This is wartime medicine – what that means for patients and health care workers

Coronavirus

CHICAGO — Hospital administrators across the country are not just talking about saving lives, they are having the tough discussions about losing patients and making decisions about which ones. For guidance, they are turning to emergency planning coordinators.

Dealing with the unknown yet looking to other countries knowing how bad it got, Dr. Nathan Goldfein, a critical care physician and emergency medicine consultant said we have to brace for the worst.

“We are probably as well off as we could be. But with that said we are still in trouble,” Goldfein said.

About 80% COVID-19 patients will not have symptoms or will have a very mild disease and 5% will need a ventilator. Already in New York, we are seeing a crisis.

“They have had to resort to having two patients on one vent,” Goldfein said.

A creative solution in the face of a ventilator shortage, but it’s not enough, hospitals need to plan for the unthinkable.

“Having to make those decisions as physicians are the decisions that we would never want to make in our entire life and that is who gets a vent and who doesn’t get a vent and whether we have to take somebody off a vent because the odds of them surviving are so much less than someone that is waiting for a vent, that’s what scares me as a physician,” Goldfein said.

Goldfein said practicing medicine is no longer the same. 

“This is no longer medicine as we practice it in the United States forever it is now a war zone and our enemy is not visible and it makes it really, really tough because we don’t know how to battle an invisible enemy,” he said. 

And that’s why Goldfein said health care workers need tangible guidance, the ventilator question needs to be answered now. Qhen they are in short supply, doctors have to consider how to put multiple patients on one ventilator. Then patients should be evaluated by their ventilation allocation score or VAS. 

Wakefield Brunswick offers a matrix which includes some brutal but crucial advice including allocating vents to the patients you can save while giving others palliative care.

“How do you make these tough decisions? And how do you set up the infrastructure in the hospital to make those so that you’re prepared when you do it?” Goldfein said.

Another move hospitals would never consider, but as they’ve done in Chicago, the best move, close the doors to suspected COVID-19 patients, triage outside then decide.

“You have to close off your hospital the entrance and exit out of that hospital,” Goldfein said.

The same goes for people at home — shut the doors and stay inside. Because this virus is not the typical flu virus. It strikes and wounds rapidly.

“They can go and very often do go from 5 ml a minute to being intubated in less than 24 hours,” Goldfein said, “The rapidity of how this disease process works and how we have to react to it as caregivers is totally different than the flu. The flu you have time to work things out.”

Goldfein said this is war medicine.

“It’s like being in the war making decisions that we would never do in the U.S. before,” he said.

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