In a massive disaster, care will be scarce

Older, sicker patients could be allowed to die in order to save the lives of patients more likely to survive a massive disaster, bioterror attack or influenza pandemic in California.

It's not how nurses and doctors are accustomed to doing things, nor how Californians expect to be treated. But it is part of a sweeping statewide plan being praised for its breadth, even as it rankles providers who will have to carry it out.

The new "surge capacity guidelines" released by the state Department of Public Health, depict a post-disaster health care environment that looks and feels nothing like the system most Californians depend on.

It provides for scenarios in which patients could be herded into school gymnasiums for life-saving care or animal doctors could stitch up the human wounded and set their broken bones.

The 1,900-page document lays the practical – and ethical – groundwork for local and county health departments, hospitals, emergency responders and any able-bodied health care worker likely to be called upon in a catastrophe.

Striking in its specificity and its frank focus on the need to suspend or flex established laws and to ration health care, the plan is being hailed as a model for the rest of the nation.

"I don't know of any state that has taken it to this level of detail in outlining a surge plan for everyone who needs to respond to an emergency of this magnitude," said Jeff Levi, executive director of Trust for America's Health, a nonprofit group that has criticized the nation's emergency preparedness. "It's exactly the kind of dialogue that has to happen."

The conversations emerging from the plan will be very painful, especially for professionals trained to save a life at almost any cost, said Betsey Lyman, deputy director for public health emergency preparedness at the state Department of Public Health.

"Today, the practice of medicine is do everything you can for an individual patient," Lyman said. "This is, 'OK, we have limited resources. How do we best save the greatest number of lives?' That can mean saying to an individual patient, I can't give you a ventilator because I don't have enough for everybody."

The $5 million plan was developed as a result of Gov. Arnold Schwarzenegger's 2006 health care surge initiative. That $172 million effort included the stockpiling of millions of doses of antiviral medications, thousands of ventilators, mobile field hospitals and extra hospital beds.

But health care officials acknowledge that when and if a global pandemic or major disaster strikes, no amount of extra drugs or supplies will be sufficient to manage the impact on an already strained health care system.

That's why the state assembled public health professionals, hospitals, ethicists, nurses and others to hash out guidelines for procedures they hope will minimize red tape and maximize survival rates.

The plan lists, for example, which responsibilities and patient protections can be waived if the governor declares a state of emergency.

Hospitals will not have to report births, deaths, infectious disease outbreaks, medication errors, and suspected child or elder abuse. Existing rules that protect patients' privacy also can be tossed out.

Dr. Ron Chapman, Solano County health officer and a key surge plan participant, cited as an example the bare-bones approach to caring for people in the wake of Hurricane Katrina. There, he said, a friend's leg was sliced open by a piece of glass while he was helping haul away debris.

"They took him to a Wal-Mart parking lot. He stood in line, walked in, they sewed him up, gave him a pack of antibiotics and sent him on his way," Chapman said. "They never asked his name or his insurance status."

The guidelines say California's strict nurse-patient ratios can be ignored, and nurses can be assigned to jobs for which they have no experience.

The scenarios worry nursing leaders. "If you are going to throw out regulations … we know the consequences can be very bad," said Donna Gerber, government regulations director for the California Nurses Association. "(The regulations) wouldn't be there except to protect the public."

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