masked people. Honestly, in 4 days, I saw one other person wearing a mask. The cider mill and ice cream shop were crowded, as were other “tourist” venues. There were Trump and “Fuck Biden” flags galore.
It’s as if COVID is just something happening in far off lands.
Ksmiami
@mali muso: as long as we r double masked (I got a booster) so….
Starfish
@White & Gold Purgatorian: The elderly and people with disabilities have the most to be concerned about here. If someone decides that a disabled person’s quality of life is not that great, they may choose not to save them.
The elderly have always been treated that way. In systems that are more supportive of assisted suicide, you see a lot of elderly folks being held up as noble for telling the medical people to save the medical equipment for someone younger.
The older population in a lot of the US is the most vaccinated, though. The amount of death COVID caused in these elder care facilities has those facilities taking more precautions than the surrounding community. With everything, the question is “Is this enough?
Starfish
@Starfish: With my mangled last sentence, I meant to ask, “Are the precautions that various institutions are taking enough?”
Are the precautions in K-12 education enough? We have seen the various nutty school board meetings where people are chipping away at even the most minimal precautions.
Are the precautions for college students enough?
Should we be having the concerts that we are having now? For example, there was a Harry Styles concert in the metro area near me. His audience is fairly young. How many unvaccinated children under 12 were at that concert?
Thinking about it all is exhausting.
Anoniminous
ICU outcomes and survival in patients with severe COVID-19 in the largest health care system in central Florida
Thus under triage conditions unvaccinated patients with other underlying conditions: heart disease, obesity, history of smoking, etc., requiring ventilation should be refused further care, allowed to die.
Edmund Dantes
@White & Gold Purgatorian: going to be at the back of the line as age, ability to survive the treatment (tied into age and current patient condition), and future life expectancy plays a role in triage. But it’s unethical to consider the person’s vaxx status.
see how that works?
Edmund Dantes
The other nasty part is people that would have been alive from car wreck, gunshot, nasty fall from ladder, et al will not be tallied against the “official” Covid deaths even though they could have potentially survived except for a lack of a bed/treatment space.
gvg
Is Idaho the first area to do this officially? Because I had the impression that Mississippi, and possibly some others were in that situation already?
Last weekend my University had no restrictions football. 88,000 people. No masks required. Granted it’s open air but it’s really crowded and the concessions and bathrooms are enclosed. It’s already bad in North Florida but cases have just started creeping down. Schools started weeks ago. Expecting 3 weeks from now another outbreak. I refused to even watch the game on TV because I felt it was so wrong. My dad watched hoping to see empty stands or lots of masks. He said nope. All idiots.
Hoosierspud
@Enhanced Voting Techniques: Coeur d’Alene is the hottest real estate market in the country. People have been moving to that area in droves the last year.
kindness
I get frustrated. Frustrated with the press, frustrated with people. Especially the Trumpers out there. I don’t want the non-Trumpers to get sick and die and I suspect those are the folk David was driving towards even though he was more inclusive than that. I see the people who are using Covid and the vaccines as chips on their shoulders not as proud, independent and steadfast. I see them as familial abusers or toddlers throwing tantrums. And I get that David wants to help everyone here but I am tired of facilitating abusers and tantrum throwing toddlers. We can’t go on enabling these miscreants. And at a certain point that is exactly what we are doing. Now the non-Trumpers? How can they be helped? Well if it was me and I lived in N. Idaho I’d pack my bags and beat feet it out of there. That’s pretty easy for me to say though being that I live in the glorious (when it isn’t on fire) People’s Republic of California.
Edmund Dantes
First three weeks of little one school in California. About one letter a week sent home about a confirmed Covid case.
this Tuesday, we got two letters for two confirmed cases. Have no way of knowing if those new cases were close contacts with previous cases or brand new independent cases as only close contacts get notified for quarantine.
Question now is does it have a foot hold in her school or will the quarantining knock it down?
Hoosierspud
@lee: I live on the WA/ID state line. People in Idaho act like there’s no pandemic for the last year and a half. Even though there are local businesses we like to patronize in Idaho, my husband and I have been steering clear of the whole state. Brad Little, the governor, finally suggested people get vaccinated a few days ago. He’s being challenged for re-election by the batshit crazy lieutenant governor. Unfortunately, the batshit craziness spills over the state line.
Hoosierspud
@Enhanced Voting Techniques: Coeur d’Alene is the hottest real estate market in the country. People are flocking to Northern Idaho in droves in the last year.
Freemark
Schools here in Southcentral Pennsabama are defying the governors mask mandate. It is ok to kill and maim children in Trumpland if it owns the libs.
Anoniminous
The hyper-active immune response in children that was a major cause of death in the 1918 Influenza Pandemic appears to be helping in the Covid-19 Pandemic.
Pre-activated anti-viral innate immunity in the upper airways controls early SARS-CoV-2 infection in children
The death rate among children is – reportedly – under 1%. We lack sufficient data to state with any degree of confidence regarding Long Covid in children. There are reports up to 50% of children may have Long Covid symptoms and affects: fatigue, persistent dizziness, etc. There are also published reports of Covid caused brain damage to children, e.g., strokes. There may be other life-long physical damage, there probably is life-long damage, but we just don’t have the data.
