COVID-19 Update from Dr. Smith: 3/28/20

Each day during the COVID-19 crisis, Dr. Craig Smith, Chair of the Department of Surgery, sends an update to faculty and staff about pandemic response and priorities. Stay up to date with us.

Dear Colleagues,

I couldn’t disguise the fact that yesterday tried my soul, for reasons I won’t revisit. I could continue in that vein by citing projections from any number of public sources that predict we will be rationing ventilators and ICU beds within a few weeks. These apocalyptic scenarios are hard to ignore if the underlying assumptions about new-case rates prove correct. Surge capacity is also based on assumptions, but our baseline resources (ICU beds, ventilators) are not. It is possible we will be overwhelmed. If we are, choices must be made.

The word "rationing” might be called a dog whistle, except that everyone hears it. When considering this unpopular prospect it’s important to remember that health care of the specific sort that depends on ICU beds and ventilators does not stop when those resources reach capacity. High-intensity, mostly successful care will continue to be delivered to every ventilated patient in an ICU bed, as long as the other resources supporting complex health care (personnel, primarily) don’t exceed capacity. Being forced to make choices about who will occupy a fixed number of ICU beds does not convert us from full resuscitation to body-stacking. I would love to replace “rationing” with something that doesn’t carry so much negative baggage. Resource-utility matching, perhaps? It helps that we have decades of experience making limited-resource decisions in organ transplantation. If we exceed capacity, we will deal with it, in ways that are thoughtful, moral, ethical, compassionate…yet imperfect.

Rather than wallowing in a prospect we might yet avoid, I’d rather mention some encouraging developments. The supply of PPE is clearly improving. N95 supply is lagging but also improving. We may reach a point at which all elements of PPE can be “rationed” to all situations in which their use is known to be efficacious, even when that term includes providing reassurance. Adequate PPE, combined with increasing sophistication in all aspects of transmission prevention, is critical to preserving the health and morale of our health-care workforce. Here I’ll paraphrase myself by reminding you that the ground substance of health care is not ICU beds and ventilators, it’s people. People like my NP, who was redeployed to a nearly-overwhelmed ICU in a system hospital two days ago. After his first day he sent me a text: “Yesterday was a reality check on how serious this is….Can’t wait to go back.”

Craig R. Smith, MD
Chair, Department of Surgery
Surgeon-in-Chief, NYP/CUIMC


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