Maurice A. Ramirez, DO, CNS, CMRO

Limited Resources and Ethics

Please discuss the ethical challenge of dealing with limited resources in a mass disaster.
(Question posed via: Ask@MauriceARamirez.com)

The importance of dealing ethically with people in times of limited resources deals not only with mass disaster, but business continuity and even daily business operations. Whether the limited resource is food water, and medical care in a disaster or wages, shifts and benefits in a business down turn a goal oriented decision process must be employed.

In a mass casualty event, Continuous Integrated Triage should be employed to determine who receives care now and who waits for care based on degree of injury balanced against resources available.

To maximize the delivery of products and services during a time of scarcity, Business Triage must be applied, even by non-healthcare enterprises.

The need for triage is not an opinion, but the consensus of the vast majority of experts in crisis management, healthcare and business continuity. To determine the ethics of such an approach, several ethics boards were asked to address the issue.

Dr. Mark Pastin, President of Health Ethics Trust believes that the need for triage is the, “simple and obvious answer.” Dr. Pastin points out that there is the “risk of violating what would ordinarily be viewed as your professional responsibilities if you do triage.” Dr. Pastin posed the example of an existing doctor-patient relationship with one of the casualties. Dr. Pastin, a long time advocate for resource based standards of care in disaster healthcare points out that the lack of such standards leaves an array of questions should the care available fall below the usual standard of care. Dr. Pastin also points out that some have even wondered if euthanasia might be appropriate to those who are suffering but not likely to be treated.

Ethicist Dr. Ken Solis finds that the distribution of limited resources equitably or most effectively is sometimes “opposing priorities.” Dr. Solis observes that “most disaster plans, for example, allocate a limited resources to health care workers (and their families so the health care worker is willing to show up at work), safety officials (police, firemen/women), and public officials to keep critical infrastructures operating and so that more subsequent people can be treated - a utilitarian or effectiveness approach. After that, most models go by ‘first come-first serve’ or ‘lottery’ to try to be equitable.   Of course, those with the most means will still tend to come in earlier due to their greater resources and might even be able to cheat the lottery in some way, e.g. pay a poor person a lot of money for their ‘ticket’."

Dr. Pastin and Dr. Solis agree that, in a disaster situation, some of the norms that guide the typical provider-patient relationship will undoubtedly become difficult to sustain. The 2001 anthrax attacks and subsequent fear resulted in behavior by physicians and other healthcare providers that culminated in a nationwide shortage of Cipro (ciprofloxin) and doxycycline.

Dr. Solis echoes the concerns of many both in and out of healthcare when he reminds us of another challenge: the competing interests that a health care worker will have balancing their family versus their patients.  “Some healthcare providers will give priority to their family, especially if their absence could cause their family harm. Similarly, the healthcare provider may decide that their presence at the disaster (e.g. an infectious disease epidemic) could cause their family harm.  During the black plaque in Europe, many doctors fled to the country side, not an effective tactic, but acted based on their personal priority.”

The decisions involved in the triage and resource allocation process will result in dissatisfaction at many levels. While the first principle of medicine for centuries had been Primum Non Nocerum (First Do No Harm), it is increasingly obvious that in disaster healthcare the first principle should be “Do the Most Good for the Most People with What You Have Now.”

Managing Expectations at The Edge of Disaster

Steven Flynn’s recent book The Edge of Disaster has garnered the expected “inside the beltway” Washington response.  Finally today a senior official at the Department of Homeland Security (no doubt in the Public Information Office) began to spout the company line and tie it to Mr. Flynn’s book.

Point by point the Department of Homeland Security and the Federal Emergency Management Agency (FEMA) again remind the American public that a federal response is always more than 24 hours away, in fact, usually 48 to 72 hours.  The familiar theme of self-responsibility and self-preparedness are trotted out again for review of a distracted American public.

Unfortunately, both the Department of Homeland Security and Mr. Flynn are right.  In America, as soon as the catastrophe or a disaster has past we busy ourselves with the activities of every day life and forget the lessons that we learned when the most recent adversity struck us.  In short, we never develop resilience.

