The Taxonomy of Calamity: The View From the Operating Room
Kenneth Kipnis, PhD Department of Philosophy, University of Hawaii, Honolulu, Hawaii
Aryeh Shander, MD Department of Anesthesiology, Critical Care, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
To comprehend the domain of public health emergencies is, in part, to attempt to catalog the species of large-scale human calamity. Think of Spanish Flu, hurricane Katrina, the Bhopal chemical disaster, the Black Death, and so on. A scalar taxonomy of insults—from the smallest to the largest—would be useful if it could show how priorities evolved as clinical responsibilities escalated. It would be especially useful if it better prepared health care professionals to ride out crises to the best extent possible. Three questions recur. First, in what ways can health care resources be overwhelmed? Second, what are the management strategies that clinicians can marshal at each level? And third, what are the ethical issues that might be anticipated?1 Beyond these 3, we might also want to consider how these inquiries could change. Obviously, the visible shape of a catastrophe can turn on the spectator’s standpoint. Hospital administrators, public health officers, school nurses, rescue personnel, epidemiologists, hospital electricians, and so on, will be stationed in different settings, charged with different tasks, and viewing phenomena through various cognitive lenses. Depending on the narrowness of the practitioners’ focus and their preparation for the unthinkable, horrific events may not be apparent until it is too late. One setting in particular, the hospital operating room, is deliberately isolated from its external environment. Its architectural features, its rituals, its staffing, its indigenous skill sets, its languages, and its equipment, are commonly specialized to the point where, in general, all of these elements require each other to function. But although THIS MANUSCRIPT IS BASED IN PART ON AND MODIFIED FROM EXCERPTS FROM: KIPNIS K. DISASTERS, CATASTROPHES, AND c 2013 CAMBRIDGE WORSE: A SCALAR TAXONOMY. CAMB Q HEALTHC ETHICS. 2013;22:297–307. COPYRIGHT UNIVERSITY PRESS. REPRINTED WITH PERMISSION. REPRINTS: KENNETH KIPNIS, PHD, DEPARTMENT OF PHILOSOPHY, UNIVERSITY OF HAWAII, 2530 DOLE STREET, HONOLULU, HI 96822. E-MAIL: [email protected]. INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 53, Number 3, 79–89 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
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a surgeon, a scrub nurse, a circulating nurse, an anesthesiologist (and residents and medical students) may be working in the same suite on the same patient, their unique tasks will direct their respective concerns to different aspects of the situation. Think of the offensive squad on a football team. The play may take only a few seconds, but each of the players on the team—quarterback, center, running back, wide receiver, etc.—performers a part of the larger job in a different cognitive world. Accordingly, despite its concern with the operating room, the focus of this paper must take us beyond the boundaries of the OR, even beyond the hospital. Mercifully, professional lives in health care are uneventfully routine, usually. Occasionally though, events beyond the clinical setting can be felt in the operating room, can damage the team’s effectiveness and, in extreme cases, can shut the unit down completely. These are the calamities that are the primary subject of this paper. The events that concern us are a function of 2 powerful elements. The first is what can be called the “burden of patient need.” This refers to the stream of treatable conditions flowing into the hospital. The other is the institution’s “carrying capacity”: the finite resources that can be brought to bear on newly arrived treatable conditions. Poised between those 2, a clinician is assigned to do triage, choreographing their engagement. When things go well—which is most of the time—patients will get what they need and the hospital goes about its job of preventing death and disability. The prime directive of the institution: No technically avoidable bad outcomes. The stream of medically treatable conditions can be mapped along 3 scales. The first is rate. How many patients are coming into the system per unit of time? The second is urgency. Many medical conditions arrive with a countdown timer. Although some patients are stable or will recover on their own, urgent conditions require timely care. Too much delay and the countdown timer rings: a patient dies, suffers loss of function, or deteriorates to the point of requiring more care than would otherwise have been needed. Each of these is a bad outcome which, but for the delay, might have been avoided. The third scale is complexity. What resources (time, staff, equipment, space) are required to improve a patient’s prospects? In the present context, a hospital’s surgical capability will be a function of the number of operating rooms, the availability of the supplies needed to provide surgical services, the presence and capabilities of essential staff, and the integrity of the institutional infrastructure. Taken all together, rate, urgency, and complexity define a hospital’s clinical responsibility. Clinical triage reconciles the burden of incoming patient need and the hospital’s carrying capacity. But when there are too many patients for whom the clock is running out, or where meeting the needs of these patients, in www.anesthesiaclinics.com
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accordance with the standard of practice, exceeds available resources, something will have to give. The balance of this paper is devoted to a rarely examined taxonomy of imbalances between the hospital’s clinical responsibility (the burden of its patients’ needs) and its carrying capacity. If, as we suspect, clinicians are “trained” to ensure that such imbalances never occur, they may be insufficiently prepared for the challenges that will arise when the unthinkable happens. Effective clinical practices will be defeated as the scale of calamity widens, and, at each juncture, the philosophy and organization of health care must evolve. As we shall see, one negotiable element will be the standard of practice: those medical interventions that are approved for specific disease conditions. The general form is this: practice P (that may include a range of options) is medically indicated when conditions A, B, C, etc., occur. This prioritization of some interventions over others is, ideally, based on the evidence grounding the profession’s collective judgment of superiority. Although we think first of a treatment’s efficacy in securing good results and averting bad ones, other factors—cost, ease of use, speed of administration, acceptability to patients, and so on—can also be important. Mounting levels of rate, urgency, and complexity can require excusable departures from everyday clinical practice as the preconditions for good clinical practice vanish. We examine 4 ordered fallback positions, each a response to the overwhelming of resources in the prior configuration. The first 2—Diversion and Disaster Triage—are familiar. The other 2 may be new to many readers.
