medical experts

 

A girl reacts while getting her H1N1 influenza vaccination in Vancouver, B.C. Oct. 26, 2009. Health care workers across the country began administrating H1N1 influenza vaccine shots across the country.

Photograph by: Andy Clark, Reuters

As Canada officially enters the second wave of human swine flu, leading medical experts gathering in Toronto on Tuesday will discuss the worst case scenario: in the remote event that the pandemic overwhelms intensive care units, who goes to the ICU, and who doesn't?
Should scarce resources go to the people most likely to survive? Should triage occur on a first-come, first-served basis? If both have equal chances of survival, should the last available ventilator go to the 20-year-old over the 60-year-old, who has had 40 more years of life?
"I know this is an area that people just don't like talking about, in part because I think we all want to say we don't have to do triage in 2009 in one of the richest countries in the world, that we have resources for all," said Dr. Robert Fowler, a critical care physician at Toronto's Sunnybrook Health Sciences Centre and member of the Canadian Critical Care Trials Group.
"That's true to a degree, but it's definitely not true to the nth degree."
Fowler said Quebec, Ontario and B.C. are seeing increased H1N1 activity in the community. "That's starting to result in increased cases in the ICUs."
During an outbreak of swine flu in Winnipeg in June, intensive care beds at the Health Sciences Centre were filled with H1N1 patients suffering severe acute respiratory distress requiring prolonged mechanical ventilation. One critical care doctor described them as the sickest patients he had have ever seen. The hospital has since made plans to double the number of ICU beds, if needed.
Experts say that, unless there is a dramatic change in the H1N1 virus or how sick it makes people, the possibility of critically ill H1N1 patients swamping intensive care units is exceedingly remote. The vaccine is now being deployed; hospitals are preparing to increase their ICU "surge" capacity and share ventilators and other critical care resources if needed.
But still they say it is wise to prepare, "because if the unthinkable happens, you don't want to make these decisions on an ad hoc basis, with incomplete consideration and information," said Dr. Anand Kumar, an intensivist with the Winnipeg Regional Health Authority who will help moderate a discussion Tuesday on the development of a triage framework for the pandemic at a national meeting of critical care doctors.
Doctors say there are no national guidelines in place to help with those life-and-death choices — deciding, for example, who goes on a ventilator if there aren't enough to go around.
Without some federal-level guidance, "and because nobody knows what the legal liability is in doing so", Kumar said, "people are going to be very reluctant to use triage."
"The danger is, you might have a case that is hopeless on the ventilator, and say you have a young 35-year-old, or 40-year-old, or a mother of three kids who needs to go on and you don't have a ventilator for them," Kumar said. "All you can do is keep them comfortable."
"The nature of triage is that you make difficult decisions. But better that those kinds of decisions are made, if they have to be made, in as open and transparent and universally-agreed approach as possible.
"If you're not open and transparent, if you don't plan in advance, fundamentally what happens is, first-come, first-served."