Columns for The Lufkin News

What If We Don’t Flatten the COVID-19 Curve?

Posted Apr 12, 2020 by Sidney C. Roberts, MD, FACR

On April 5, 2020, US Surgeon General Jerome Adams said, “The next week is going to be our Pearl Harbor moment. It’s going to be our 9/11 moment.”[1] The same day Dr. Anthony Fauci, arguably our most trusted spokesperson during this coronavirus crisis, said, “We’ve got to get through this week that is coming up because it is going to be a bad week.”[2] One oft-cited set of projections showed deaths from COVID-19, the illness caused by the novel coronavirus, and resource use (including ICU beds and ventilators) were expected to peak this weekend.[3] That all of this is happening during Easter and Passover only adds to the sorrow.

For those of us in Texas, the wait to peak is a bit longer. Estimates a week ago were for peak resource use on May 6, 2020, but that prediction has now moved up to April 22, with peak in daily deaths on April 24.[4] Texas appears to be flattening the curve. In Angelina County, we have 16 confirmed cases of COVID-19 as of April 9, but only 283 people have been tested so far.[5] We can only hope that the wise and early decisions by our local elected officials, including the Stay Home – Stay Safe[6] order, will have flattened our curve enough to avoid the healthcare crisis experienced in New York, New Orleans, and other cities.

But what if our hopes are unfounded? What if we get a surge of COVID-19 cases beyond what our healthcare system can handle? In New York City, some COVID-19 victims could be temporarily buried in mass graves in a park,[7][8] as morgues don’t have the capacity to handle the mounting casualties.[9]

Thankfully, doctors across the nation have been giving much thought to this grim prospect. After the 2003 SARS outbreak, North Texas physicians came together to answer that very question: What would they do if a really big pandemic hits and hospitals are overwhelmed?[10] The result was the formation of the North Texas Mass Critical Care Council. The council established that during a time of crisis, the ethical, moral, and medical approach should be that “access to treatment would be based upon the patient’s ability to benefit from it, using objective physiologic criteria.”[11] In other words, medical evidence[12] – rather than insurance status, social standing, what have you – would guide decision-making about which patients are most likely to benefit from ICU interventions when there are not enough ICU beds or ventilators for every patient. The goal – as it should be in any medical crisis – is to save “as many lives as possible.”[13]

In a similar fashion, CommonSpirit Health, the Catholic health system that is the second-largest nonprofit hospital chain in the US (and the parent of CHI St. Luke’s Health Memorial Lufkin), developed Crisis Response Guidelines for Hospital and ICU Triage Allocation.[14] These guidelines are not based on opinion or guesswork. The many criteria used to prioritize who would benefit from ICU and ventilator support are validated in the medical literature and have been compiled to arrive at a robust sequential organ failure assessment (SOFA) score, based on the degree of dysfunction or failure of the heart, lungs, liver, kidneys, brain, and blood system.[15] This SOFA assessment, well known to emergency and intensive care specialists, is used routinely to predict mortality in any critically ill patient.

Based on SOFA scores and other medical criteria, doctors might determine that an elderly patient with COVID-19 whose organs are functioning well is more likely to recover using a hospital ventilator than a young patient with multiple organs shutting down from the virus, but the decision would be based entirely on whether the treatment is likely to help the patient recover. Doctors are expressly prohibited from considering social status, money or other nonmedical criteria when making these decisions.[16] The last thing doctors want to be accused of is indiscriminately playing God.

A recent Wall Street Journal opinion implied that merely considering apocalyptic scenarios would lead to legalizing euthanasia, and that not having guidelines (and thereby wasting resources on those that would not benefit) was morally superior to sound medical decision making.[17] Texas Health and Safety Code §166.009 acknowledges that sometimes difficult choices have to be made and states that provision of life-sustaining treatment is not required if it “cannot be provided to a patient without denying the same treatment to another patient.”[18] There is a larger problem of futile care in this country that did not start with the coronavirus pandemic and it won’t end once this virus is under control.

Crisis guidelines are not written to decide who lives and who dies; they help direct the most aggressive care to those who are most likely to benefit so that the most lives can be saved. Regardless, all patients are to be treated with dignity and receive appropriate and compassionate care. If I, as a physician and community leader, have little to no chance of survival if placed on a ventilator – based on solid medical criteria – but an illegal immigrant (for example) has a good chance of survival, guess who gets the ventilator? Not me. And that is the way it should be.

We must continue to follow the social distancing recommendations of our city, county, and health district leaders in order to minimize the impact of the coronavirus locally. We can do this – we ARE doing this. As the Lufkin/Angelina County Chamber of Commerce is encouraging us, we are #BetterTogether and #AngelinaStrong.

[1] https://www.theguardian.com/world/2020/apr/05/pearl-harbor-us-surgeon-general-coronavirus-deaths-donald-trump-white-house-briefing

[2] https://www.theguardian.com/world/2020/apr/05/pearl-harbor-us-surgeon-general-coronavirus-deaths-donald-trump-white-house-briefing

[3] https://covid19.healthdata.org/projections accessed on April 9, 2020.

[4] https://covid19.healthdata.org/projections accessed on April 9, 2020.

[5] Update from Angelina County & Cities Health District as of April 9, 2020.

[6] http://www.cityoflufkin.com/pdfs/2020/2020-04-02_Stay-Home-Order.pdf

[7] https://www.nytimes.com/2020/04/06/nyregion/coronavirus-new-york-update.html?action=click&module=Spotlight&pgtype=Homepage

[8] https://theweek.com/speedreads/907102/new-york-city-plans-temporarily-bury-coronavirus-victims-park

[9] https://apnews.com/75e97a636f40bcd98f0827dfaa09e3ff

[10] https://www.dallasnews.com/opinion/commentary/2020/04/03/n-texas-doctors-developed-guidelines-to-determine-which-patients-get-ventilators-if-there-is-a-shortage/

[11] https://www.dallasnews.com/opinion/commentary/2020/04/03/n-texas-doctors-developed-guidelines-to-determine-which-patients-get-ventilators-if-there-is-a-shortage/

[12] https://www.dallas-cms.org/tmaimis/DCMS/Public_Health/Mass_Critical_Care/DCMS/PublicHealth/Mass_Critical_Care.aspx?hkey=9f1e00e9-17f8-47f1-a874-2c315f147674

[13] https://www.dallasnews.com/opinion/commentary/2020/04/03/n-texas-doctors-developed-guidelines-to-determine-which-patients-get-ventilators-if-there-is-a-shortage/

[14] CommonSpirit guideline created April 2020.

[15] https://www.mdcalc.com/sequential-organ-failure-assessment-sofa-score

[16] https://www.dallasnews.com/opinion/commentary/2020/04/03/n-texas-doctors-developed-guidelines-to-determine-which-patients-get-ventilators-if-there-is-a-shortage/

[17] https://www.wsj.com/articles/rage-against-the-bioethicists-and-the-dying-of-the-light-11585937451

[18] https://texas.public.law/statutes/tex._health_and_safety_code_section_166.009

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