Suzanne
@Freemark: Pittsburgh Public Schools has a mask mandate in place, even before Gov. Wolf’s order. Urban areas FTW.
stinger
@jonas:
Not only is this unethical, it’s an extremely slippery slope and just unworkable. What if the car accident was the fault of the injured person? Or what if that cancer patient over there was a smoker? Every person coming to the hospital would have to be quizzed on the cause of their injury/illness–and what if they lied?
This is too reminiscent of the pre-existing conditions that insurance companies used pre-ACA to deny coverage. Diagnosed with breast cancer? Did you sometimes skip your monthly self-exam, or fail to get a mammogram once? No coverage for you!
Triage is based on who is likely to survive, not on who is least responsible for their current condition. And I say this as a vaccinated person who masks and keeps 6 feet apart whether indoors or out.
That said — emotionally I can agree with your comment!
Hoosierspud
Puddinhead
@Freemark: yeah, the butthurt is pretty strong around here. When you have to deal with their unassailable logic that a virus which contains probably a couple of million atoms sails right through all masks but CO2, which has three atoms, is trapped and poisoning their precious little snowflakes, it makes it kinda tough. If Tom Corbett were still governor and proposed a mask mandate, I wonder what the reaction would have been.
Enhanced Voting Techniques
@Hoosierspud: ah, and bringing their diseases with them.
rikyrah
@Tony Gerace:
It totally should happen.
piratedan
@stinger: ty for making the point… the ethics of the profession prevent this from being any other way than it is…
Trust me on this, as soon as something like “they deserved it, they had a perfectly free vaccine to take and they didn’t do it” gets implemented as a policy, a whole parade of parables where the GOP is in charge would follow. Granted the GOP may do that anyway, but the good faith that is supposedly instilled in the profession would be lost. I don’t mean to imply that there aren’t some seriously fringy types involved here (those that were just in it for the money, or perhaps the family profession etc etc etc, there are cautionary examples everywhere) but that the GOP in building their cult of personality would claim another profession’s integrity as lost. Look at what they’ve done to journalism and academics and politics. Each and every step along the way, they destroy “expertise” and replace it with their own prejudices and biases.
Ken
Around 100 million, if the google is to be believed.
Now you know — and knowing is half the battle.
geg6
If decisions of treatment and how much have to be made and it is COVID patients (something like 90% of which are the unvaxxed) who are creating the crisis in ERs and ICUs, then that is a factor which should be taken into account when these decisions are being made. In a crisis, hard decisions are inevitable and it seems to me to be more unethical to refuse treatment for those who have not taken unnecessary risks that are ridiculously easily avoided. Someone with an aneurysm should definitely be treated before an unvaxxed COVID patient and I cannot understand how that would be unethical. Maybe I’m missing some argument about ethics, but if so, I’m fine with being unethical in this instance.
lee
OT but I think important.
“Abbott says Texas will ‘eliminate all rapists’ in defending abortion bill”
The current thinking is that Texas is going to change the laws to narrowly define rape so that it makes it very very hard to claim rape.
FYI Marital rape was only outlawed in Texas in 1994.
RSA
@White & Gold Purgatorian:
I posted a link to “Principles for allocation of scarce medical interventions,” (The Lancet, 2009) last year. I liked it because it laid out candidate ethical principles and briefly talked about their plusses and minuses. Likelihood of survival falls under the article’s category of maximizing benefits.
sab
@kindness: We can wear masks too.
My youngest grandchild is unvaxxed in school now, with masks. Her older sister went to school (unvaxxeddue to her mother’s intransigence but masked in a mostly unmasked school) and just got covid and brought it home to her baby brother. We are not going to cut off all contact with these kids and their siblings so I go masked everywhere. I don’t want the bank tellers and the grocery cashiers getting breakthrough covid from me.
Ken
“We’ve had this capability for decades, but it never seemed worth the effort.”
Taken4Granite
@Enhanced Voting Techniques: Low population density doesn’t help so much when the only place in the county, and in some cases for several surrounding counties, that you can buy groceries is the local Wal-Mart. Sure, the virus doesn’t get there as quickly as it hits the big cities, so these places have time to get mitigation measures in place. But COVID-19 has been around long enough that that advantage no longer exists.
Searcher
@Ken: Another fact sheet gives it a mass of 1000 megadaltons. The average atomic mass in plants is about 14 daltons, 13 daltons in animals (different CHON ratios). That would translate to 70-75 million atoms, or, given the single digit of precision on the initial 1000 megadaltons, round to about 100 million atoms.
sab
@jonas: In my very extended family, the anti-vax mom and dad are fine. The baby is the one in the hospital and his teenage sister who wanted a vax but was a minor without parental permission is also sick with covid. Not everyone unvaxxed chose to be so.
Flea, RN
As an ED nurse, I do triage every day – we are the definitive destination for every sick person within 50 miles, and have limited resources. Most of the time, we are not close to the limit of what we *could* do, but when we are, those resources need to go to the people who can’t wait; in theory, a person with a ruptured appendix could wait for hours (with the proper antibiotics) before further treatment, but a person with a gunshot wound to their aorta will die if they don’t get surgery now – the gunshot victim goes to the head of the line.
I would just like to make a few points, expanding a bit on what some of you have already said:
Thanks for listening.
p.a.
@Ken: Texas to euthanize all males, just to be thorough…
Enhanced Voting Techniques
@Taken4Granite: Still, it’s that hard to wear a mask into a Wallmart? I mean those places are a hygiene disaster at the best of times. Not to mention is it that hard for the State to lean on Wallmart to clean the filters on their HVACs?