It is gratifying to me, having declared 2007 unofficially the year of resilience, that speakers and pundits around the country are now reframing their message not in terms of disaster preparedness or response, but in terms of resilience, the ability of a community or an individual to thrive in the face of adversity.  Dory Riceman characterized resilience as mastery against adversity and nothing could be more true.

The Federal Government, as is its habit, has turned disaster preparation into yet another unfunded mandate.  The cost for training and preparation often exceed $100,000.00 per facility falls completely on these private agencies and the individual practitioners within them.  Full scale disaster drills that are coordinated within the community can cost hundreds of thousands of dollars and are now a yearly requirement on all hospitals and healthcare facilities. 

The Institutes of Medicine have soundly criticized hospitals for not including communities, EMS, law enforcement and other responders in both their disaster plans and exercises.  The Federal Government has even gone to the point of setting the stage for several and even criminal prosecution of hospitals and healthcare facilities that continue to bill Medicare, Medicaid, Tri-Care, but are not in compliance with National Incident Management Systems and the National Response Plan.  These penalties were promulgated within the Federal Government, but by so doing became incumbent upon those who build a Federal Government under the Medicare, Medicaid and Tri-Care systems due to a little known clause which requires an attestation of compliance with “all regulations” promulgated by or upon CMS.

The problems do not exist just within healthcare, however.  Disaster preparedness and response are closely linked in the public mind, but separated in time by the event.  As the Department of Homeland Security regularly points out there is not sufficient resources within a one hour response time of every community in the United States. Communities cannot rely on federal assets or even state assets in the event of adversity. 

If resilience is mastery over adversity then that mastery is achieved through ensuring that resources never exceed needs.  Disaster is when you need to exceed your resources.  If you can prevent that single failure you can prevent disaster.

There is an unfortunate tendency to believe that disaster is unpredictable in its timing, scope and nature.  The Department of Homeland Security itself echoes this myth as does Steven Flynn and many other authors and “experts.”  The predictability of disaster is in fact absolute.  If your needs exceed your resources regardless of the nature of the adversity that you face, you have a disaster. Similarly, if your needs exceed all ability to respond, you will face a catastrophe. 

On the other hand, the same pundit’s government officials and experts state that resilience is severely lacking in America.  The 9/11 attacks proved quite the opposite.  Resilience comes to us in four areas of life: 

• Our physical resilience; that is the resources internal and external that we hold in reserve for moments of adversity.
• Our emotional resilience; that internal ability to draw on our experiences and our emotional strength garnered from our relationships that allow us to cope with the stress and impact of adversity.
• Our relationship resilience; those community, professional and family connections that we have nurtured such that we may tap into them to garner additional resources whether physical or emotional to assist in mitigating disaster.
• Our spiritual resilience; that strength that is gained from believing.  It is in fact not important what we believe, but that we believe because it is in the mere act of believing that we gain strength and resilience.

Government by its nature is reactive, not proactive.  It responds to the needs of voters, it responds to the needs of constituents, it responds to the needs of society and it responds to the needs of the law.  It is only natural that in their world, the narrow world of reactivity, disaster is unpredictable. 

Fortunately, the rest of us live in a world where we are proactive.  In a proactive world we use our personal and societal experiences to predict the likelihood of future events, even adversity.  By knowing the types of adversities we have faith in the past, we can prepare for those adversities in the future.  If our preparation is strong, if our preparation is strong, if it is comprehensive, if it is now, we will prevent adversity from becoming disaster in the future…  We will achieve mastery against adversity.

The Edge of Disaster and Modern Healthcare

Stephen Flynn's recent book The Edge of Disaster, featured on national public radio this week, describes a number of large scale vulnerabilities across the United States.  His thoughts on pandemic flu, while certainly concerning, pale in comparison to the real numbers. 

Mr. Flynn describes 80 million infected with as many as 800,000 dying of the disease.  However, a review of Avian flu pandemic over the last 300 years shows that one-third of the U.S. population or 100 million people will be infected.  If this is not enough one half of these individuals or 50 million will require some level of hospitalization or institutional care from bone health all the way up to intensive care unit services.  As Mr. Flynn correctly pointed out there are fewer than 970,000 hospital beds in the United States far less than the 50 million that will be required. 