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Level 1: Patient Surges and Staff Shortages— Diversion
The problems here can affect hospitals as often as several times a month. Staff shortages and patient surges can temporarily compromise a hospital’s carrying capacity, making it impossible to avert avoidable bad outcomes. Hospitals must then implement the first fallback position, which is closing their doors and diverting patients. If hospitals have a general duty to be open to the health care needs of incoming patients, surges and staff shortages can often justify diverting ambulances to other nearby centers. Despite delay, the goal is still to prevent bad outcomes insofar as medical and nursing skills can make it so. Here we must distinguish between the carrying capacity of a single medical center and the carrying capacity of a region’s hospitals. Although a patient surge or staff shortage can compromise the functioning of a single hospital, not much is lost if the regional carrying capacity—the total capacity of all hospitals in the area—remains equal to or exceeds the regional burden of patient need. Assuming that the patients www.anesthesiaclinics.com
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who are turned away are not in urgent need of treatment and the additional time needed to transport patients to nearby hospitals will not result in death, loss of function, or deterioration, the sharing of responsibility among separate hospitals can augment the functionality of community resources. The possibility of such disruption creates an antecedent obligation to formulate regional collaborative agreements. Blood, operating rooms, drugs, essential personnel, etc., may need to be pooled. The closing of a hospital’s doors would be ethically problematic absent a grounded expectation that other less-burdened institutions were ready to help manage the overflow. Here the challenged hospital (or some other coordinating agency) must track the resources available at other regional hospitals, relocate staff and supplies as needed, and redirect emergency vehicles to clinics that can manage the incoming patients needing care. Usually these tasks of coordination will be unproblematic. But regional hospitals should confer and plan for effective collaboration long before it becomes necessary. The orchestrated response to the Boston Marathon bombings is an example. Hundreds of Boston’s prehospital and hospital-based responders had already learned the basics of blast-injury care and the operational challenges their city could face before this event. In 2009, Rich Serino, then Boston’s EMS chief and now deputy administrator of the Federal Emergency Management Agency, hosted the first “Tale of Our Cities” conference in Boston, at which clinicians from India, Spain, Israel, Britain, and Pakistan who had managed the aftermath of terrorist attacks explained the nature of the blast injuries they treated, the triage systems they used, and other lessons responders can use to save lives. More than 750 locals attended. Experience has shown that such a framework is necessary to ensure a well-coordinated response to a sudden mass-casualty event. Boston’s health care providers reacted the way they did because they knew what they were supposed to do, and those who did not were able to follow the lead of those who did. That’s how a “ritualized” disaster plan works. Like the damaged roof that nobody fixes because it’s not raining, it can be too easy to dismiss the urgency of the problem before the storm comes and impossible to implement a remedy once the downpour begins.
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Level 2: Disasters—Triage
Like wars, disasters can be a mass producers of wounds. But this larger influx of prospective patients is qualitatively different from a simple surge of patients. Rather, a “disaster” (as the term is used here) is a large-scale disruptor that creates a burden of patient need exceeding the region’s clinical carrying capacity. Diversion fails as a fallback www.anesthesiaclinics.com
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position because the other medical centers are also overwhelmed. We now need a second backup plan. Disaster triage, the second fallback position, relies upon rapid initial assessment as prospective patients enter the system—90 seconds is the standard—and a dynamic tagging process that monitors the urgency and complexity of injuries. And because it is now impossible at Level 2 to treat every one of these patients in accordance with the standard of practice, the earlier prime directive—No technically avoidable bad outcomes—must give way to a norm that reflects the hospital’s role as a steward of scarce and vital resources. The new prime directive is Avoid waste. Those presenting for care are commonly assigned to one of 3 categories arrayed along a bellshaped horizontal scale: the most seriously injured (the black-tagged expectant patients) toward the right of the central bulge, the least seriously injured (the green-tagged walking wounded) toward the left, and the redtagged patients in the middle. Disaster triage reduces clinical responsibility by lopping away the patients at both ends: those at the right, who are likely to die even if treated, and those at the left, who are likely to live even if not treated. At Level 2, clinicians focus on the red-tagged casualties in the middle: those who are likely to live if treated and likely to die if not treated. And within this middle group, priority goes to those whose conditions are the most urgent and the least complex. A patient with an otherwise fatal sucking chest wound can be stabilized in seconds with a plastic bandage. Fundamentally, disaster triage solves a mathematical problem: how do we save the maximum number of lives with finite resources? This shift in focus, from the patient to the population, palpably transforms the ethical landscape. Here are 2 salient differences: (1) It is no longer an option to prevent every technically avoidable death. The resources are not there. Although everyday practice in the emergency department affords prioritized attention to the most lifethreatening injuries, disaster requires those same patients to be blacktagged and set aside, even as less seriously injured patients are treated. For some clinicians, it will be tempting to accede to the everyday moral imperative to attend first to the worst-off. But in a disaster, such compassion will waste resources and raise the death toll. This is far too high a price. (2) Consider also that it can seem obligatory and heroic to persevere despite exhaustion. Although mindful and supportive of their coworkers’ need to take a rest to maintain optimal performance, some clinicians may end up ignoring their own limited capacity to go on and on without a break. Recall that, as tempting as it might be to take up a heroic “Superman” or “Superwoman” role, doctors and nurses cannot function indefinitely without sleep. Accordingly, incident commanders must order clinicians to rest, to avert the erosion of staff functionality as early as the 16-hour mark.2 These issues should be discussed regularly as an essential element of disaster www.anesthesiaclinics.com
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preparedness. As difficult as it may be, these new practices, and the good reasons for them, must be understood. We can now appreciate how Jehovah’s Witness patients, by conscientiously refusing to consent to blood transfusions, may have inadvertently helped the medical profession improve the prospects of patients in need of blood when transfusion is not an option. What is not often appreciated is that severe shortages of blood create exactly the same problem: How to manage when the standard of practice is not an option? When the burden of patient need exceeds carrying capacity, 1 option is to resort to new experimental therapeutic modalities that might extend your resources. There are anecdotal reports emerging from an embattled Syria that describe doctors with no access to anesthesia waiting for exsanguinating patients to lose consciousness, and only then operating upon them. Here we do not pass judgment on such strategies but only call attention to the circumstances that constitute the occasion for considering such departures from the standard of practice.