My point is these people are idiots, maybe the medical community needs to get sneaky and find work arounds for their stupidity, since the medical community refuses to do the brute force methods like denying these idiots care? What they were saying about the Governor of West Virginia being a good at talking Idiot
Scolding these idiots during their esoteric crises induced murder suicide attempt is obviously not going to work.
stinger
@Flea, RN: Thank you so much for this. And for your daily work.
Searcher
@stinger: There’s also the problem of knowing.
We can’t just roll someone out of their ICU bed and into the street if a “more deserving” patient comes along; aside from the ethics of that, you may not have time to turn-around that space if someone else needs it now.
So you would need to deny care to some people just in case a “more deserving” might need it instead.
Wvng
Here in WV, currently the “hottest covid market” in the country, an old friend just lost her 44 year old unvaccinated nephew to covid and one of her vaccinated sons is pretty sick with it. We’re like Idaho in Trump adoration and vaccine/mask refusal and ICU beds are very scarce. The governor talked about triage decisions just the other day. So frustrating.
Enhanced Voting Techniques
@Flea, RN: Yep, it’s easy to say “the anti-vaccines should just do without” but how in the heck is some ER going to sort that one out?
Wvng
@Flea, RN: Thank you for the reality check from the trenches, and for all you do.
brendancalling
I have some step-inlaws down in North Carolina who are holy rollers with 5 or more kids, all under 12 and who can’t be vaccinated. They had to be dragged kicking and screaming by my dad and stepmom into getting their kids the standard measles/mumps/whooping cough etc vaccines, and neither parent is vaccinated against covid. Every day I wake up expecting a call from my dad that one or more of these people—adults and children alike—are hospitalized. It’s a Herman Cain Award waiting to happen.
They are part of the problem. They’re part of the reason states are beginning to ration care and triage patients. And although they’re family, my sympathy will only extend as far as the kids, who have no say in the matter.
OzarkHillbilly
@Flea, RN: Thanx for speaking.
RSA
@Flea, RN: Wow. Thanks for your work, and thanks for laying all this out in such a clear and compelling way.
Steeplejack
@lee:
Do you have a source for that “current thinking”? It’s not in the story that you linked. It sounds like unsourced speculation (and snark) that I’ve seen on Twitter, etc.
scav
@p.a.: Be damned ironic if they did a prenatal test and eliminated all males pre-birth.
PenAndKey
And you know what? I’d be perfectly fine with doing so in the middle of an active pandemic that’s crippling our medical system. In fact, stick them in their own facilities and if we don’t have enough, which we don’t, they can handle being put in a medical tent in the parking lot for basic palliative care. If that’s not good enough, I hear that they can self medicate at home with their horse dewormer to their liver’s content. The unvaccinated fools currently forcing hospitals to enact triage protocols brought it on all of us. If denying them a bed ensures that it’s open for car crash victims, gallstone emergency surgeries, heart attacks, and anything similar that may roll through the doors then that’s just fine.
OzarkHillbilly
@Steeplejack: It is, but the flip side of that coin is, “If it’s so easy to eliminate, why haven’t you done it already?”
Steeplejack
@Flea, RN:
Great post, very informative. Thanks!
smith
The statistics are stark and convincing: Unvaccinated people are much less likely to survive a stint in ICU than vaccinated ones. Setting aside all moral judgments about personal choices, why wouldn’t this be part of the calculus in figuring out who is most likely to survive?
eclare
@Flea, RN:
Thank you for your post.
Raoul Paste
If you’re on a list to get a liver transplant, and then they find out you’ve been drinking, you are taken off the list
That’s a pretty good analogy
NotMax
@<a href=”https://balloon-juice.com/2021/09/08/crisis-standards-of-care/#comment-8281713″>OzarkHillbilly</a>
“It’s not rape, it’s enhanced courting.”
//
jonas
@stinger: I get your point and understand the slippery-slope argument. My one response is that car accidents, heart disease, cancer, etc., aren’t mostly preventable with a safe, free, widely-available vaccine. Serious Covid illness is.
NotMax
@NotMax
No idea what FYWP did there.
Kent
My wife is a physician who is on the advisory panel for her organization to figure out how to organize (ration) care if this region gets slammed similar to Idaho.
Most common sentiment and comment from other staff colleagues is “Build tents in the parking lot where the unvaccinated staff can take care of the unvaccinated patients.
People are fresh out of fucks at this point.
lee
@Steeplejack:
I’ve seen it in a couple of threads on other websites in a non-snarky context. It also falls exactly inline with how the GOP in Texas thinks/works.
lee
@Kent: I would think that if someone is vaccinated, they would show up to the ER with their vaccination card in hand.
Texas has ImmTrac where registered healthcare providers can access a patients vaccination records. Hopefully my covid vaccine is registered as I presented it to my PCP shortly after getting my second.
smith
@Raoul Paste: I was just thinking about this, and did some googling. As far as I can tell, the current thinking is less about whether your past drinking destroyed your liver, and more about whether you’re likely to abuse your new liver in the future by continuing to drink. In some ways that seems like an even slipperier slope to me — it’s much easier to find out the truth about past behavior than to accurately predict future behavior, and allows much more room to be swayed by the personal biases of the decider.
And it’s still about behavioral choices. Is this scarce resource going to be wasted by the choices you are likely to make? The only basis you have for making that prediction is the person’s past behavior.