Of greater concern is the fact that half of those requiring hospitalization will develop a life threatening lung condition know as Acute Respiratory Distress Syndrome (ARDS).  Twenty-five million people requiring advanced lung care will quickly overwhelm not only the capacity of our hospitals but of our respiratory therapists and our nurses.  Of those with ARDS half will require ventilator support, unfortunately there are only 105,000 ventilators in the United States and only 16,800 are available at any given moment to treat these 12.5 million ARDS patients.  Of those that require ventilators, approximately 6.25 people.  This last number is eight times that predicted by Mr. Flynn and has been substantiated in multiple scientific reviews of the major pandemic of the past 300 years.

Mr. Flynn also spends a significant amount of time discussing surge capacity and when asked by his NPR host about the economics of increasing surge capacity beyond the pitiful 12 percent currently available nationwide Mr. Flynn simply said it was an investment in the future, an "insurance policy."  Those knowledgeable in healthcare surge capacity and healthcare vulnerability analysis differ with Mr. Flynn's otherwise star analysis of the other vulnerabilities of the United States.

Immersion Simulation based disaster training for hospitals and healthcare facilities results in a new protocol in the minds of those who are trained.  They learn to deal with triage on a moment to moment basis with every patient whether there is an ongoing disaster or not.  Those hospitals that adopt this model quickly learn that they can activate their emergency plan even when their hospital is only suffering from the daily surge of patients.  Hospitals in New York, Boston and Philadelphia have done this with increasing frequency when emergency room await times have been only two times the norm.  As a result the hospital activates its emergency operation center, calls in additional staff and increases the number of patient care areas in the hospital by re-tasking administrative and non-patient care areas to the treatment of non critical individuals.  These “green” treatment areas decrease the backlog in the emergency room lobby with surprising results.

• Fewer people leave the hospital without medical care because the wait has been reduced.
• There is an increase in hospital admissions because greater diagnoses are made by less stressed doctors, nurses.
• There is a net increase in hospital revenue despite the cost for staff and re-tasking facility.
• Patient satisfaction is improved with patient satisfaction scores on survey rising.
• The hospital saves money because a surge capacity emergency plan activation counts as one of the yearly required disaster drills.

In addition to Mr. Flynn's "insurance policy" approach to surge capacity there is a real world economic advantage for hospitals and healthcare facilities to participate in large scale disaster planning and preparation.  Every hospital in the United States has now accepted money from the federal government under HRSA grants or through various government based insurance payment programs.  As a result these facilities are now required to be compliant with the 17 elements of the National Incident Management System implementation plan for hospitals and healthcare facilities.  In addition, they are required to maintain a surge capacity equal to 20 percent of licensed hospital beds or 500 bed per million population in the geographic license area of the hospital or whichever is greater, less these facilities be guilty of fraud.

The stakes are high for healthcare not only because of the duty and responsibility they take on as part of their role in society but now as a result of the financial assistance they have accepted for the past five years as they were supposed to be preparing for all hazards and all disasters.

Mr. Flynn's book and the features on national public radio this week have brought the spotlight to bear on the vulnerabilities in America, the question is will we respond now or lament the next catastrophe?

Mechanisms of Injury and The All Hazards Approach

The “all hazards” approach to disaster preparedness is based on the concept that while adverse events can not be predicted in their timing, location or type there are limited ways in which they can impact a community, business, or individual. In disaster medicine we call these limited “mechanisms of injury.”  In individuals the mechanisms of injury that may arise regardless of the type of adverse event are:

• Asphyxiation
• Burns
• Crush injury
• Drowning
• Environmental exposure
• Fractures
• Group infections
• Historically poor health
• Impale
• Jolts
• Knucklehead
• Laceration
• Mental health
• Nutrition

Asphyxiation covers everything from smoke inhalation to oxygen-poor environments to noxious gasses to chemical weapons.