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Level 3: Physical and Medical Catastrophes—Forced Abandonment and Redeployment
We have distinguished between a region’s everyday carrying capacity— the largest burden of patient need that can be managed on an unremarkable day—and its “disaster-level” carrying capacity—the much-larger burden that can be managed regionally when black-tagged and green-tagged patients are essentially set aside. Usually, triage is as far as disaster planning goes (Who gets the ventilator?). But events can overwhelm regional carrying capacity even when it is augmented in this way. To be sure, there are multiple strategies that can tweak capacity: empty as many beds as possible, sending well-enough patients home; summon supplementary health care workers, for example, veterinarians, retired clinicians, hospice workers, chaplains, volunteers; adapt hallways, parking areas, lobbies, lawns, and rooftops, for decontamination and patient care; and prepare to evacuate casualties should the opportunity arise. But these may not suffice to preserve the functionality of medical centers. As used here, “catastrophe” refers narrowly to the unanticipated collapse of a previously functional health care institution. (Note that this clinically focused definition is narrower than the broader social conception of catastrophe developed by Quarentelli.3) Just as surges and disasters call for new ways of conceiving organizational and professional responsibility, so too can the collapse of a medical center. There are 2 types of disruptors here: physical and medical. We will consider these separately.
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Physical Insults
To fix the idea, consider the events at New Orleans’ Memorial Medical Center following Hurricane Katrina.4–8 These references are pertinent discussions of the events at Memorial Medical Center. Fink’s7 Pulitzer Prize winning New York Times Magazine article was later enlarged into a book.8 It is a close-up view of a hospital experiencing catastrophic failure. The protective sea walls had failed and the waters from Lake Ponchartrain and sewers had flooded the area, inundating the hospital’s lower floors. Lacking electricity and plumbing, temperatures in the building rose in the New Orleans heat, toilets overflowed and medical devices were disabled. Katrina had crippled the hospital’s capacity to care for patients and the building may have become a health hazard. The catastrophic failure of a functioning hospital generates 2 successive dilemmas, both of which can be anticipated. The first: When, if ever, are health care personnel at liberty to leave? The ready answer would be “When all patients have been evacuated.” But, as happened in New Orleans, it had been authoritatively announced that evacuations were not to be expected.4,5 What to do then? One answer: “Health care professionals are obligated to remain at their posts until the last patient dies or is evacuated. They must do this regardless of the burdens and risks of remaining on duty, regardless of the futility of the efforts they might make on behalf of the remaining expectant patients, regardless of other obligations they may have or could take on.” It is not clear that such heroism is obligatory or even wise. At some point doctors and nurses will have done everything that could reasonably be expected of them. Although a health care professional should then be free to leave, locating that point may be one of the hardest ethical decisions in health care. Let us assume there is a line beyond which there is no duty to remain and that, for clinicians at some stricken hospital, the line has been crossed. If clinicians undertake to withdraw, they would face the second dilemma: Should they abandon their black-tagged patients to die unmedicated and unattended, or should they euthanize them before leaving? This is a horrific choice, and, tragically, there is no third option. This second quandary emerges from the collision of 2 salient medical norms: the prohibition against abandoning patients and the prohibition against euthanizing them. When (1) it is impossible to evacuate patients and (2) dangerous and futile to remain with them, 1 of these 2 norms must give way. Although there is an official consensus on the impermissibility of abandonment and the impermissibility of euthanasia, there is almost no discussion on how these norms should be prioritized when, as here, they conflict. A practical framework to consider when faced with such “devil’s choices” has been suggested.6,9 Kipnis6 argues that if both options-euthanasia and abandonment—are
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prohibited, and there are no other options, then, absent a clear priority rule, the exercise of either alternative would be excusable.
Medical Insults
Beyond physical damage to hospitals, medical disruptors can be catastrophic when an epidemic illness or biowarfare attack is sufficiently lethal, infectious, and difficult to treat. An inundation of critically ill people can exceed the number that can be assessed, stabilized, and monitored. And as crowding can potentiate new infections, foraging for care during a pandemic catastrophe may be fraught with grave and avoidable risk. At some point hospital doors must be closed and the crowds of prospective patients and accompanying caregivers turned away. In that the attention required by a handful of patients with inhalational anthrax cannot be offered to thousands, hospitals may not be able to serve as the primary locus of health care during a medical catastrophe. Accordingly, regional hospitals may have to close their doors well before they reach disaster-level capacity, diverting patients and redeploying staff and supplies to peripheral emergency health care venues. As with the decision about whether to leave black-tagged patients behind, the community decision to shut down a region’s hospitals will be as difficult as it is consequential. Although the details will depend on the specific challenge, here is a sketch of catastrophe-level health care: health care without hospitals. (1) We should emulate the Israelis who, concerned about biowarfare, have implemented “shelter in place.” If an invisible deadly plume is passing over my city, I am at greater risk if I move about; I am safer if I stay put.10 Despite the common sense view that serious illness requires a trip to a hospital, the infirm must understand the requirement to stay home. (2) We should designate suitable locations as peripheral health care venues, with supplies, decontaminating showers, floor space, and robust communication links, for example, schools, fire stations, pharmacies, cafeterias, and hotels. These outposts can support house calls and home care. Radio and the internet can be used to provide advice to home caregivers. The goal is to reduce crowding and travel, thereby preventing infection and cross-contamination. (3) We should consider how to assign health care personnel to peripheral health care venues if and when a “code black” is called, signaling that regional hospitals have become dysfunctional. Registries should be set up for clinicians and volunteers who will need to know where to go if hospitals are to be avoided. Military doctors have long known that the scattering of vital resources creates a more robust system. www.anesthesiaclinics.com
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Level 4: Megapandemics—Social Distancing and Logistics