Kent
@Taken4Granite: That is a point that many people don’t understand. If you have a remote rural area with one grocery and the clerk at the checkout line is sick and contagious, he/she could invest the entire region because everyone is no more than one degree of separation from that person. It isn’t the population density, it is the choke points.
Betsy
@lee: Let me guess, the “parade” was motor vehicles and boats. Both make a small turnout look disproportionately big, since vehicles plus the room needed between them take up 100 time the space needed for actual humans.
When *we* march, it’s actual people filling the streets.
Kent
@lee: My wife works for Kaiser. Your vaccination record is automatically part of your electronic medical record that all doctors will see when they pull up your chart, which is the first thing they will do at the ER. They know. You don’t need to bring your card in with you.
The Dangerman
It may be me (too little sleep or coffee, too much stress), but goodness when I call a medical office these days, I am hold something approaching forever. I have a seriously long fuse but I’m ready to scream and throw shit by the time I reach a person.
Someone should Invent a way to place the Folks on hold on hold so you don’t have to listen to that shit music and hear the same announcement scores of times. If I’m on hold for a few hours, I might as well be listening to some Floyd as opposed to their schlock.
OzarkHillbilly
@NotMax: Heh.
Betsy
@Enhanced Voting Techniques: Population density has little to no correlation with COVID prevalence.
People coming together indoors is where it spreads. That has little to do with how densely populated an area is.
I remember lots of Republican acquaintances trying to spread the idea early on last March that we really have nothing to worry about in rural areas because population was low, so we should keep going to restaurants and bars.
They got incredibly whiny when I challenged them to explain how restaurants and bars don’t work the same way in rural areas as they do in towns and cities.
OzarkHillbilly
@NotMax: It FYNM there.
OzarkHillbilly
@The Dangerman: Here’s an idea somebody much smarter than I can make money on: A personalized on hold music app for your smart phone.
Kent
@The Dangerman: Most of the places that I call these days will let you get in a queue for a call-back which is what I prefer.
Barbara
@jonas: I am finding responses by ethicists and posters here to comments like yours to be unsatisfying. So let me try. First and foremost, imperfect information makes any kind of treatment decision based on moral hazard to be really, really questionable. Does it matter if the guy in the car accident was wearing a seat belt or texting his office while driving? Does the answer change if he is working two jobs to support disabled dependents? And how would anyone with immediate responsibility for allocating resources know these things?
No, these judgments will be real time with virtually no clear context available for making them. Which raises the second problem: If you introduce this kind of value based judgment, they will not be systematic, but will seem and probably will be practically random. Random is not good and allows for personal bias that often penalizes marginal communities. Getting away from value laden judgments in cases like organ donation has been an ongoing battle. You don’t really want to go backwards.
Having said all of that, in my view, it would be ethical for an institution to reach a need based consensus on issues such as how long someone can remain in an ICU bed before the possibility of survival becomes low enough to reallocate that bed to someone with a better chance of survival. If that means Covid anti-vaxxers are likely to bear the brunt of that policy, that’s okay. It just can’t be its purpose.
brendancalling
@smith: I follow a nurses page on Reddit, and many of them are asking the same question as you. My kid’s mom is a nurse, as are many of my friends, and they’re all burning out quickly. Especially galling is people insulting them and questioning their knowledge skills when it comes to the vaccine, then running to the very same doctors and nurses for treatment when they get sick, THEN arguing when the doctors decline to prescribe ivermectin and hydrocholoriquine.
“Gimme, gimme, gimme
I need some more
Gimme, gimme, gimme
Don’t ask what for
One, two, three, four
Standing here like a loaded gun
Waiting to go off
I’ve got nothing to do
But shoot my mouth off…”
Kent
@Betsy: For redneck Trumpers, the vehicle is part of their male identity. It is phallic. That is why so many blue collar guys making mediocre wages spend $70 grand on high-end diesel trucks. And driving a powerful truck is the only power that they actually have. If you can’t roll them out during protests, what is the point?
White & Gold Purgatorian
@Edmund Dantes: “see how that works?”
Yes. Yes I do see how that works. It is the stuff my nightmares are made of.
The Dangerman
@OzarkHillbilly: Exactly. I put the other party on hold and play my tunes from my phone library (or just blessed silence). It would have to be smart enough to know when liveware comes on the line.
Ken
@Kent: @Betsy: Don’t forget the churches. “We’re pretty isolated out here, except every Sunday when the entire county crowds into three churches.”
Old Man Shadow
So once again Republicans have projection issues. They brought us Death Panels.
lee
@Betsy: Yep a parade of about 4 vehicles (trucks and jeeps). The one on water I think had a grand total of 5 boats.
@Barbara:
I think I’m missing something.
I do remember a time that an unrecovered alcoholic would be denied a liver transplant. Is this still not the case?
Ruckus
@Ken:
Seems a lot of them do want death panels. They just didn’t want them for republicans.
Life is a bitch when you have zero understanding of how life works.
Roger Moore
@Ohio Mom:
I don’t know that everyone knows what “triage” means, but everyone knows what “crisis” means. “Crisis standard of care” gets across the point that the hospitals are no longer in normal operating mode and are officially in a crisis very nicely.
Betsy
@Kent: Yes, all true, and also they can’t muster out more than 100 people, but it does look a lot bigger if it’s 100 trucks.
Bonus of being enclosed in a vehicle: they don’t actually have to engage with anybody.