Burns may be thermal burns, such as those found in fires and explosions; chemical burns, as found in chemical weapons and inadvertant chemical releases; as well as radiation burns from criticality and non-criticality events alike. 

Crush injuries include everything from motor vehicle accident related injury to entrapment under a fallen building and cave collapses. 

Drowning is quite obvious. 

Exposure includes exposures to hot, cold environments as well as radiation in both the criticality and non-criticality type event.

Fractures are not limited only to bones, but to any body tissue or shock sensitive organ system.

Group infections deal with the events of the sanitation that impact evacuees, refugees and even the rescuers (everybody has heard of the “FEMA flu”). Group infections also include epidemics, pandemics and biological weapons.

Historically poor health deals with that 97% of all medical care rendered after the disaster.  It is the exacerbation of pre-existing medical conditions that is inherent when chronically ill people are exposed to austere medical environments. 

Impalement is again as obvious as drowning.  It includes not only falling upon an object, but being thrown against a penetrating object or having a penetrating object thrown through you.  Thus, it includes bullets as well as shrapnel. 

Jolts are simply electrical injuries. 

Knuckleheads represents all of the group events that culminate in the social anarchy like that which surrounded Hurricane Katrina.  It was the knuckleheads who threw there fellow evacuees from the tops of parking structures and shot at the rescuers and rescue helicopters that attempted to come to the aid of survivors.

Lacerations are again obvious.

Mental health issues are often difficult to differentiate and are only now being recognized as the largest portion of healthcare surge after and event. 

Finally, nutritional issues are perhaps the most difficult to deal with.  A poorly prepared citizenry who themselves have not yet stocked sufficient amounts of food and water for even three days begin the problems while amassing large numbers of refugees and evacuees are a challenge for even the most organized of government agencies.

The predominant theme in “all hazards” preparedness is to develop resilience around the mechanisms of injury and ensure that there are sufficient resources to mitigate any stress along any mechanism.

Integrated Triage Flow Chart

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Get Out of Crisis Mode and Stay Out: Utilizing Resource-Based Decision-Making in Your Organization

Two economic sectors dominate the field when it comes to decision-making: one operates on a resource-based model and the other runs on a continuous crisis model. Many organizations choose the latter model because they place tremendous emphasis on saving money minute to minute, not on investing in future need. But resource-based decision-making offers a process that helps you make instant decisions, and more important, introduces small changes that, over time, prevent your organization from getting into future bad situations.

Once you have assessed a situation, you need to determine the best course of action. But before you can make a decision about what to do, you must have the resources to put that action into place. Giant retailers operate on the principle of building “surge capacity,” and your organization can, too. Basically, surge capacity involves investing in plenty of extra resources and having people trained and at the ready to use those resources when necessary.

Here’s how it works: a super-store like Wal-Mart may have thirty cash registers, and while they may have fifty employees trained to work in check-out, at most times only five to ten clerks staff the registers. However, the store prepares based on its assessment of when business is likely to be slow and when it will suddenly mushroom to a point that necessitates bringing on additional staff to utilize those empty registers. On the day after Thanksgiving and Christmas Eve, for example, the retailer will need to add temporary workers and all available permanent staff to get customers’ money and then get them out the door with a minimal wait.

With Resources, Timing is Everything
The idea of surge capacity originated in hospitals that brought in additional help when necessary to utilize their reserve resources in the case of pandemic outbreaks or massive accidents. Ironically, most hospital administrators have now given up using the idea of surge capacity in their emergency rooms, which is why patients must sometimes wait as long as twenty-four hours to see a doctor. Business models in every industry provide similar examples when they function without back-up resources or surge capacities. In manufacturing, does it cost more to store parts (resources) than it does to shut down the line and pay everybody if a strike means you’re unable to obtain just one necessary part? In your business, how often is a similar situation likely to happen? Knowing this will determine your risk model. What is your tolerance for risk? And what are your customers willing to accept as a failure?

