Preparing for mass casualties

Counting of pandemic flu cases indicates that the number of Americans becoming infected is now increasing at an exponential rate. This has started within the last two weeks. Because deaths usually lag infections by several weeks, we won’t see most of the deaths from this rise in infections until November, although we are already seeing indications of an increase of severely ill people and deaths.

We don’t know if the current exponential increase in pandemic cases in the US will continue or if it will be blunted by vaccine. However, given the minimal amount of vaccine that has been deployed thus far, it seems likely that we will see many more infected people in the immediate future. As many others have suggested, the ability of our health care system to handle the surge in severely ill people is extremely limited. The natural consequence of this is that life-saving treatments will need to be rationed. The natural consequence of that is planned killings.

From the New York Times, October 24, 2009:

Federal officials say the possibility that America’s already crowded intensive care units would be overwhelmed in the coming weeks by flu patients is small but they remain vigilant.

The triage plans have attracted little publicity. New York, for example, released its draft guidelines in 2007, offered a 45-day comment period, and has made no changes since. The Health Department made 90 pages of public comments public this week only after receiving a request under the state’s public records laws.

Mary Buckley-Davis, a respiratory therapist with 30 years experience, wrote to officials in 2007 that “there will be rioting in the streets” if hospitals begin disconnecting ventilators. “There won’t be enough public relations spin or appropriate media coverage in the world” to calm the family of a patient “terminally weaned” from a ventilator, she said.

State and federal officials defend formal rationing as the last in a series of steps that would be taken to stretch scarce resources and provide the best outcome for the public.

The suggestion by federal officials that the possibility that  ICUs overwhelmed by flu patients is “small” is ridiculous. There are already indications that some ICUs are becoming overwhelmed. ECMO, which results in a much better outcome than ventilators, is already being rationed. People who would benefit from it  are already being denied access.

But it can get worse.

Yesterday, President Obama declared a National Emergency with respect to the H1N1 pandemic. Partisans eagerly engaged in a distracting war of words about what this means. It does *not* mean martial law. But it does mean that many rights that people take for granted when receiving medical care may be taken away during the pandemic.

From President Obama’s Proclamation:

…I hereby declare that the Secretary may exercise the authority under section 1135 of the SSA to temporarily waive or modify certain requirements of the Medicare, Medicaid, and State Children’s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule throughout the duration of the public health emergency declared in response to the 2009 H1N1 influenza pandemic.

What does section 1135 of the Social Security Act specifiy? Here are some excerpts:

Secretarial Authority.—To the extent necessary to accomplish the purpose specified in subsection (a), the Secretary is authorized, subject to the provisions of this section, to temporarily waive or modify the application of, with respect to health care items and services furnished by a health care provider (or classes of health care providers) in any emergency area (or portion of such an area) during any portion of an emergency period, the requirements of titles XVIII, XIX, or XXI, or any regulation thereunder (and the requirements of this title other than this section, and regulations thereunder, insofar as they relate to such titles), pertaining to—

(1)(A) conditions of participation or other certification requirements for an individual health care provider or types of providers,

(B) program participation and similar requirements for an individual health care provider or types of providers, and

(C) pre-approval requirements;

(2) requirements that physicians and other health care professionals be licensed in the State in which they provide such services, if they have equivalent licensing in another State and are not affirmatively excluded from practice in that State or in any State a part of which is included in the emergency area;

(3) actions under section 1867 (relating to examination and treatment for emergency medical conditions and women in labor) for—

(A) a transfer of an individual who has not been stabilized in violation of subsection (c) of such section if the transfer arises out of the circumstances of the emergency;

(B) the direction or relocation of an individual to receive medical screening in an alternative location—

The contingency plans for a severe pandemic include transferring flu patients from hospitals to “alternative locations”. These may include tent hospitals, hotels or convention centers. I believe the National Emergency proclamation was intended to lay the legal groundwork for directing and relocating flu patients to such treatment centers.

The thing is, severely ill flu patients aren’t going to find ECMO or even ventilators at these “alternative locations”. They will be lucky if they receive morphine to ease their dying.

And all of this, because the government chose not to close the schools.


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