Nor hold a conversation with their fellow Trump worshipers, because even though they agree on politics, the conversation would probably be unpleasant since it’s a bunch of sociopaths and people who live far away from other people for a reason.
But the bonus for us: they can’t table or have sign up sheets like at a real rally or protest.
yellowdog
@White & Gold Purgatorian: I’m a healthyish 73 year old. I think I would belong ahead of the unvaxxed but behind everyone else. But, I live in the DC burbs and that kind of shit ain’t happening here.
yellowdog
@Raoul Paste: They gave Mickey Mantle, an alcoholic, a new liver. Some people go to the head of the line, no matter what.
burnspbesq
Given how Republicans like to weaponize absolutely everything, if I were an MD in this situation I would be lawyered up before participating in any discussion about anything that could be characterized (or even egregiously mischaracterized) as rationing care. It’s a virtual certainty that some docs are going to face bullshit license suspension/revocation proceedings.
smith
@Betsy: One of the most interesting things to me about the covid culture wars is the fact that red/rural people are blissfully unaware of how much harder rural areas have been hit, not in terms of infection rates, but in terms of death rates. Starting a little over a year ago rural death rates moved substantially ahead of urban ones. They were about the same during the downslope from the winter peak, but the advent of vaccines has increased the differential again. There are probably multiple factors underlying this, including age distributions and availability of advanced medical care, but I would also guess that the refusal in rural areas to do any mitigation at all probably meant greater exposure, greater viral load, and more severe cases.
Ruckus
@jonas:
Because that’s not how medicine works. When overloaded it always does this, those most able to survive go to the head of the line. Supplies, medicine, oxygen, beds, doctors/nurses, when they get in short supply you work on who has the best chance of survival, not on those who have the least. When it gets worse……
You don’t get to make distinction on what put them in need of care, you get to care for them as best as possible. Those in better shape to survive get care, those in dire need that take massive resources and still have a very low chance of survival, don’t.
It isn’t necessarily fair but it is as humane as resources allow.
Do you want that doctor not to care for you if you have – red hair, or black skin, or political stupidity? Doctors work on what they can do, and when that isn’t enough they have to allocate what they can do. Lost causes go to the back of the line. No matter the cause.
Mary G
@Flea, RN: Add me to the list of admirers of your post. It’s easy for us to play the theoretical games about who gets cared for first, but being confronted with actual human beings must be a different thing. I’m glad you have clear guidelines in advance.
I do worry about mass PTSD/burnout for people like you. I hope you can stay as dedicated as you are; I know I couldn’t.
PenAndKey
@yellowdog: The rich and well connected have always operated under the “rules don’t apply to us, we get what we want” system.
burnspbesq
@Kent:
And it has to be LOUD.
This is why I think the F-150 Lightning is going to be a dud in the Texas retail market. Fleet buyers may be another story, but for the average dimwit an electric truck just ain’t gonna cut it.
Barbara
@lee: Only if you aren’t Mickey Mantle. And who decides what it means to be “recovered”?
Seriously, if you want a better example try this one: a person who needs a kidney transplant is “downgraded” because they don’t have a supportive family or they have an impermanent living situation. That’s a hell of a lot more common than the alcoholic would be liver recipient. And yes, I think that is something that we should try to avoid — by providing adequate social support rather than shrugging our shoulders and making the effects of historic bias permeate to the core of a person’s existence.
At least in Idaho they are likely pitting one set of Caucasians against another, so they don’t have race issues to contend with.
Ruckus
@Flea, RN:
Thank you.
IdahoGoatGirl
I live in north-central Idaho, in one of the two health districts that went to crisis care. It is infuriating, depressing, and horrifying to live here. When we drive around our little town there are no masks, or maybe one mask. Back a month ago when we were racing in and out of the grocery store with our masks on I would get snarky remarks. The Trump flags are all still around and the pandemic is all Fauci’s fault and they are not gonna wear a face diaper or get that vaccine that doesn’t work and kills so many people. I have, in the past, been accosted by my neighbor while trying to get my mail. She would wait on me to walk by and then run out to see how worked up she could get me. I fell for it once, resulting in a bit of a shouting match where I called her a fucking idiot. Not my finest moment. Our town cancelled part of the fair, which was amazing and only happened because some folks that work at our hospital are also on that committee. The town and county are mostly furious over this decision. Our elementary school is closed for two days because of covid… what will two days do???? Our county of 8,500 or so people was the Idaho hotspot on Friday with the highest infectivity rate. We remain battened down in enemy territory, the only reason we stay here is we are in a beautiful spot that we love and we have some like-minded friends in the area and we try to support each other. Wish us luck.
TriassicSands
I live in rural western Washinton. Last year, due to geographic isolation, my county was always among the bottom four or five in rate of infection. After the CDC’s ill-considered relaxation of COVID-19 precautions (follow the science — ignore human behavior — ignore the delta variant), and the ensuing, completely predictable surge, the same county has become one of the worst.
Because of COVID-19, I’ve been denied care I would have received (and did receive) last year. That hasn’t threatened my imminent survival, but it makes my quality of life and functionality extremely poor and could, conceivably, have even worse implications. This could have been prevented if Americans had behaved responsibly.
The ethics of refusing to be vaccinated, wear a mask, and avoid risky situations are not part of the ethical decisions about treatment. You could have refused to do all of the above resulting in the (possible? or even certain) infection and death of any number of people and still be at the head of the line for treatment — even ahead of those you infected.