Although even a mild pandemic can be devastating to those it affects (eg, the 1957-1958 “Asian Flu” took about 70 thousand US lives), those outbreaks are unlikely to strain regional carrying capacity. In 1918, the more deadly Spanish flu sickened about 30% of the US population (about 34 million people). Of those, about 2% died (675 thousand), a far greater mortality than the typical seasonal flu.11,12 By comparison, an equally severe insult with today’s much larger population would sicken more than 90 million Americans and kill nearly 2 million. Fatalities would be expected to occur in waves over many months. As hellish as this would be, such a pandemic might be managed by disaster triage, redeployment of health care resources, and reduction of human-to-human contact (social distancing). Much will turn on the simplicity and efficacy of treatment. And yet there is an even worse scenario that cannot be ruled out, one that takes us to the next level. As used here, a “megapandemic” has 4 defining characteristics: it would be extremely contagious, it would have very high mortality, it would be global (ruling out emigration and evacuation as strategies for avoiding infection), and it would be, as a practical matter, untreatable. In effect, all those felled by such an illness would be black-tagged. Among present day illnesses, it is worth considering Avian flu. As a “thought experiment,” let us assume a highly contagious variant H5N1 outbreak infecting 30% of the population (somewhat similar to a seasonal flu) and at least 50% mortality among infected cases (roughly what the World Health Organization has seen among diagnosed cases of H5N1).13 Such a pandemic could be expected to kill about 15% of the US population or more than 45 million people. Globally, the death toll would be about 1 billion. In its scale, its infectiousness and its resistance to treatment, such an outbreak would be comparable with the 14th century’s Black Death. It would be hard enough to prepare for the 2 million fatalities from a latter-day Spanish flu. But while the implications of a vastly larger mortality rate might vex the thinking of those with responsibility for disaster preparedness, that unwelcome possibility cannot be ruled out. In the face of a megapandemic, it will not be enough to close hospitals and redeploy clinical resources. Without effective treatments and vaccines, we may have to accept the powerlessness of medicine. There would, however, be 1 remaining role for clinicians. Research should be the salient responsibility of hospitals during medical catastrophes and megapandemics, carried out even after the facilities are closed to patient care. A small number of research subjects could be admitted, and, until we knew which treatments were effective, head-tohead trials could be used to inform clinical practice. Generic protocols for on-the-fly investigations—possibly under the waiver of informed www.anesthesiaclinics.com
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consent for emergency research or an Expanded Access program (also known as “compassionate use” as defined by US Food and Drug Administration)—should be submitted to institutional review boards for approval well before any disease manifests. Study results should be disseminated broadly and quickly. If the idea of a catastrophe introduced us to health care without hospitals, the idea of a megapandemic (as defined above) introduces us to health care without clinicians. What to do when all patients are blacktagged? Even if hospitals shut their doors when regional disaster-level carrying capacity is overwhelmed, even if no effective treatment is available, we would not then be without resources. Enhanced social distancing can save lives, but only if we plan for it. To hunker down in our homes for weeks on end, we will need functional electrical, plumbing, and communications systems, and the delivery of food and pharmaceuticals in ways that do not require us to come into contact with each other. While complicated, such arrangements are feasible. The heroes of that horrific time will be the people who keep the water, electricity, and information flowing, who deliver medications and groceries to our doorsteps and driveways, who keep the networked pipelines of food and medicine functional during the waves of infection; and who can safely gather the dead. Those found to be immune to a newly virulent H5N1, or who have recovered, may have to be pressed into this final service, a necessity that presents unexplored ethical, legal, and social issues. Can we compel them to serve their communities in these ways? Can we condition offers of experimental or scarce drugs on a willingness to serve if there is recovery with immunity? Certainly as effective drugs become available, those at the pandemic battlefront have weighty claims to places at the head of the line.
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Epilogue
Beyond staff shortages and patient surges, even beyond disaster, hospitals may have to contend with poorly understood medical catastrophes, and megapandemics. Each creates its own moral universe with unique bioethical dilemmas and norms. Within each, responsible action requires a clear understanding of the context, its demands, the distinctive ethical issues that are likely to arise, and the organizational and normative strategies demanded by the occasion. It can be deeply disquieting to think through these hellish possibilities. But the duty to do so is a part of the responsibility for preparedness.
The authors declare that they have nothing to disclose.
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References
1. Kipnis K. Disasters, catastrophes, and worse: a scalar taxonomy. Camb Q Healthc Ethics. 2013;22:297–307. 2. Landrigan CP, Jeffrey M, Rothschild JM, et al. for the Harvard Work Hours, Health and Safety Group. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848. 3. Quarantelli EL. Catastrophes are different from disasters: some implications for crisis planning and managing drawn from Katrina. 2006. Available at: http://under standingkatrina.ssrc.org/Quarantelli/. Accessed May 18, 2014. 4. Deichmann RE. Code Blue: A Katrina Physician’s Memoir. Bloomington: Author House; 2006. 5. Meitrodt J. For dear life: how hope turned to despair at Memorial Medical Center. New Orleans Times-Picayune. 2006. Available at: http://connect.nola.com/user/ jmeitrodtTP/posts.html. Accessed May 18, 2014. 6. Kipnis K. Forced abandonment and euthanasia: a question from Katrina. Social Research. 2007. Available at: http://www.stanford.edu/Bmvr2j/sfsu09/extra/Kipnis.pdf. Accessed May 27, 2015. 7. Fink S. The deadly choices at Memorial. New York Times Magazine. August 30, 2009. p. 28. Available at: http://www.nytimes.com/2009/08/30/magazine/30doctors.html. Accessed May 18, 2014. 8. Fink S. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Random House; 2013. 9. Swann SW. Euthanasia on the battlefield. Mil Med. 1987;152:545–549. 10. Sorenson JH, Vogt BM. Will Duct Tape and Plastic Really Work? Issues Related to Expedient Shelter-In-Place. Oak Ridge: Oak Ridge National Laboratory; 2001. Available at: http://www.fas.org/irp/threat/duct.pdf. Accessed May 18, 2014. 11. Department of Health and Human Services. Pandemic flu history. Available at: http:// www.flu.gov/pandemic/history/. Accessed May 18, 2014. 12. Heartland Kidney Network. Pandemics & Threats, 1900-2006. Available at: http:// www.esrdnetwork18.org/pdfs/QI%20-%20Pandemic_Flu/PandFlu_Threats1900to2006.pdf. Accessed May 18, 2014. 13. World Health Organization. Cumulative number of confirmed human cases for avian influenza A (H5N1) reported to WHO, 2002-2012. Available at: http://www.who.int/ influenza/human_animal_interface/EN_GIP_20120810CumulativeNumberH5N1 cases.pdf. Accessed May 18, 2014.