In your own organization, you must look at what resources you have and make decisions about those resources on an ongoing basis. When you have resources in reserve and aren’t doing a lot of business, financial prudence may be wise, but as you approach the end of your available resources, you must reorganize priorities. When that happens, you get out of your comfort zone and front-load the system with more resources. Otherwise, you will provide worse customer service when your resources are only sufficient to meet immediate needs and face disaster when your resources exceed your needs. In extreme cases, you could end up with a full-blown catastrophe on your hands, where your needs exceed all ability to respond or recover. Fortunately, this doesn’t happen often, but when it does, it’s usually in the form of a total business failure. To keep your organization from holding too many resources—whatever you consider your equivalent of too many empty registers—you need to start as soon as possible to notice patterns. When you begin to experience back-up, should you restrict product outflow or availability? Increase business through incentives at off-peak times so you need to concern yourself less with the peak times? These are all early resource-based decisions that keep you from getting into or exceeding your surge capacity.

Resource Availability and Adaptability are Key
You have to know your resource availability. This may seem like common sense, but cost arguments will arise, so prepare for opposition to this model in the majority of corporate value systems. While super-centers operating on the surge capacity system accept the necessity of only using fifty percent of their registers the vast proportion of the year, the airlines’ practice of overselling flights is far more common. For many such industries, angry customers seem like a small price to pay until the system is maximally stressed. As you move further into your surge capacity, you need to bring in additional resources so you can utilize those physical resources you’re holding in reserve. In the retail model, this means spreading work throughout the store by pulling people off their positions and on to the registers.

With resource-based decision-making, you’ll learn that you need to adapt; sometimes it’s easier to get employees, and sometimes it’s easier to get equipment. If you’re an auto detailer, all you need to do routine business is your car and cleaning supplies until a surge period like Valentine’s Day, when you may need to hire additional office help to handle calls for service while you go out and detail cars, or you may need to hire other detailers while you stay in the office booking clients. Many of us learned to make resource-based decisions but rarely as an ongoing practice. You’re taught to plan, but as situations develop, you’re likely to go off the plan, making up new plans as you go, thinking outside the box. But you need to think outside box before the box careens off the cliff. If you’re trying to make resource-based decisions in the middle of the crisis, you’re behind, and if yours is a resource-limited situation, you’ll stay behind.

Make Your Case for Resource-Based Decision-Making
No one’s likely to listen to a lone wolf advocating a resource-based decision model, especially in the midst of a crisis. To achieve buy-in, work patiently to change the corporate culture, introducing the ideas before the organization hits crisis mode. If you’re already at the disaster point, prepare to wait until the organization moves through the emergency, and then seek out key decision makers and suggest half-day conferences to familiarize them with the system’s principles. Post-crisis, many leaders are open to new thought processes that will provide a way to avoid future calamities. In the end, resource-based decision making beats the crisis model 100 percent of the time. The key is to keep at it consistently and to always be evaluating your resources and making adjustments as necessary. By adopting this practice in your company, you’ll have an edge over the competition, happier customers, and less stress in times of challenge or change. And those are the true keys for a business that thrives.

Disaster Life Support: The 21st Century’s CPR

When CPR was invented in the 1970s, the goal was to train as many potential bystanders as possible to help if someone had a heart attack or choked in public. In an effort to educate everyone about the importance of learning basic chest compression and the Heimlich maneuver, even Hollywood got in on the act, incorporating the practices into movie and TV storylines. As a result of great marketing, these days, virtually everyone knows what CPR is, and hundreds of thousands of people are trained to do it. In the new millennium, a heightened awareness of both terrorism and the impact of natural disasters has created a need for a “new CPR,” core skills that will help both laypeople and medical professionals meet the challenges of man-made and natural disasters. Why is this important?

Consider this:
· The 1994 Oak Ridge, California, earthquake wiped out eight hospitals and affected twenty million people.
· Last year, Hurricanes Katrina, Rita, and Wilma decimated much of three major Gulf Coast cities.
· In 2004 Hurricanes Charlie, Frances, Ivan, and Jeanne laid waste to Florida.
· And no one will ever forget the World Trade Center bombings on September 11, 2001.