While I accept that it is ethical to deny me care in these circumstances, I’m not so certain that the situation involving critically ill patients is as unambiguously clear as ethicists and DA would argue. There are no “surges” in ICU admissions caused by lung cancer patients who smoke(d). There could be occasional competition for resources, but we’re in a pandemic that is being fueled specifically by the irresponsibility of millions of people who can be saved (or receive care) by virtue of being a little younger or not having a pre-existing condition or auto-immune disease.
What the current system does is free doctors from making very difficult decisions. It’s much easier to decide who has a better chance to survive¹ than to determine which patients are more deserving. I don’t think that automatically means that it is more ethical.
¹ Though doctors can be wrong.
kindness
Wrt transplanting livers….I do the paperwork for N. Cal Kaiser members transplants. If the member tells us they are still drinking when they want to be on the liver transplant list, they are immediately disenrolled from the transplant program. Same thing goes if they ever fail an alcohol screening test which they will get every time they see a physician. Livers are scarce and they treat the ones they are able to get with great care. I would imagine it’s the same with drugs but I hardly see that. I do see people getting removed from the transplant program all the time for failing the tox screening.
Roger Moore
@gvg:
The “no masks required” thing is so infuriating. The Los Angeles area is a great story of how important masks are. We saw a scary uptick in cases back in early July, and the public health authorities quickly reinstated a requirement to wear masks in public indoor spaces. Other places weren’t quite as fast on the trigger, but the big urban counties mostly followed within a week or two. Case counts continued to climb for a few weeks- a lot of those cases were probably baked in at that point, so no intervention could have stopped them- but they leveled off and started to fall without reaching crisis levels.
And that was with basically no other interventions, just a return to masks when indoors. Businesses are still open, schools are running, and the state is mostly running along pretty smoothly. Mostly. The quick return to indoor mask wearing was largely limited to urban counties and a few rural ones like Imperial that had been hard hit earlier. A lot of the places that had avoided the worst of the pandemic so far refused to believe it could happen to them and did nothing. Now they’re being crushed. Fortunately, the most populous parts of the state still have hospital rooms available, so there’s some place to send their overflow.
Kent
@burnspbesq: Naw, they will use all that electrical power to ramp up the noise level. Noise pollution from electric trucks will be the next rolling coal. Mark my words. Some of them will be so loud the pavement will vibrate.
Kent
@kindness: Heart transplants in WA are also being denied to those who are unvaccinated for Covid. The idea is that the transplant process suppresses the immune system so you are at greater risk of dying if you are unvaccinated. Makes sense to me.
Ksmiami
@TriassicSands: to me it’s the marginal cases like if a 49 year old comes in with heart issues but is vaxxed etc, he deserves the extra effort to save him over the anti vaxxer so let’s save the resources.
Ruckus
@dr. luba:
Reality is a strange place to a lot of humans. They don’t understand it, they don’t like it, and they think they can create their own, through politics or religion, or even their thoughts alone.
Reality knows better, they don’t.
Reality is smarter, they aren’t.
Barbara
@TriassicSands: See my comment above. These “difficult” decisions are loaded with the biases of those making them. In my view, consistency and fairness of application are part of any ethical standard.
stinger
@Ruckus:
Stealing this. Will credit Ruckus!
?BillinGlendaleCA
@Roger Moore: Now if we could just get folk to wear their masks correctly…OVER THE NOSE FOLK.
The Pale Scot
Unvaccinated? to back of the line please.
No insurance coverage for the unvaccinated. The government/insurance co. doesn’t have the money, I’m sure you understand
This is the only way to deal with these people. Not vaccinated? here some horse paste and NyQuil, Please go to the Ark B departure area, I understand Alex Jones will be speaking, he’ll explain everything to you
Roger Moore
@smith:
They’ve been hit hard by infection rates, too. The states with the most total cases per capita aren’t New York and New Jersey; they’re Tennessee and North Dakota. And the deaths thing is really scary. We hear all about the death rate in New York because they were hit so hard early in the pandemic, but Mississippi has passed New York for second place in the deaths per capita category, and they’re within a week of passing New Jersey for first.
Mississippi is especially frustrating. They are
dead lastEdit: third to last in the nation in COVID vaccination rate, and it’s 100% political. They know how to vaccinate people there, since they’re first in the nation in MMR vaccination rate. They could get everyone vaccinated if they wanted to, but they’ve just said fuck it and let people die.Roger Moore
@?BillinGlendaleCA:
Don’t get me started. I’m also pissed off there are still people going maskless on Metro, and that the sheriff’s department has publicly stated they won’t do anything to enforce mask requirements. It’s Villanueva we should be recalling, not Newsom or Gascon.
Miss Bianca
Update on my sister, because it’s relevant to the discussion at hand…
On top of just getting diagnosed with pancreatic cancer (early stages, sounds like her medical team is optimistic about treatment options), yesterday she landed in the hospital because she had suffered a stroke! Apparently about 3 pm ET, which is probably right around the time I tried to call her…and didn’t get an answer. Neither did anyone else, including her daughter, who had called about 5-6 times at that point. Finally one of my other sisters called the police and the police did a wellness check, and that’s when they found her – about 8 pm ET.
So, she’s alive, she’s coherent, but her left side has been affected. She’s still in ER while they get a bed ready for her. Throws all her treatment plans into a bit of upheaval, BUT – here’s the point, I did have one – she was able to GET into the hospital because she lives in New England, not Florida or Texas or Mississippi. And still, up there, there are unvaxxed assholes clogging up the system. She was lucky. Damned lucky.
