Shards writ large. Health care fragmentation disaster response implications

Above, a scene from the tsunami following the horrific 2011 Tōhoku earthquake. I wonder if that man lived.

I finished reading Sheri Fink's excellent, painful book about the aftermath of the 2005 Hurricane Katrina "Five Days at Memorial" the other day -- the central topic of my prior post.

A non-fiction masterwork, it reads at first like a totally suspenseful early Michael Crichton novel, then like a John Grisham legal drama. It will push your sense of "empathy" to the firewall. It should leave you furious at the myriad iterative and recursive failures of the breadth of authority -- some of them spanning decades, some the fruits of venality, some "merely" the progeny of incompetence. Failures that ended up leaving front-line clinicians beset by impossible moral quandaries amid the most dire of circumstances, resulting in the whole acrimonious finger-pointing "playing God" thing -- the wafts of which continue to echo to this day.

From the Amazon blurb:

In a voice at once involving and fair, masterful and intimate, Fink exposes the hidden dilemmas of end-of-life care and reveals just how ill-prepared we are in America for the impact of large-scale disasters—and how we can do better. A remarkable book, engrossing from start to finish, Five Days at Memorial radically transforms your understanding of human nature in crisis.

Again, you can get a searing sense of the disaster from her 2009 Pulitzer-winning ProPublica piece "The Deadly Choices at Memorial" (a long read). Strongly recommend you buy this book and read it closely.

Major props to Ann Neumann for turning me on to this book via one of her Facebook posts.

The epilogue of Five Days at Memorial examines the subsequent halting post-Katrina policy efforts to clarify workable normative "medical ethics" pertaining to large-scale disaster response operations, wherein exigent needs far outstrip available resources.

Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond— our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses. [Five Days at Memorial, Kindle Locations 7732-7734]

It's not like any of this is news. e.g., citing Einer Elhauge's 1994 "Allocating health care morally" (pdf) on the topic of "triage."

One might think that one could just rely on medical judgment to determine how best to allocate a fixed set of resources to maximize the health of a group. But this has not actually been a traditional focus of medical attention. Physicians have generally regarded the lack of resources to provide care for all treatable illnesses as a temporary problem requiring a budget increase, not the development of sustainable principles of allocation. Indeed, the development of such principles has sometimes been shunned as tantamount to admitting defeat. The dominant forms of nonprice rationing practiced by the medical profession have thus tended to be makeshift and poorly-conceived.

Rationing at the bedside via ad hoc, seat-of-the-pants judgments is a common phenomenon, a "method" of allocation dubbed "ad hockery." Most medical rationing does not involve even this level of conscious thought. Absent emergencies, patients are usually treated on a first-come, first-served basis that may be regarded as a means of random allocation akin to using lotteries."' But in fact, both the priority given to emergency cases and the use of waiting lists flow from the medical premise, no matter how unrealistic, that eventually all the patients will be treated.

The resulting waiting lists (interrupted only by emergencies) often produce irrational allocations that effectively deny some persons care entirely and cause needless suffering and worse health outcomes because patients deteriorate during the wait. Indeed, because first-come, first-served treatment favors patients who have waited the longest, it tends to select the sickest patients for treatment (as does emergency priority) even if they are the least able to benefit from it. But these facts either are studiously ignored to preserve the illusion that only the timing of care is being affected or are strategically highlighted in calls for greater funds. Some have even argued in favor of using random means of allocating health care in order to provoke a public outcry that might in turn produce greater funds. Rarely do the above problems provoke a conscious medical rethinking of the allocation problem.

One partial exception to this refusal to allocate is the system used in time of war or natural disasters: medical triage. But triage does not really offer a means of systemic allocation. Traditionally, medical triage sorts individuals into three categories-those who will die regardless of treatment, those who will live regardless, and those for whom treatment makes the difference between life and death-and then treats the last group first. Such triage, however, is generally used merely to time the order of treatments where it is assumed that the health problems of those who will live without immediate treatment will be treated later. Medical triage thus has little implication for how to order priorities where treatment of those whose lives can be saved (albeit for a short time and in poor condition) means nontreatment of those whose health could be significantly improved.

Hidden — and often quite dubious — allocative judgments are often imbedded in seemingly innocuous measures of medical effectiveness... [pp. 1494-1495]

"Triage." In the case of Katrina and Memorial hospital, it was mostly about the ad hoc prioritization of the order of evacuation rather than tx per se, given insufficient evac resources -- and what to do about those among the still-barely-living who would not be evacuated at all. A terrible circumstance.

On contributory/exacerbating "fragmentation" in health care. Recall my citing of Elhauge in my post "The U.S. healthcare "system" in one word: "shards."

That stuff just goes to the adverse effects of our chronically vexing health care space fragmentation during normal times.