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Kenneth Kipnis, PhD Department of Philosophy, University of Hawaii, Honolulu, Hawaii
Aryeh Shander, MD Department of Anesthesiology, Critical Care, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
To comprehend the domain of public health emergencies is, in part, to attempt to catalog the species of large-scale human calamity. Think of Spanish Flu, hurricane Katrina, the Bhopal chemical disaster, the Black Death, and so on. A scalar taxonomy of insults—from the smallest to the largest—would be useful if it could show how priorities evolved as clinical responsibilities escalated. It would be especially useful if it better prepared health care professionals to ride out crises to the best extent possible. Three questions recur. First, in what ways can health care resources be overwhelmed? Second, what are the management strategies that clinicians can marshal at each level? And third, what are the ethical issues that might be anticipated?1 Beyond these 3, we might also want to consider how these inquiries could change. Obviously, the visible shape of a catastrophe can turn on the spectator’s standpoint. Hospital administrators, public health officers, school nurses, rescue personnel, epidemiologists, hospital electricians, and so on, will be stationed in different settings, charged with different tasks, and viewing phenomena through various cognitive lenses. Depending on the narrowness of the practitioners’ focus and their preparation for the unthinkable, horrific events may not be apparent until it is too late. One setting in particular, the hospital operating room, is deliberately isolated from its external environment. Its architectural features, its rituals, its staffing, its indigenous skill sets, its languages, and its equipment, are commonly specialized to the point where, in general, all of these elements require each other to function. But although THIS MANUSCRIPT IS BASED IN PART ON AND MODIFIED FROM EXCERPTS FROM: KIPNIS K. DISASTERS, CATASTROPHES, AND c 2013 CAMBRIDGE WORSE: A SCALAR TAXONOMY. CAMB Q HEALTHC ETHICS. 2013;22:297–307. COPYRIGHT UNIVERSITY PRESS. REPRINTED WITH PERMISSION. REPRINTS: KENNETH KIPNIS, PHD, DEPARTMENT OF PHILOSOPHY, UNIVERSITY OF HAWAII, 2530 DOLE STREET, HONOLULU, HI 96822. E-MAIL: [email protected]. INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 53, Number 3, 79–89 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
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a surgeon, a scrub nurse, a circulating nurse, an anesthesiologist (and residents and medical students) may be working in the same suite on the same patient, their unique tasks will direct their respective concerns to different aspects of the situation. Think of the offensive squad on a football team. The play may take only a few seconds, but each of the players on the team—quarterback, center, running back, wide receiver, etc.—performers a part of the larger job in a different cognitive world. Accordingly, despite its concern with the operating room, the focus of this paper must take us beyond the boundaries of the OR, even beyond the hospital. Mercifully, professional lives in health care are uneventfully routine, usually. Occasionally though, events beyond the clinical setting can be felt in the operating room, can damage the team’s effectiveness and, in extreme cases, can shut the unit down completely. These are the calamities that are the primary subject of this paper. The events that concern us are a function of 2 powerful elements. The first is what can be called the “burden of patient need.” This refers to the stream of treatable conditions flowing into the hospital. The other is the institution’s “carrying capacity”: the finite resources that can be brought to bear on newly arrived treatable conditions. Poised between those 2, a clinician is assigned to do triage, choreographing their engagement. When things go well—which is most of the time—patients will get what they need and the hospital goes about its job of preventing death and disability. The prime directive of the institution: No technically avoidable bad outcomes. The stream of medically treatable conditions can be mapped along 3 scales. The first is rate. How many patients are coming into the system per unit of time? The second is urgency. Many medical conditions arrive with a countdown timer. Although some patients are stable or will recover on their own, urgent conditions require timely care. Too much delay and the countdown timer rings: a patient dies, suffers loss of function, or deteriorates to the point of requiring more care than would otherwise have been needed. Each of these is a bad outcome which, but for the delay, might have been avoided. The third scale is complexity. What resources (time, staff, equipment, space) are required to improve a patient’s prospects? In the present context, a hospital’s surgical capability will be a function of the number of operating rooms, the availability of the supplies needed to provide surgical services, the presence and capabilities of essential staff, and the integrity of the institutional infrastructure. Taken all together, rate, urgency, and complexity define a hospital’s clinical responsibility. Clinical triage reconciles the burden of incoming patient need and the hospital’s carrying capacity. But when there are too many patients for whom the clock is running out, or where meeting the needs of these patients, in www.anesthesiaclinics.com
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accordance with the standard of practice, exceeds available resources, something will have to give. The balance of this paper is devoted to a rarely examined taxonomy of imbalances between the hospital’s clinical responsibility (the burden of its patients’ needs) and its carrying capacity. If, as we suspect, clinicians are “trained” to ensure that such imbalances never occur, they may be insufficiently prepared for the challenges that will arise when the unthinkable happens. Effective clinical practices will be defeated as the scale of calamity widens, and, at each juncture, the philosophy and organization of health care must evolve. As we shall see, one negotiable element will be the standard of practice: those medical interventions that are approved for specific disease conditions. The general form is this: practice P (that may include a range of options) is medically indicated when conditions A, B, C, etc., occur. This prioritization of some interventions over others is, ideally, based on the evidence grounding the profession’s collective judgment of superiority. Although we think first of a treatment’s efficacy in securing good results and averting bad ones, other factors—cost, ease of use, speed of administration, acceptability to patients, and so on—can also be important. Mounting levels of rate, urgency, and complexity can require excusable departures from everyday clinical practice as the preconditions for good clinical practice vanish. We examine 4 ordered fallback positions, each a response to the overwhelming of resources in the prior configuration. The first 2—Diversion and Disaster Triage—are familiar. The other 2 may be new to many readers.