I hate this timeline so fucking much.
stinger
@Miss Bianca: Trouble on top of trouble. She was lucky in that way — and will continue to need luck as well as good medical treatment and supportive family! Best wishes to her and you.
The Pale Scot
@David Anderson:
In what way? With limited resources the COVID infected unvaccinated DO HAVE the worse outcomes. Sedate them and roll them into a storage room.
All of my family are vacced. If I’m told my niece can’t get into ICU because willfully ignorant aggressively stupid goobers have taken all the slots, well…
This isn’t about ethics, this would be about a ten year old girl suffering needlessly. I’d likely to use my 2cd amendment rights and make some room in the ICU
TriassicSands
@Barbara:
However, fairness of application and fairness are not the same thing. Part of my point was that the current system may be necessary, for a variety of reasons, but that doesn’t mean it is unquestionably the most ethical system.
@Miss Bianca:
Your poor sister. What a terrible development added to a terrible, if hopeful, diagnosis. I hope she can get through all this.
Barbara
@Miss Bianca: I am so sorry to hear this, and I hope she recovers from the stroke quickly. PC is a hard diagnosis, best of luck to her.
Barbara
@TriassicSands: Understood. It’s a fair point, and I guess my response is that consistency of application is essential for any ethical standard. So I guess I quibble with the idea of an unattainable goal being thought of as “fairest.”
Annie
@Flea, RN:
Thank you for this. I found it most instructive.
The Pale Scot
@stinger:
Unvaccinated and over 30 are very likely not to survive, That has to be taken into account
The Pale Scot
@piratedan:
So they stop going to Doctors, I don’t see the problem
Yutsano
@The Pale Scot: Roll, please to slow.
PenAndKey
@The Pale Scot: And they’re likely to take critical resources for weeks while having low probability of walking out of the hospital ever again anyway. It’s not just about them being in the bed already, it’s also about telling the multiple people who won’t get beds or treatment while an unvaccinated ICU patient likely to die anyway squanders a bed in vain that their lives are less valued because they didn’t play musical chairs fast enough. This is a trolly question scenario, basically. Only the stakes are far higher than only hypothetical.
Ruckus
@Kent:
They will install fake exhaust pipes with speakers in them and play engine noises – loudly.
Around where I live in socal we have basically 2 kinds of noisy vehicles. Small cars, lowered with 4 cyl engines with 2 very large exhaust pipes, or 4x4s with massive lifts, like 8 inches or more and loud pipes and the biggest off road tires available – so big that they would never fit in the wheel wells so they have to be jacked. The tires make more noise from pavement contact than the exhaust.
Ruckus
@Roger Moore:
Son, I like the way you think!
Tony Gerace
@lee: A “Trump Won” parade. The new Lost Causes for these idiots. A hundred sixty years from now they’ll have statues of Trump, just like the Confederate statues that are still up south of the Mason Dixon Line today.
JoyceH
Had a sad and discouraging experience yesterday. I was just pulling out of my driveway to go pick up my dog at the groomers and saw one of my neighbors on the road talking to another dog owner. I usually only see and visit with this woman when we meet dog walking, and it’s been too bleeping hot for me to walk my dog lately, so it’s been quite a while since I’ve seen her. So I rolled down the window and talked for a few minutes.
When last we talked, her husband had been diagnosed with some dire thing (the name of which I’m blanking on), but a bone marrow transplant could give him ‘a few more years’. Now she told me her husband had the operation and was back home doing well, but had been through hell – had a brain bleed and had to have holes drilled into his skull.
Then I asked if her kids got vaccinated, and she said no, ‘they’re never going to get vaccinated.’ I know from our previous discussions that, since he is immuno-compromised and she is taking care of him, she’d told the kids that they couldn’t visit either of their parents until they were fully vaccinated. But Dad going through all that and Mom going through it with him was apparently not enough to get these whatsits to take a damn shot. Geeeeeeeeez…..
TriassicSands
No argument there. But because it depends on human judgment and humans have biases (acknowledged or not) there is never a guarantee that any standard will be truly consistently applied.
Doctors can not only be wrong about who is most likely to survive, they can decide someone is more likely to survive by weighing the factors unfairly. Also, a lot of decisions may (will) be made on the basis of statistical probabilities, which are true for populations but not for individuals. And these are individual decisions.
Ruckus
@JoyceH:
Pig ignorant is pig ignorant.
You might think that their minds could be changed. But their minds are full of, well something, and it isn’t rational thought. As humans we haven’t taught rational thought for a long time. We teach fun, sales slogans, repetitive motion, the absolute right to do your own thing (which is supposed to be the same thing everyone else wants to buy) because that make someone money – sells stuff. Rational thought doesn’t do that. Rational thought makes less money for those who create wasteful crap.
The Pale Scot
Life is unfair
Or so I’ve heard
Miss Bianca
@JoyceH: Tell me about it. My younger brother, this morning when I called to tell him about my sister, started in on the cancer cures that BIG PHARMA didn’t want you to know about (yes, he used those words – apparently dandelion root and turmeric mixed with black pepper will just knock that shit out, did you know? Neither did I!) and then started in on how he was never going to get COVID-vaxxed.
I hung up on him.
JoyceH
@Miss Bianca: Oh and I forgot to mention that these kids (well, adults, but her kids) at least know that COVID is a real thing, since their grandfather died from it.