Today, you need DLS more than CPR.

Ironically, many people believe they need CPR training more than they need training in Disaster Life Support (DLS), owing to thirty years of great public relations efforts on behalf of CPR. The fact is, you are far more likely to be called upon at some point in your life to utilize Disaster Life Support skills than you are likely to be a bystander when someone experiences sudden heart death, for which CPR was designed. The key idea here is heightened awareness; like heart attacks, disasters have
always happened, but we’re more aware of disasters than ever before and are therefore called upon to respond as never before. The number of people in the last decade who have been directly affected by natural disaster exceeds the number of people who have experienced sudden heart death in the last two decades. In other words, the likelihood that you, your family, or your neighbors are going to need Disaster Life Support skills is actually twice as great as the chance that you will ever need to use your CPR skills! DLS training available for everyone.

If Disaster Life Support is the new CPR, then the National Disaster Life Support Foundation (NDLS) parallels the American Heart Association. Established by the American Medical Association, this group of universities and government agencies saw an evolving risk two years before 9-11 and a need for the lay-public, health care providers, and advanced health care providers to have basic skill sets in the event of a disaster.

Training in Disaster Life Support is offered as a public service, usually through universities, although it is not yet consistently marketed well, so you may not know about it in a timely fashion. Though universities and the federal government feel the critical need to train health care providers and first responders, they also offer training to anyone who wants to come to a Core Disaster Life Support course.

To train citizens to first protect themselves and then deal as first responders and medical responders to natural and man-made disaster, the NDLS designed three courses:

1. Core Disaster Life Support (CDLS) is the equivalent of CPR; it is “for the people.” Designed for the layperson, this course teaches participants how to prepare for a natural or man-made disaster, how to know a disaster is coming, and how to survive the first 72 hours after the crisis, when you are likely to be awaiting rescue and are responsible for own and your family’s well-being.

2. Basic Disaster Life Support (BDLS) teaches rescue personnel and some health care providers specifics about treating injuries and other immediate medical consequences of disasters as well as many of the basic skills of the CDLS course, so they, too, can keep themselves and their families safe and avoid distraction as they set about helping others.

3. Advanced Disaster Life Support (ADLS) lasts two days and involves participants in live disaster drills in conjunction with local fire, rescue, and police departments. Tailored to the community’s needs, the programs may provide terrorism, hurricane, or tornado drills to train high-level, advanced providers who are called upon every time there’s a disaster. The scene is set as if the disaster has already happened, with actors and mannequins as victims. Participants earn
certification as qualified to run a disaster scene.

Specialized training in the “new CPR” for businesses Some large businesses have been doing CPR training in-house for years, so Business Disaster Life Support programs have been designed to offer a specialized core Disaster Life Support course for employees and managers as well as some specialized planning and contingency issues for the business itself, such as providing a model for
securing the facility in the event of an evacuation. BizDLS, as the program is known, helps organizations answer important questions such as “When should we stay open and when should we get the heck out of town?” With this training, organizations can better integrate into their communities during the disaster and during the immediate recovery period. Far-sighted businesses have responded well.

Four hour investment = Life-changing empowerment

Disaster Life Support training at all levels must become the standard in the U.S. and internationally, just as CPR did in the 1970s and 1980s. The public must be trained to care for themselves as much as possible, and every doctor, nurse, paramedic, respiratory therapist, and even veterinarian must learn basic Disaster Life Support. That way, they can first protect themselves and their families so they then feel safe, secure, and competent to aid the public in the event of a disaster. The ultimate goal is to avoid the chaos of unpreparedness that followed Hurricane Katrina in 2005 and increase the number of people who are rescued successfully and receive care.

DLS courses are not scary; they are four-hour classes that are fun and empowering, as you learn to take control in disaster situations. In fact, every course for the last three years has sold out, around the country and the world. The training gives you a chance, as CPR courses did, to walk out and say, “I not only know how to take care of myself, but I also know how to save lives.” But there’s a difference: With CPR you can only save one person. With CDLS, you can learn to save your family, your neighborhood, your business, or even your entire community.