The battle cry for the delivery of more hospital ventilators to treat critical COVID-19 patients reached a crescendo last week. With the possibility that there wouldn’t be enough medical equipment to meet every patient’s needs, many had wondered just how care would be rationed in a worst-case scenario. Who would decide which patients would receive a ventilator, and which wouldn’t in an overwhelming shortage?
In daily briefings last week, Gov. John Bel Edwards warned that the New Orleans area, the epicenter of the crisis in the state, was on a trajectory to exceed its ventilator capacity some time this week, potentially forcing healthcare workers to decide which patients would get life-saving treatment and which would die. (New Orleans did not get there this week. The rate of new ICU admissions and ventilator use has since begun to slow in the region, and Edwards has since said area hospitals are no longer on track to overrun capacity in the near future.)
So troubled by dire predictions of inadequate mechanical equipment here in Louisiana, one group, Disability Rights Louisiana issued a letter in late March to Edwards, Louisiana Department of Health Secretary Stephen Russo and other top state officials asking for assurances that treatment standards would not discriminate against the disabled. The letter read, in part, as follows:
“As Louisiana may be in the position of having to make rationing decisions on the use of ventilators in a matter of days, DRLA strongly urges Louisiana to adopt statewide guidelines to ensure that these requirements and principles for the delivery of care are followed, as recently outlined by the National Council on Disability and the Consortium for Citizens with Disabilities.”
“That letter was prompted by prior issues in Washington state and Alabama in which complaints were filed with the Office of Civil Rights in Washington, D.C. over discriminatory written policies of the rationing of care, which were totally contrary to stated guidelines already in place under the Americans With Disabilities Act,” said Christopher Rodriguez, Executive Director of Disability Rights Louisiana. “Some of those objectionable and discriminatory Washington guidelines were on the LDH website.”
The language was contained in a guidance document called “Scarce Resource Management & Crisis Standards of Care.”
“In the event of a large-scale disaster, either a no-notice event such as a natural disaster or a prolonged situation such as a pandemic, there is the potential for an overwhelming number of critically ill or injured patients,” the document said “In these situations, certain medical resources may become scarce and prioritization of care may need to be considered.”
As in the Washington state guidance that prompted the complaint, the document on the LDH included language on what to consider when screening patients and considering whether to admit them to the ICU or transfer them to outpatient or palliative care. Among the factors to consider: “Baseline functional status (consider loss of reserves in energy, physical ability, cognition and general health).”
“Certainly, these are all understandable concerns on the part of DRLA,” said Dr. Joseph Kanter, Assistant State Health Officer at the Louisiana Department of Health. “The disabled have historically been discriminated against at every turn, so their speaking out has historically been instrumental in attaining protective and equal rights.”
On March 28, The Office for Civil Rights at the federal Department of Health and Human Services issued a bulletin that stated healthcare entities under HHS programs were required to abide by laws that prohibit discrimination under the Affordable Care Act and the Rehabilitation Act on the basis of race, color, national origin, disability, age, sex, and exercise of conscience and religion.
On April 5th, LDH sent a letter to DRLA stating that the objectionable guidelines from Washington had been removed from their website and replaced with a link to the bulletin from the Office of Civil Rights.
“At this point in time, no specific guidelines have been put forth by the state vis-à-vis the coronavirus pandemic. However, as a result of going through Hurricane Katrina, we do have general crisis management in place,” Kanter said. “We are monitoring the current pandemic closely and if there is an imminent possibility that this situation is worsening, there would be conversations with a broad range of stakeholders … physicians, hospitals, lawyers, and DRLA, covering everyone including those with disabilities. However, barring discrimination, it would still be up to those individual hospitals to apply any and all guidelines to each and every patient individually based on good medical practices.”
DRLA told The Lens are satisfied with the state’s response as well as Dr. Kanter’s and will proceed further only if the situation warrants it.