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Level 1: Patient Surges and Staff Shortages— Diversion
The problems here can affect hospitals as often as several times a month. Staff shortages and patient surges can temporarily compromise a hospital’s carrying capacity, making it impossible to avert avoidable bad outcomes. Hospitals must then implement the first fallback position, which is closing their doors and diverting patients. If hospitals have a general duty to be open to the health care needs of incoming patients, surges and staff shortages can often justify diverting ambulances to other nearby centers. Despite delay, the goal is still to prevent bad outcomes insofar as medical and nursing skills can make it so. Here we must distinguish between the carrying capacity of a single medical center and the carrying capacity of a region’s hospitals. Although a patient surge or staff shortage can compromise the functioning of a single hospital, not much is lost if the regional carrying capacity—the total capacity of all hospitals in the area—remains equal to or exceeds the regional burden of patient need. Assuming that the patients www.anesthesiaclinics.com
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who are turned away are not in urgent need of treatment and the additional time needed to transport patients to nearby hospitals will not result in death, loss of function, or deterioration, the sharing of responsibility among separate hospitals can augment the functionality of community resources. The possibility of such disruption creates an antecedent obligation to formulate regional collaborative agreements. Blood, operating rooms, drugs, essential personnel, etc., may need to be pooled. The closing of a hospital’s doors would be ethically problematic absent a grounded expectation that other less-burdened institutions were ready to help manage the overflow. Here the challenged hospital (or some other coordinating agency) must track the resources available at other regional hospitals, relocate staff and supplies as needed, and redirect emergency vehicles to clinics that can manage the incoming patients needing care. Usually these tasks of coordination will be unproblematic. But regional hospitals should confer and plan for effective collaboration long before it becomes necessary. The orchestrated response to the Boston Marathon bombings is an example. Hundreds of Boston’s prehospital and hospital-based responders had already learned the basics of blast-injury care and the operational challenges their city could face before this event. In 2009, Rich Serino, then Boston’s EMS chief and now deputy administrator of the Federal Emergency Management Agency, hosted the first “Tale of Our Cities” conference in Boston, at which clinicians from India, Spain, Israel, Britain, and Pakistan who had managed the aftermath of terrorist attacks explained the nature of the blast injuries they treated, the triage systems they used, and other lessons responders can use to save lives. More than 750 locals attended. Experience has shown that such a framework is necessary to ensure a well-coordinated response to a sudden mass-casualty event. Boston’s health care providers reacted the way they did because they knew what they were supposed to do, and those who did not were able to follow the lead of those who did. That’s how a “ritualized” disaster plan works. Like the damaged roof that nobody fixes because it’s not raining, it can be too easy to dismiss the urgency of the problem before the storm comes and impossible to implement a remedy once the downpour begins.
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Level 2: Disasters—Triage
Like wars, disasters can be a mass producers of wounds. But this larger influx of prospective patients is qualitatively different from a simple surge of patients. Rather, a “disaster” (as the term is used here) is a large-scale disruptor that creates a burden of patient need exceeding the region’s clinical carrying capacity. Diversion fails as a fallback www.anesthesiaclinics.com
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position because the other medical centers are also overwhelmed. We now need a second backup plan. Disaster triage, the second fallback position, relies upon rapid initial assessment as prospective patients enter the system—90 seconds is the standard—and a dynamic tagging process that monitors the urgency and complexity of injuries. And because it is now impossible at Level 2 to treat every one of these patients in accordance with the standard of practice, the earlier prime directive—No technically avoidable bad outcomes—must give way to a norm that reflects the hospital’s role as a steward of scarce and vital resources. The new prime directive is Avoid waste. Those presenting for care are commonly assigned to one of 3 categories arrayed along a bellshaped horizontal scale: the most seriously injured (the black-tagged expectant patients) toward the right of the central bulge, the least seriously injured (the green-tagged walking wounded) toward the left, and the redtagged patients in the middle. Disaster triage reduces clinical responsibility by lopping away the patients at both ends: those at the right, who are likely to die even if treated, and those at the left, who are likely to live even if not treated. At Level 2, clinicians focus on the red-tagged casualties in the middle: those who are likely to live if treated and likely to die if not treated. And within this middle group, priority goes to those whose conditions are the most urgent and the least complex. A patient with an otherwise fatal sucking chest wound can be stabilized in seconds with a plastic bandage. Fundamentally, disaster triage solves a mathematical problem: how do we save the maximum number of lives with finite resources? This shift in focus, from the patient to the population, palpably transforms the ethical landscape. Here are 2 salient differences: (1) It is no longer an option to prevent every technically avoidable death. The resources are not there. Although everyday practice in the emergency department affords prioritized attention to the most lifethreatening injuries, disaster requires those same patients to be blacktagged and set aside, even as less seriously injured patients are treated. For some clinicians, it will be tempting to accede to the everyday moral imperative to attend first to the worst-off. But in a disaster, such compassion will waste resources and raise the death toll. This is far too high a price. (2) Consider also that it can seem obligatory and heroic to persevere despite exhaustion. Although mindful and supportive of their coworkers’ need to take a rest to maintain optimal performance, some clinicians may end up ignoring their own limited capacity to go on and on without a break. Recall that, as tempting as it might be to take up a heroic “Superman” or “Superwoman” role, doctors and nurses cannot function indefinitely without sleep. Accordingly, incident commanders must order clinicians to rest, to avert the erosion of staff functionality as early as the 16-hour mark.2 These issues should be discussed regularly as an essential element of disaster www.anesthesiaclinics.com
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preparedness. As difficult as it may be, these new practices, and the good reasons for them, must be understood. We can now appreciate how Jehovah’s Witness patients, by conscientiously refusing to consent to blood transfusions, may have inadvertently helped the medical profession improve the prospects of patients in need of blood when transfusion is not an option. What is not often appreciated is that severe shortages of blood create exactly the same problem: How to manage when the standard of practice is not an option? When the burden of patient need exceeds carrying capacity, 1 option is to resort to new experimental therapeutic modalities that might extend your resources. There are anecdotal reports emerging from an embattled Syria that describe doctors with no access to anesthesia waiting for exsanguinating patients to lose consciousness, and only then operating upon them. Here we do not pass judgment on such strategies but only call attention to the circumstances that constitute the occasion for considering such departures from the standard of practice.
