Who Lives and Who Dies?
Three men, theoretically, show up at a hospital with COVID-19 symptoms—fever, cough, sore throat, difficulty breathing, the works:
• JR is, let’s say, a 29-year-old call center operator who is on leave without pay while his company’s business is on pause. He arrives alone but has a wife and school-age daughter at home.
• Mac is an executive currently working from home for one of the big corporate groups. He’s in his fifties, has hypertension and diabetes, and is a friend of the family that owns the hospital.
• Tranquilino is 72 years old. He was recently brought back into government service. He has five children and seven grandchildren. Even his friends call him “Sec Lino”.
Who among these three will be tested for the novel coronavirus? Who will be admitted to the hospital and who will be turned away?
One by one, Metro Manila hospitals have been issuing statements that they are at full capacity and will not be admitting additional COVID-19 related cases. It’s really the only responsible thing for them to do. They had a limited number of ICU beds to begin with, many of them already occupied by other patients, and each bed must have a certain number of health care workers coming out of a staff badly depleted by quarantine restrictions. Not to mention the fact that the presence of COVID-19 cases in the hospital puts everyone there at some risk despite the most stringent precautions. Nevertheless, as hospitals close their doors to COVID-19 cases, some of those who suspect they are infected, yet are repeatedly turned away, may have no choice but to go home, receive little to no effective care, and die.
No one knows for sure how many Filipinos will be infected with the coronavirus. The estimates based on models, projections and mathematical calculations range from 75,000 to 70 million. We can debate the numbers and the effectiveness of the lockdown until we are blue in the face and ourselves experiencing difficulty breathing. It won’t change the fact that the official number of confirmed cases is continuing to rise, while many hospital facilities and staffs are already stretched beyond their limits today. Before this pandemic, we saw mothers pumping air into their sick babies’ lungs by hand because the hospitals lacked ventilators. Even with modernization and even with repurposing of hospital space and even with the dedication of entire hospitals to COVID-19 care, in all likelihood we will again and again face the difficult question of who will get a ventilator and who will not.
Triage has been around some say since the Napoleonic wars, while others point to World War I as the moment when it came into extensive use. It refers to the act of choosing among several patients—wounded soldiers pouring into a field hospital in the midst of a heated battle—to determine who will be treated first. Most of us have quite vividly experienced triage in emergency rooms when a nurse sitting behind a desk interviewed us then stuck our forms on top, in the middle or at the bottom of a pile in front of the ER doctors.
In battlefield situations, the general rule might be: treat the soldier with the worst wounds first. When it’s just a matter of time before every patient will be adequately attended to, this system might work. When the number of wounded soldiers and the severity of their injuries exceed the available medical resources, however, things get complicated. Then, the patients most likely to survive with the application of the least amount of time, supplies, equipment and personnel might be the ones treated first. If the tactical situation requires the walking wounded to quickly get back into the fight, then they might be treated first. While the coronavirus crisis is often likened to a war, do the rules of battlefield triage seem squarely applicable?
Some government officials have suggested that we can respond to the pandemic as if it were a natural disaster like a super typhoon, massive earthquake, or volcanic eruption—occurrences we unfortunately have much experience with. These catastrophes, however, generally cause medical problems over short, intense periods of time and in particular, bounded locations. Consequently, disaster triage might consider the possibility of delaying treatment or evacuating patients to unaffected areas. What are the principles of triage in a pandemic affecting the entire world with no end in sight?
When they shut out new COVID-19 cases, hospitals are in effect implementing a simple “first-come-first-served” policy. Is that fair? Why do you deserve treatment simply because you got infected earlier or arrived at a medical facility ahead of the others?
Going back to JR, Mac and Lino, our trio of hypothetical patients, a first-come-first-served rule might be fair if all three men were equal in all respects, but clearly they aren’t.
Shouldn’t JR be prioritized over the others because he is the youngest, the most likely to survive and live a longer life, and most likely to have only a mild case of COVID-19 requiring the least expenditure of medical assets? Shouldn’t it matter that he supports a young family?
Or should Mac be the one given a valuable hospital ICU bed and a chance to be on a ventilator because he will surely be able to pay his hospital bill? If he calls the president of the hospital or the medical director and asks for a personal favor, should that matter?
Or should it be Sec Lino who is allocated some of the scarce medical resources because he is a member of the vulnerable older population, because the country needs his service as a top government official, or because he is a well-known politician and celebrity?
Or maybe the hospitals should ask each of them what they want and try to honor their choices. Maybe Mac will give up his slot in favor of either JR or Lino out of altruism.
Or perhaps hospitals should try to give a little amount of care to all three of them even if spreading out resources in this way means no one gets enough and all three of them could die.
And what about all the other patients? Who should get priority to a ventilator – a lung cancer patient or a COVID-19 patient? If one of them is already on a ventilator, when can it be withdrawn and given to the other?
Tough questions. Tough questions for doctors and for our society as a whole. These are tough questions already being answered in gut-wrenching ways in Italy and Spain. Soon in New York and New Orleans. What will our answers be? At the very least, we can be honest, consistent and transparent.
We hope and pray that the number of severe and critical COVID-19 cases does not rise to the point where our health care system will be completely overwhelmed, but we should prepare as if it will. We are well past the point where it makes sense to build quarantine facilities in Metro Manila to contain the spread of the virus. It has already spread. Besides, without mass testing, we have no idea where and to whom it has spread. We need instead to shift to mitigating the effects of the spread. We should focus all our efforts and resources on building, equipping and staffing medical care facilities in order to accommodate more of those who become severely sick, reduce the need to ration critical care, and, in other words, reduce the number of times we have to ask and answer the tough questions. These are more difficult and more expensive tasks than converting motels into quarantine areas, which is why we need to focus. The real scandal today is not that another person has been infected but that another infected person cannot be treated. The real tragedy is when someone dies when he could have lived if we had been better prepared.