“Too often the hardships caused by times of crisis are felt exponentially by individuals with disabilities when compared to the experiences of their typically-abled peers,” Rodriguez said. “The situation and circumstances surrounding the COVID-19 pandemic are no exception. Disability Rights Louisiana was pleased with the swift action taken by the Louisiana Department of Health to address the concerns of the disability community with regards to the potential of discrimination based on disability when determining rationing of care and prioritization of medical services.”
Meanwhile, for the more than 2,000 hospitalized Louisianians who have tested positive for the disease, safeguards are still in place to prevent shortages. Many local hospitals are a part of much larger hospital systems — including LCMC Health and Ochsner Health Systems — and that allows for sharing between the individual facilities. Should ventilators run short at one hospital, a supply from another hospital is sent over. And, as we have seen across this country when one hospital’s census goes down, vital PPE and ventilators have been transferred to hospitals more in need, even when they aren’t a part of the same hospital group.
“LCMC and Ochsner have big footprints, so there’s a lot of moving supplies around,” explained Dr. Ben deBoisblanc, Professor of Medicine and Physiology at LSU Health Sciences Center, and a pulmonologist who treats patients at University Medical Center, which is publicly owned but managed by LCMC Health.
“We are prepared to use our ventilators from the OR in the ICUs if we need to. There are some very smart people around here who know how to modify them for different uses,” he said. “And, fortunately, at this point, we have not had to make a decision about who gets a vent and who doesn’t, as they have had to in other countries that were overwhelmed very suddenly. We are also doing a better job upfront of assessing patients — even without coronavirus — as to who will benefit more from oxygen, or from palliative care so that we’re not providing life support to those who don’t really need it or won’t benefit from it. But, to be clear, this is not based on a patient’s disability, but rather on the totality of the patient and any preexisting conditions such as COPD, diabetes, hypertension, or even morbid obesity. We also make decisions based on the severity of the COVID-19 individual case.”
“I assure you, there’s no Dr. Death scenario here where doctors are running around in the middle of the night pulling plugs on ventilators.”
The eventuality of running short of ventilators seems less likely this week than it did last. The consensus among New Orleans hospitals is that we are plateauing, meaning discharges are catching up with new admissions, putting less stress on the entire system and making the likelihood of life and death decisions far less likely down the road.
“I want to be perfectly clear that we would only take people off ventilators because we’re practicing good medicine, not because we’re trying to move the next patient into the ICU who might need this equipment,” said Abdul Khan, M.D., pulmonary intensivist and director of Ochsner’s West Bank ICU. “We don’t wait for situations to become critical, either. When we see we’re running low, we start talking to everyone else across the state which still has inventory. The really good news is that this week, for the first time, I’m seeing non-COVID-19 patients admitted to the ICU, which means we have room for them. That hasn’t happened in a good while.”
The Lens has previously reported on rationing of protective gear at LCMC hospitals. But deBoisblanc said many have managed to find other, more creative solutions to running short on supplies.
“We have gotten really close to tapping out on our supplies … masks, gowns, and ventilators,” he said. “But there are many creative people out there, so many MacGyvers finding solutions. We’ve leveraged some of our relationships with our engineering departments at LSU in Baton Rouge. They’ve been laser-cutting PPE for us in the form of plastic shield masks, and they’ve even reconditioned some of the older ventilators in our stockpile so they’re like new.”
Kanter said that while the rate of critical patients taking up hospital beds and ventilators has shown signs of abating, deaths from COVID-19 are likely to go up in the immediate future, as many of the sickest patients now in ICU beds may not survive. But numbers over the past week give some indications that the curve is beginning to bend.
“We are seeing some early evidence around the state of flattening the curve, but we only have about a week’s worth of data and sometimes the numbers change radically throughout the week, “ explained Dr. Kanter. “We need a longer period of time of lessening numbers to render an opinion about the real direction this is going.”
“No one should become complacent. This is not the time for an Easter gathering, or a picnic at the lake. Social distancing while wearing masks is still the order of the day, if we want to continue this downward trend, and come out of this on the other side.”