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Level 3: Physical and Medical Catastrophes—Forced Abandonment and Redeployment
We have distinguished between a region’s everyday carrying capacity— the largest burden of patient need that can be managed on an unremarkable day—and its “disaster-level” carrying capacity—the much-larger burden that can be managed regionally when black-tagged and green-tagged patients are essentially set aside. Usually, triage is as far as disaster planning goes (Who gets the ventilator?). But events can overwhelm regional carrying capacity even when it is augmented in this way. To be sure, there are multiple strategies that can tweak capacity: empty as many beds as possible, sending well-enough patients home; summon supplementary health care workers, for example, veterinarians, retired clinicians, hospice workers, chaplains, volunteers; adapt hallways, parking areas, lobbies, lawns, and rooftops, for decontamination and patient care; and prepare to evacuate casualties should the opportunity arise. But these may not suffice to preserve the functionality of medical centers. As used here, “catastrophe” refers narrowly to the unanticipated collapse of a previously functional health care institution. (Note that this clinically focused definition is narrower than the broader social conception of catastrophe developed by Quarentelli.3) Just as surges and disasters call for new ways of conceiving organizational and professional responsibility, so too can the collapse of a medical center. There are 2 types of disruptors here: physical and medical. We will consider these separately.
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Physical Insults
To fix the idea, consider the events at New Orleans’ Memorial Medical Center following Hurricane Katrina.4–8 These references are pertinent discussions of the events at Memorial Medical Center. Fink’s7 Pulitzer Prize winning New York Times Magazine article was later enlarged into a book.8 It is a close-up view of a hospital experiencing catastrophic failure. The protective sea walls had failed and the waters from Lake Ponchartrain and sewers had flooded the area, inundating the hospital’s lower floors. Lacking electricity and plumbing, temperatures in the building rose in the New Orleans heat, toilets overflowed and medical devices were disabled. Katrina had crippled the hospital’s capacity to care for patients and the building may have become a health hazard. The catastrophic failure of a functioning hospital generates 2 successive dilemmas, both of which can be anticipated. The first: When, if ever, are health care personnel at liberty to leave? The ready answer would be “When all patients have been evacuated.” But, as happened in New Orleans, it had been authoritatively announced that evacuations were not to be expected.4,5 What to do then? One answer: “Health care professionals are obligated to remain at their posts until the last patient dies or is evacuated. They must do this regardless of the burdens and risks of remaining on duty, regardless of the futility of the efforts they might make on behalf of the remaining expectant patients, regardless of other obligations they may have or could take on.” It is not clear that such heroism is obligatory or even wise. At some point doctors and nurses will have done everything that could reasonably be expected of them. Although a health care professional should then be free to leave, locating that point may be one of the hardest ethical decisions in health care. Let us assume there is a line beyond which there is no duty to remain and that, for clinicians at some stricken hospital, the line has been crossed. If clinicians undertake to withdraw, they would face the second dilemma: Should they abandon their black-tagged patients to die unmedicated and unattended, or should they euthanize them before leaving? This is a horrific choice, and, tragically, there is no third option. This second quandary emerges from the collision of 2 salient medical norms: the prohibition against abandoning patients and the prohibition against euthanizing them. When (1) it is impossible to evacuate patients and (2) dangerous and futile to remain with them, 1 of these 2 norms must give way. Although there is an official consensus on the impermissibility of abandonment and the impermissibility of euthanasia, there is almost no discussion on how these norms should be prioritized when, as here, they conflict. A practical framework to consider when faced with such “devil’s choices” has been suggested.6,9 Kipnis6 argues that if both options-euthanasia and abandonment—are
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prohibited, and there are no other options, then, absent a clear priority rule, the exercise of either alternative would be excusable.
Medical Insults
Beyond physical damage to hospitals, medical disruptors can be catastrophic when an epidemic illness or biowarfare attack is sufficiently lethal, infectious, and difficult to treat. An inundation of critically ill people can exceed the number that can be assessed, stabilized, and monitored. And as crowding can potentiate new infections, foraging for care during a pandemic catastrophe may be fraught with grave and avoidable risk. At some point hospital doors must be closed and the crowds of prospective patients and accompanying caregivers turned away. In that the attention required by a handful of patients with inhalational anthrax cannot be offered to thousands, hospitals may not be able to serve as the primary locus of health care during a medical catastrophe. Accordingly, regional hospitals may have to close their doors well before they reach disaster-level capacity, diverting patients and redeploying staff and supplies to peripheral emergency health care venues. As with the decision about whether to leave black-tagged patients behind, the community decision to shut down a region’s hospitals will be as difficult as it is consequential. Although the details will depend on the specific challenge, here is a sketch of catastrophe-level health care: health care without hospitals. (1) We should emulate the Israelis who, concerned about biowarfare, have implemented “shelter in place.” If an invisible deadly plume is passing over my city, I am at greater risk if I move about; I am safer if I stay put.10 Despite the common sense view that serious illness requires a trip to a hospital, the infirm must understand the requirement to stay home. (2) We should designate suitable locations as peripheral health care venues, with supplies, decontaminating showers, floor space, and robust communication links, for example, schools, fire stations, pharmacies, cafeterias, and hotels. These outposts can support house calls and home care. Radio and the internet can be used to provide advice to home caregivers. The goal is to reduce crowding and travel, thereby preventing infection and cross-contamination. (3) We should consider how to assign health care personnel to peripheral health care venues if and when a “code black” is called, signaling that regional hospitals have become dysfunctional. Registries should be set up for clinicians and volunteers who will need to know where to go if hospitals are to be avoided. Military doctors have long known that the scattering of vital resources creates a more robust system. www.anesthesiaclinics.com
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Level 4: Megapandemics—Social Distancing and Logistics
