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First Person

First Person

No One is Ready for This

Mosley, Mark MD, MPH

Emergency Medicine News: May 2020 - Volume 42 - Issue 5 - p 30
doi: 10.1097/01.EEM.0000666280.94726.61
    COVID-19, coronavirus

    I am an Oklahoma boy. In many parts, the land is red clay, and the landscape is so flat it seems you can see forever. The storms are conjured from a mythical old world like something unlocked from hell. When a hot wind suddenly turns cool, red plumes and coils of dust rise up and an iron-black sky descends on the red horizon, devouring light and land like a locomotive.

    People stand on the porches of small wooden houses and stare across the fields as if they were looking at a billowing death. There is a steady fear as everything goes eerily quiet. One can hear only the breath escaping from the body and the heart pounding in the ears. But there is no resignation, only the humble certainty of resilience. These folks, they have been here before.

    Even men who don't say much pull the family together with a certain warm sternness, telling the children there's something they need to know. It is time to prepare for the worst, and it has to be spoken while there is time.

    As most of the country waits, looking up at the sky, knowing it is coming, we are trying to find our breath. It is time to pull the staff on your shift together, gather your family, and speak. There is no need to scare anyone, just a warm sternness. In some small way, you have been here before—when EMS traffic goes off, and you know what's coming in is going to need everyone's focus, cohesion, and resilience.

    Get Ready

    Speak to them now about which patients you probably will not intubate during that shift. The one with out-of-hospital asystolic cardiac arrest. The patient on anticoagulants or antiplatelets with a head bleed. The one who has COPD (Gold class C/D) and is oxygen-dependent. Dialysis, chemo, and paraplegic patients. Patients with congestive heart failure and an ejection fraction over 20 percent. All patients over 80. Skilled nursing home patients.

    This is only a partial list, and I reserve the right to change my mind based on circumstances.

    There is one word we never use in regular emergency department practice: salvageable. Its pragmatic sterility is repulsive. We have never thought that way. Yes, your ethics committee will use someone else's protocol to determine who to put on your limited number of ventilators and who to take off. Most of us haven't even thought about this, much less read through the rationing guidelines for ventilators.

    The majority of U.S. emergency facilities—small town EDs, medium-size hospitals, and freestanding emergency departments—don't have teams of chaplains and ethics consultants, to say nothing of staff to address the legal questions.

    Your nurses have not thought about this. Your techs and respiratory therapists haven't either. Neither has security, who stands nearby when you go out to the parking lot (because she can't come in) to tell your patient's wife that he was too sick to put on a ventilator. Your security officer watches as she goes ballistic that you've “decided to kill” her loved one because he is poor or a different color or because he smoked his whole life.

    Get ready. No one is ready for this.

    The Whole Team

    Then there is your scribe, the registrar, and housekeeping. They never got the memo that you would be making the decisions about who lives. These people are your shift family. You need their support to bear the storm. You must have them on your side. If you morally horrify one of them, you will lose their trust and support for the shift and many, many more.

    Talk through the list now, while it is still quiet. Huddle everyone, including security. Listen to their questions. Gather them for consensus on who you will not intubate—at least until someone can give us better clarity—because we have never seen a storm like this.

    Another thing to consider: COVID-19 patients who are intubated have extremely high mortality, maybe 70-85 percent. Talk about that stark reality. Don't get tunnel vision with COVID-19. It may be better to intubate the 20-year-old overdose patient who you can get off the vent tomorrow than the 60-year-old obese individual with diabetes and hypertension with presumed COVID who will use the ventilator for many days and still die. It is about deciding who is salvageable before they come into your department.

    Keep in mind that the people in your community being hospitalized and those who will die in your ED will be separated from their loved ones. Young children will see only strangers in a mask. Everyone who is dying will see only masks. And, maybe worse, the loved ones wait separated, somewhere else.

    Can you imagine your mother, your spouse, your children, your best friend dying without you there? We need to be thinking and talking about this. Use iPads, cell phones, and FaceTime; figure out how to put the patient in contact with faces of love. It might be the best thing we are able to do.

    Dr. Mosleyis an emergency physician in Wichita, KS.

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