Monday, August 24, 2009

H1N1: Why we are unprepared

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.


  1. Thanks for bringing up some of the very important points related to this issue (and also for letting me know you heard the podcast!). The good news is that there are a small number of physicians and other leaders in the US who have been trying to advance this agenda for many years, and only now are finally being heard. Hopefully not too late. Many states have actually adopted our Canadian triage protocol in their planning, some with minor modifications.
    Although the plan is on paper, we are still faced with the challenge of operationalizing this plan if demand outstrips supply. So far with H1N1, unfortunately the nature of the disease is not what most pandemic plans had in mind. The respiratory failure, when it happens, can be incredibly severe and in many cases cannot be treated with a regular ventilator. The number of specialized centers, with specialized equipment to manage severe H1N1 cases, is limited and if most of the cases requiring ICU care need this sort of specialized equipment, the supply is worse than the numbers suggest. What is also important to know is that some of the patients who receive the most aggressive care do survive and go home, but only after weeks of artifical life support.
    In the US, just as in Canada, society needs to be prepared for difficult decisions in the worst case scenario. The doctor at the bedside who has to decide which patient gets the ventilator will be faced with a dramatic shift in priorities, as we are trained to advocate for individuals rather than society on a larger scale. We all hope that we don't need to go down this path, but if we do, we need to ensure that society supports our best efforts to give the best chance for survival to as many people as possible.

    And in defense of the Society of Critical Care Medicine, the education has been available for years, but the demand has dropped since 9/11. Disaster preparedness comes in waves. Behind the scenes, many of the professional societies have been working with government to put plans together. You might also refer to the recent supplement in the journal Chest that includes many of the same players and attempts to give concrete suggestions to guide action.

    Thanks for your efforts in following this issue!

    Best regards,
    Randy Wax, MD

  2. Thanks for taking the time to leave this thoughtful comment, Randy! I know that there are a lot of efforts at preparedness at both the state and the federal levels. I think we agree that the challenge remains in putting the schemes that exist (yours or that of the American College's of Chest Physicians) into practice. There is tremendous cultural resistance to both centralization of operations and to considering sensible allocation of limited resources, which is what we are potentially talking about, if the various predictions come to pass.

    As for SCCM, I am very appreciative of their efforts. The web cast, however, should be much more accessible and, dare I say it, free. Attendance should be encouraged broadly, as the situation is quite fluid and the community needs updating. I understand the tough economic times, and wonder if the SCCM could have gotten a grant to do this at no cost, so as to encourage more attendees. Further, SCCM should plan a series of these over the next few months as the situation evolves.

    Final thought, these challenges really underscore the problems of our fragmented healthcare system and what I call "the culture of me". We still have an opportunity to do some things right, but this will require the strengthening of our sense of community and citizenship at the very least.

    Again, thanks for visiting and your comments. Let's continue the hard work and the conversation.