The recent nationwide shortage of injectable solutions, such as normal saline and Lactated Ringer's (given intravenously to a patient to replace fluids and electrolytes lost from illness or injury), illustrates how a resource shortage can lead to a need to ethically allocate available resources.
At the local level, the decision is usually made on a case-by-case basis. For example, if a hospital has two patients, both of whom need the same resource – like saline or a ventilator – and only one resource is available, a medical provider or small group of providers (often with input from the patient’s family) determines which patient should receive the needed care, medicine or equipment.
They also determine what alternative treatment can be used for the other patient until the ideal treatment is available. It may be a matter of minutes or hours, or could be a matter of days, depending on the nature of the resource and what caused the shortage. It can be very difficult to make an allocation decision on a day to day basis, but it’s even more difficult in a catastrophic disaster. In a catastrophic situation healthcare providers won’t have time to consult with each other and ask the family; no one else may be available to ask.
Hospitals, healthcare facilities and state and local planners need to start engaging their community members now so that they can work together to decide how these difficult decisions will be made. So if (or when) the time comes, members of the community understand how medical resources and other emergency management resources (fire, rescue, law enforcement, etc.) will be used. By engaging community members before an event occurs, they may be more likely to see the process as a legitimate one and they may better understand how actions that they take in an emergency can impact their health or the health of their loved ones.
The federal government can provide additional personnel and medical supplies in catastrophic situations yet like all other resources, ours are finite, too. And like every community, we too need a protocol – a way of making decisions about where to send the resources we have available and help communities save as many lives as possible.
ASPR coordinates the public health and medical resources available through the federal government to support states and communities in emergencies. A participant in the 2011 drill noted that ASPR has no protocol to make allocation decisions when the demand for federal support exceeds the supply of resources.
A lot of factors are involved in figuring out how to allocate resources. In planning for it, all levels of government have to think about the effects of a catastrophic event on transportation because this affects how and where resources can be transported into the area and set up, and on how those resources can be supported (the responders need a place to stay, food, and water, and they will need medical resupply). It will matter where those resources are located: have any been affected by the disaster? Are any cut off from getting to the affected area?
Other considerations include whether there are active response operations going on, or if it's a time of year when we know disasters such as tornados or hurricanes are likely to occur which could create additional requests for those same resources.
Unlike the decisions commonly made in an emergency room, decisions about how to respond in a catastrophic situation go beyond the needs of one or two patients. In deciding how to respond to such a catastrophic disaster, medical providers, emergency managers and leaders at all levels of government cannot use the same model of medical ethics that a doctor would turn to when deciding which patient should get the ventilator. The decisions have to consider the public health needs of a significant portion of the country's population.
So ASPR's Office of Emergency Management developed a framework for the type of ethical decision-making required in catastrophic situations when resources are scare nationwide or possibly even worldwide. The framework is only for federal public health and medical resources. It could be a model for your state or your community.
This blog is the first in a series on the allocation of scarce resources in a disaster. We'll discuss the framework and processes in future blogs. To learn about new posts to the ASPR Blog and other topics related to public health emergency preparedness, response and recovery, follow us on Twitter or like us on Facebook.
Has your community already started one of these crucial conversations? If so, share your community’s story in a comment to this blog post. Let us know what worked, what didn’t, and how this discussion impacted your community.