Although even a mild pandemic can be devastating to those it affects (eg, the 1957-1958 “Asian Flu” took about 70 thousand US lives), those outbreaks are unlikely to strain regional carrying capacity. In 1918, the more deadly Spanish flu sickened about 30% of the US population (about 34 million people). Of those, about 2% died (675 thousand), a far greater mortality than the typical seasonal flu.11,12 By comparison, an equally severe insult with today’s much larger population would sicken more than 90 million Americans and kill nearly 2 million. Fatalities would be expected to occur in waves over many months. As hellish as this would be, such a pandemic might be managed by disaster triage, redeployment of health care resources, and reduction of human-to-human contact (social distancing). Much will turn on the simplicity and efficacy of treatment. And yet there is an even worse scenario that cannot be ruled out, one that takes us to the next level. As used here, a “megapandemic” has 4 defining characteristics: it would be extremely contagious, it would have very high mortality, it would be global (ruling out emigration and evacuation as strategies for avoiding infection), and it would be, as a practical matter, untreatable. In effect, all those felled by such an illness would be black-tagged. Among present day illnesses, it is worth considering Avian flu. As a “thought experiment,” let us assume a highly contagious variant H5N1 outbreak infecting 30% of the population (somewhat similar to a seasonal flu) and at least 50% mortality among infected cases (roughly what the World Health Organization has seen among diagnosed cases of H5N1).13 Such a pandemic could be expected to kill about 15% of the US population or more than 45 million people. Globally, the death toll would be about 1 billion. In its scale, its infectiousness and its resistance to treatment, such an outbreak would be comparable with the 14th century’s Black Death. It would be hard enough to prepare for the 2 million fatalities from a latter-day Spanish flu. But while the implications of a vastly larger mortality rate might vex the thinking of those with responsibility for disaster preparedness, that unwelcome possibility cannot be ruled out. In the face of a megapandemic, it will not be enough to close hospitals and redeploy clinical resources. Without effective treatments and vaccines, we may have to accept the powerlessness of medicine. There would, however, be 1 remaining role for clinicians. Research should be the salient responsibility of hospitals during medical catastrophes and megapandemics, carried out even after the facilities are closed to patient care. A small number of research subjects could be admitted, and, until we knew which treatments were effective, head-tohead trials could be used to inform clinical practice. Generic protocols for on-the-fly investigations—possibly under the waiver of informed www.anesthesiaclinics.com
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consent for emergency research or an Expanded Access program (also known as “compassionate use” as defined by US Food and Drug Administration)—should be submitted to institutional review boards for approval well before any disease manifests. Study results should be disseminated broadly and quickly. If the idea of a catastrophe introduced us to health care without hospitals, the idea of a megapandemic (as defined above) introduces us to health care without clinicians. What to do when all patients are blacktagged? Even if hospitals shut their doors when regional disaster-level carrying capacity is overwhelmed, even if no effective treatment is available, we would not then be without resources. Enhanced social distancing can save lives, but only if we plan for it. To hunker down in our homes for weeks on end, we will need functional electrical, plumbing, and communications systems, and the delivery of food and pharmaceuticals in ways that do not require us to come into contact with each other. While complicated, such arrangements are feasible. The heroes of that horrific time will be the people who keep the water, electricity, and information flowing, who deliver medications and groceries to our doorsteps and driveways, who keep the networked pipelines of food and medicine functional during the waves of infection; and who can safely gather the dead. Those found to be immune to a newly virulent H5N1, or who have recovered, may have to be pressed into this final service, a necessity that presents unexplored ethical, legal, and social issues. Can we compel them to serve their communities in these ways? Can we condition offers of experimental or scarce drugs on a willingness to serve if there is recovery with immunity? Certainly as effective drugs become available, those at the pandemic battlefront have weighty claims to places at the head of the line.
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Epilogue
Beyond staff shortages and patient surges, even beyond disaster, hospitals may have to contend with poorly understood medical catastrophes, and megapandemics. Each creates its own moral universe with unique bioethical dilemmas and norms. Within each, responsible action requires a clear understanding of the context, its demands, the distinctive ethical issues that are likely to arise, and the organizational and normative strategies demanded by the occasion. It can be deeply disquieting to think through these hellish possibilities. But the duty to do so is a part of the responsibility for preparedness.
The authors declare that they have nothing to disclose.
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References
1. Kipnis K. Disasters, catastrophes, and worse: a scalar taxonomy. Camb Q Healthc Ethics. 2013;22:297–307. 2. Landrigan CP, Jeffrey M, Rothschild JM, et al. for the Harvard Work Hours, Health and Safety Group. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848. 3. Quarantelli EL. Catastrophes are different from disasters: some implications for crisis planning and managing drawn from Katrina. 2006. Available at: http://under standingkatrina.ssrc.org/Quarantelli/. Accessed May 18, 2014. 4. Deichmann RE. Code Blue: A Katrina Physician’s Memoir. Bloomington: Author House; 2006. 5. Meitrodt J. For dear life: how hope turned to despair at Memorial Medical Center. New Orleans Times-Picayune. 2006. Available at: http://connect.nola.com/user/ jmeitrodtTP/posts.html. Accessed May 18, 2014. 6. Kipnis K. Forced abandonment and euthanasia: a question from Katrina. Social Research. 2007. Available at: http://www.stanford.edu/Bmvr2j/sfsu09/extra/Kipnis.pdf. Accessed May 27, 2015. 7. Fink S. The deadly choices at Memorial. New York Times Magazine. August 30, 2009. p. 28. Available at: http://www.nytimes.com/2009/08/30/magazine/30doctors.html. Accessed May 18, 2014. 8. Fink S. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Random House; 2013. 9. Swann SW. Euthanasia on the battlefield. Mil Med. 1987;152:545–549. 10. Sorenson JH, Vogt BM. Will Duct Tape and Plastic Really Work? Issues Related to Expedient Shelter-In-Place. Oak Ridge: Oak Ridge National Laboratory; 2001. Available at: http://www.fas.org/irp/threat/duct.pdf. Accessed May 18, 2014. 11. Department of Health and Human Services. Pandemic flu history. Available at: http:// www.flu.gov/pandemic/history/. Accessed May 18, 2014. 12. Heartland Kidney Network. Pandemics & Threats, 1900-2006. Available at: http:// www.esrdnetwork18.org/pdfs/QI%20-%20Pandemic_Flu/PandFlu_Threats1900to2006.pdf. Accessed May 18, 2014. 13. World Health Organization. Cumulative number of confirmed human cases for avian influenza A (H5N1) reported to WHO, 2002-2012. Available at: http://www.who.int/ influenza/human_animal_interface/EN_GIP_20120810CumulativeNumberH5N1 cases.pdf. Accessed May 18, 2014.
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