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Tough Questions and Creative Thinking in Times of Crisis

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“The best laid plans of mice and men often go awry.” The famous line adapted from poet Robert Burns’s To a Mouse conveys the likelihood of unexpected changes in even the most detailed and carefully planned projects. While the phrase might be applied to any number of scenarios, it is most certainly true when trying to care for patients during crises, as the very nature of the situation ensures unpredictability.

“When disasters affect health care facilities, they put lives in jeopardy, making the decisions and factors to be considered exponentially more difficult,” said Steven Joffe, MD, MPH, vice chair of Medical Ethics at the Perelman School of Medicine. “In these situations the issues we face can present very difficult ethical questions. As we try to plan for every possible scenario, it’s important to look at emergency situations that happen across the country and the world and to ask ourselves ‘what can we learn from this?’ or ‘if this happened in our facility, how would we have handled it?”

Citing examples from hospitals affected by Hurricanes Katrina and Sandy, and health care facilities treating patients infected with the Ebola virus in West Africa, Pulitzer Prize winning reporter and author (and physician) Sheri Fink recently addressed some of most difficult ethical challenges imaginable during her talk at the Arthur and Ilene Dalinka Penn Medicine Ethics Grand Rounds. Fink’s award-winning book, Five Days at Memorial, chronicles patient deaths at a New Orleans hospital in Katrina’s path of destruction.

Throughout her lecture, Fink posed questions to the audience that the health care providers in New Orleans, New York, and Liberia faced during their respective emergencies, including:

  • When resources are low, is it better to divide them up amongst a larger number of less critically ill patients, or provide the care to those who need it most?
  • In times of crisis, when you can’t even handle the patients who are already in your facility, can you close your doors and turn people away knowing they have nowhere else to go?
  • What responsibility, if any, do you have to stay and help during a crisis that places your own life in harm’s way? And if you stay, should you be held accountable for the exquisitely difficult decisions you make concerning patient care in a crisis?

Many of these questions were met with an almost uncomfortable and stunned silence. They are tough questions, and there are no easy answers -- if there are answers at all.

“It’s reasonable to consider vulnerability and chance of recovery as two main factors when determining an evacuation priority for patients, but in some sense, the two are inherently contradictory,” Joffe said. “We often think of attending first to the sickest patients. But if the very sickest are unlikely to survive no matter what we do, perhaps we ought to focus instead on those who are more likely to survive, or for whom care or evacuation is likely to make the largest difference between survival and death. These are not easy questions.”

Though Fink addressed how those questions were approached and answered in each of the situations on which she reported, she also posed an alternate option to be considered in future times of crisis. Instead of focusing on answering the question presented to you, creative thinking might lead to viable alternatives – or at least buy you some time.

For example, Fink discussed the unimaginable situation health care providers in New Orleans faced when record floods from the levee failure after Hurricane Katrina overtook the hospital’s backup generators, shutting down the air conditioning and power supply needed for ventilators and other medical interventions that were keeping many patients – including 16 critically ill newborns whose fragile bodies depended on incubators to maintain proper internal temperature and ventilators to help them breathe –alive.

Helicopters were able to land on the roof of the hospital to begin evacuations, but the process was slow and allowed only a few patients to be transported at a time. Unable to put incubators or ventilators on the helicopters, the care team might have seen no other way to get the babies out. But instead, they babies were placed in their shirts to keep them warm and ventilated by hand until they reached safety. The solution allowed some of the hospital’s most vulnerable and tiniest patients to get out quickly, while also evacuating twice as many people with each trip. Similar methods were used in another instance where boats were used to evacuate patients who were stable enough to sit up and medical staff charged with safely transporting critically ill babies.

At times, creative thinking has led to patients actually being brought in as care providers to aid in difficult circumstances. For example, in Liberia, resources were scarce and safeguards were in place to prevent the spread of Ebola, limiting the number of staff available to care for infected patients. With the number of patients increasing, care providers were facing a rationing situation, but creative thinking introduced a new solution. Realizing that patients who had survived the virus would be immune to a repeat infection and could therefore work in the facilities without risk to their own health, the staff asked them to assist with caring for those who were still suffering. Though they couldn’t provide medical care, they could provide comfort and assistance in other ways.

Thinking creatively often requires working together in novel ways. For example, Fink said one team of care providers delayed having to make difficult decisions about patient prioritization by figuring out how to keep their power supply working. When flooding causing fuel pumps for the generators to malfunction, the staff banded together to form a human chain to manually fuel and operate the pumps. The solution worked long enough for rescue workers to reach the hospital and begin evacuations.

Emergency preparedness, safety and rescue teams have learned many lessons from Hurricanes Katrina and Sandy – such as not placing back-up generators in basements of hospitals in flood-prone areas. The lessons learned and things to consider, however, extend far beyond the tangible changes that can be made to avoid these situations. These hard questions, questions for which there may not be answers, are likely to accompany the inevitable disasters we will face despite our best efforts to anticipate them.

“Emergencies are a breeding ground for ethical controversies on issues from resource distribution and allocation, to safety and job responsibilities, and not one of these questions is for a single person to answer,” Joffe said. “At every turn, these issues require critical, creative thinking, and teamwork, because at the end of the day, they are not black and white. And whenever possible, the ideal answer to these tough questions is to find creative solutions that avoid having to decide which of a set of bad options is best.”

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