As the omicron variant brings a new wave of uncertainty and fear, I can’t help reflecting back to March 2020, when people in health care across the U.S. watched in horror as COVID-19 swamped New York City.
Hospitals were overflowing with sick and dying patients, while ventilators and personal protective equipment were in short supply. Patients sat for hours or days in ambulances and hallways, waiting for a hospital bed to open up. Some never made it to the intensive care unit bed they needed.
I’m an infectious disease specialist and bioethicist at the University of Colorado’s Anschutz Medical Campus. I worked with a team nonstop from March into June 2020, helping my hospital and state get ready for the massive influx of COVID-19 cases we expected might inundate our health care system.
When health systems are moving toward crisis conditions, the first steps we take are to do all we can to conserve and reallocate scarce resources. Hoping to keep delivering quality care – despite shortages of space, staff and stuff – we do things like cancelling elective surgeries, moving surgical staff to inpatient units to provide care and holding patients in the emergency department when the hospital is full. These are called “contingency” measures. Though they can be inconvenient for patients, we hope patients won’t be harmed by them.
But when a crisis escalates to the point that we simply can’t provide necessary services to everyone who needs them, we are forced to perform crisis triage. At that point, the care provided to some patients is admittedly less than high quality – sometimes much less.
The care provided under such extreme levels of resource shortages is called “crisis standards of care.” Crisis standards can impact the use of any type of resource that is in extremely short supply, from staff (like nurses or respiratory therapists) to stuff (like ventilators or N95 masks) to space (like ICU beds).
And because the care we can provide during crisis standards is much lower than normal quality for some patients, the process is supposed to be fully transparent and formally allowed by the state.
What triage looks like in practice
In the spring of 2020, our plans assumed the worst – that we wouldn’t have enough ventilators for all the people who would surely die without one. So we focused on how to make ethical determinations about who should get the last ventilator, as though any decision like that could be ethical.
But one key fact about triage is that it’s not something you decide to do or not. If you don’t do it, then you are deciding to behave as if things are normal, and when you run out of ventilators, the next person to come along doesn’t get one. That’s still a form of triage.
Now imagine that all the ventilators are taken and the next person who needs one is a young woman with a complication delivering her baby.
That’s what we had to talk about in early 2020. My colleagues and I didn’t sleep much.