Miss Bianca
@JoyceH: *facepalm*
Well, that trumps my brother’s contention that the Delta variant was actually a GOOD thing, because it wasn’t very dangerous, yada yada. Talking like a guy with no personal experience with it, that’s for sure.
Told him that I hoped he had his will updated (he’s a lawyer), and his burial plans in place. Oh, he’s also a diabetic, so comorbidity factors.
I had to hang up before I asked him whether or not he was also eating horse paste. (Altho I can just imagine him saying, “No way, I’m not CRAZY!” in real indignation just as easily as not.)
Brit in Chicago
@The Pale Scot: Life is indeed unfair, but when someone sees a way to make it less unfair shouldn’t they do that? (Rather than using the general unfairness as an excuse.)
kindness
@Kent: The anti-rejection drugs you get put on after a transplant function by reducing your immune response. Transplanted people are going to be at risk the rest of their lives. Another terrible side effect of the drugs they give to liver transplant patients is that it kills renal cells. Most people who have had a liver transplant will need a kidney transplant down the road if they live long enough.
TriassicSands
@Miss Bianca:
Geez, what a time to have a brother like that. I really feel for people whose families have been disrupted by MAGAts, anti-vaxxers & refusers, etc.
TriassicSands
@kindness:
In terms of numbers though, I imagine that those with auto-immune diseases are the majority of the immuno-suppressed. In most cases, they too will be on life-long suppressants, unless there are treatment breakthroughs that find a different way to deal with the conditions or outright cures are found. The list of auto-immune diseases is long.
Roger Moore
@Brit in Chicago:
The difference between liberals and conservatives is that liberals see “life is unfair” as a call to action, while conservatives see it as an excuse for inaction.
The Pale Scot
@Brit in Chicago:
Absolutely. But the current subject is whether the unvaccinated have a right to monopolize care needed for people who aren’t willfully stupid. It’s evolution in action, unvaccinated people over 30 should go to the back of the line. I’ve done a lot of stupid stuff, been to prison. I didn’t blame it on anyone but my idiot self.
Stupid people have to own their stupidity during a pandemic, there is no other way out of this. I have family that’s too young to be vaccinated, so fuck all them.
White & Gold Purgatorian
@TriassicSands: “I really feel for people whose families have been disrupted by MAGAts, anti-vaxxers & refusers, etc.”
The heartbreaking reality is that these people are the same family we have always had, but this crisis has revealed something in them we may not have seen previously. My niece is the same person she has always been. So is her daughter, who was a really sweet kid but is now a staunch anti-vaxxer.
Half of Americans are more gullible than the average. The Republican Party has been selecting members based on gullibility for at least 40 years. That is why so many Evangelicals are also Republicans; no one is better prepared to believe the impossible. Why should anyone be surprised that Republican voters are so willing and able to swallow COVID lies? They have been conditioned to believe any damned thing as long as it comes from a source they trust.
We should direct the hottest jet of our anger at the sources who mislead these people, some of whom genuinely aren’t able to sort out facts on their own. There should be a way to crack down on the lies being broadcast, even on cable and the internet, because those lies have led to the crisis in our hospitals. Put the snake oil salesmen out of business and the buyers won’t be so much of a problem.
susanna
@White & Gold Purgatorian: We
@Flea, RN: I feel like you gave a glimpse of the trenches you very competent and caring professionals are facing and dealing with on a daily basis. Thank you for voicing your challenges, and may you find at least one new positive from all this for your life.
Bravo to all of you.
Ruckus
I think it’s more than that. It has become that clear, at least to me, that republicans are actually desperate. Their Covid response says to me that they are trying to kill off their opposition and accepting the consequences for their side if they have to because they see that their only way forward is to not have an other side. They can’t win if there is truth, only if voting is fixed. They are pleading with people to do stuff that kills them and I think they are doing this until they are all by wiped out or win. Look at all the national anti vax republicans who have been vaccinated. Quietly, privately. They claim to be anti vax and Covid is a joke but they don’t see it that way for themselves. And how many have gone on air to say get vaxed? Their concept of killing off the opposition is doing the exact opposite. They didn’t take the risk, they told their followers to take the risk, that the entire thing is a joke. And it hasn’t worked, it’s backfired.
Splitting Image
@Roger Moore:
Yep. See also “human nature”.
susanna
@Miss Bianca: I’m sorry about this diagnosis and having a stroke upon that is a lot to absorb. And I hope you’re both able to realize fulfillment from the strengths you’ll find, for yourselves and to help her.
If you haven’t read it, Viktor Frankl’s book, Man’s Search For Meaning, might provide some answers as well as questions. The scenario of the book is not what it’s about.
LiminalOwl
@Flea, RN: Thank you very much, both for your comments and for your work. I was in the past sometimes open to the idea of triaging out the unvaxed, and have learned a great deal from what you and others said here. I am grateful for the education.
LiminalOwl
@brendancalling: I’m so sorry.
LiminalOwl
@OzarkHillbilly: Have you seen AOC’s tweet? https://twitter.com/aoc/status/1435772160916787204?s=21
LiminalOwl
@smith: Yes. And unfortunately, f the person is still drinking after being diagnosed with liver disease of that magnitude, it’s not very chancy to predict future behavior.
(I lost a client, a couple of years ago, who was rejected for transplant on those grounds. I’m sad, and I miss her, but… I can’t say they made the wrong decision.)