We just published a paper in PLoS Currents: Influenza estimating what our ICUs can expect this flu season in the US due to the H1N1 pandemic. The picture is not pretty: about 300,000 extra patients needing assisted breathing from ventilators, and some of them requiring advanced modes of ventilation available only in specialized centers! Herein lies the paradox of this flu: by and large it does not cause a particularly severe disease, save in a small proportion of its victims. However, its contagion potential is high, and large numbers of the US population are likely to be affected (about 46 million by our estimates), accompanied by a large number of critically ill, thus potentially overwhelming the ICUs.
Here is how it fits into the overall picture of critical care in the US. ICU beds are perennially occupied, personnel numbers are shrinking and the volume of the sickest of the sick is growing at a clip 6 times that of all hospitalizations. Not to mention that 1/3 of all hospitals are financially in the red, and ~1/2 of all EDs are on diversion at some point (and, by the way, in the majority of these situations the reason for diversion is lack of ICU bed availability). Given that there are about 1 million patients on ventilators in the US annually, we are talking about a 33% surge likely compressed into a few months of the flu season! So what do you think is going to happen?
My friends on the ground tell me that we are not ready. Jeremy Kahn, MD, MS, Assistant Professor of Medicine and Epidemiology at the University of Pennsylvania School of Medicine and Senior Scholar in the Leonard Davis Institute of Health Economics, who happens to be one of the foremost experts on ICU capacity and regionalization in the US, told me that "we are woefully under prepared" for this pandemic. He is very concerned that critical care bed and ventilator supply will be outstripped by demand. But what concerns him even more is that "most municipalities do not have resource allocation or disaster preparedness plans in place". What this means is that we do not have plans in place to use the available resources optimally.
There are other ways in which we are unprepared. One is manifesting itself in our current national discourse on healthcare reform. The level of immaturity and selfishness in this "debate" makes me worry that we are not prepared as a population to make the tough decisions that have to be made during a disaster, which is what this pandemic is promising to be. Canadian Critical Care investigators came up with a protocol for their ICU resource allocation in case of a mass casualty event. This is an explicit scheme spelling out how prioritization is to take place. (Oh, yes, there will be prioritization). In a Society of Critical Care Medicine's podcast Dr. Randy S. Wax, a co-author of the Canadian protocol to triage ICU care during a pandemic, talks about this scheme. He uses the phrase "distributive justice". What this boils down to is that in the face of a public health disaster a bedside doc is responsible to the society at large even more so than to an individual patient. It is critical to have an explicit and transparent prioritization protocol, developed and put into place with full participation of community members. This is necessary as much for clarity and community buy-in as it is for protection from liability. The Canadian scheme has been available for 3 years -- have we heeded the call? Clearly not. And what is the Society of Critical Care Medicine doing? Well, to be fair, they have offered some disaster management courses. Now, at the 11th hour, they are advertising a web cast on September 17 at a cost of $65.00 for individual non-members!
So, where does all this leave us? As I said before, with our pants down! Is this sad state of affairs another reminder why we need a healthcare system devoid of the profit motive? A few days ago I reviewed a paper in the New England Journal of Medicine comparing Israeli preparedness scheme to ours. Some of the pivotal differences between our two systems are the centralized nature of planing and enforcement functions (they have it, we don't), competition between centers (they don't have it, we do), and the profit motive (they don't have it, we do).
Since it is too late for this pandemic to benefit from a philosophical and infrastructural overhaul, we need to have a realistic national plan. We have to do as much as we can to put plans into place that optimize the use of currently available resources. At the same time, prevention is clearly going to be the cornerstone of this effort. I believe that we need to be exceedingly aggressive with preventive efforts, including school and business closures, travel restrictions and the like. In fact, this may be a great opportunity to test to its fullest our communications web. It is possible that if we handle this potential catastrophe with some measure of common sense, we may gain useful insights not only into who we are as a community, but how our vast technological resources can make us into a more compassionate and efficient work force.