Fink exposes the hidden dilemmas of end-of-life care and reveals just how ill-prepared we are in America for the impact of large-scale disasters...

Yeah, OK,well think about this:

When the 2011 earthquake and tsunami struck Tohoku, Japan, Chris Goldfinger was two hundred miles away, in the city of Kashiwa, at an international meeting on seismology. As the shaking started, everyone in the room began to laugh. Earthquakes are common in Japan—that one was the third of the week—and the participants were, after all, at a seismology conference. Then everyone in the room checked the time.

Seismologists know that how long an earthquake lasts is a decent proxy for its magnitude. The 1989 earthquake in Loma Prieta, California, which killed sixty-three people and caused six billion dollars’ worth of damage, lasted about fifteen seconds and had a magnitude of 6.9. A thirty-second earthquake generally has a magnitude in the mid-sevens. A minute-long quake is in the high sevens, a two-minute quake has entered the eights, and a three-minute quake is in the high eights. By four minutes, an earthquake has hit magnitude 9.0...

Most people in the United States know just one fault line by name: the San Andreas, which runs nearly the length of California and is perpetually rumored to be on the verge of unleashing “the big one.” That rumor is misleading, no matter what the San Andreas ever does...

Just north of the San Andreas, however, lies another fault line. Known as the Cascadia subduction zone, it runs for seven hundred miles off the coast of the Pacific Northwest, beginning near Cape Mendocino, California, continuing along Oregon and Washington, and terminating around Vancouver Island, Canada. The “Cascadia” part of its name comes from the Cascade Range, a chain of volcanic mountains that follow the same course a hundred or so miles inland. The “subduction zone” part refers to a region of the planet where one tectonic plate is sliding underneath (subducting) another. Tectonic plates are those slabs of mantle and crust that, in their epochs-long drift, rearrange the earth’s continents and oceans. Most of the time, their movement is slow, harmless, and all but undetectable. Occasionally, at the borders where they meet, it is not...

Under pressure from Juan de Fuca, the stuck edge of North America is bulging upward and compressing eastward, at the rate of, respectively, three to four millimetres and thirty to forty millimetres a year. It can do so for quite some time, because, as continent stuff goes, it is young, made of rock that is still relatively elastic. (Rocks, like us, get stiffer as they age.) But it cannot do so indefinitely. There is a backstop—the craton, that ancient unbudgeable mass at the center of the continent—and, sooner or later, North America will rebound like a spring. If, on that occasion, only the southern part of the Cascadia subduction zone gives way—your first two fingers, say—the magnitude of the resulting quake will be somewhere between 8.0 and 8.6. That’s the big one. If the entire zone gives way at once, an event that seismologists call a full-margin rupture, the magnitude will be somewhere between 8.7 and 9.2. That’s the very big one...

When the next very big earthquake hits, the northwest edge of the continent, from California to Canada and the continental shelf to the Cascades, will drop by as much as six feet and rebound thirty to a hundred feet to the west—losing, within minutes, all the elevation and compression it has gained over centuries. Some of that shift will take place beneath the ocean, displacing a colossal quantity of seawater ... The water will surge upward into a huge hill, then promptly collapse. One side will rush west, toward Japan. The other side will rush east, in a seven-hundred-mile liquid wall that will reach the Northwest coast, on average, fifteen minutes after the earthquake begins. By the time the shaking has ceased and the tsunami has receded, the region will be unrecognizable. Kenneth Murphy, who directs FEMA’s Region X, the division responsible for Oregon, Washington, Idaho, and Alaska, says, “Our operating assumption is that everything west of Interstate 5 will be toast.”

In the Pacific Northwest, the area of impact will cover some hundred and forty thousand square miles, including Seattle, Tacoma, Portland, Eugene, Salem (the capital city of Oregon), Olympia (the capital of Washington), and some seven million people. When the next full-margin rupture happens, that region will suffer the worst natural disaster in the history of North America. Roughly three thousand people died in San Francisco’s 1906 earthquake. Almost two thousand died in Hurricane Katrina. Almost three hundred died in Hurricane Sandy. FEMA projects that nearly thirteen thousand people will die in the Cascadia earthquake and tsunami. Another twenty-seven thousand will be injured, and the agency expects that it will need to provide shelter for a million displaced people, and food and water for another two and a half million. “This is one time that I’m hoping all the science is wrong, and it won’t happen for another thousand years,” Murphy says.

In fact, the science is robust, and one of the chief scientists behind it is Chris Goldfinger. Thanks to work done by him and his colleagues, we now know that the odds of the big Cascadia earthquake happening in the next fifty years are roughly one in three. The odds of the very big one are roughly one in ten. Even those numbers do not fully reflect the danger—or, more to the point, how unprepared the Pacific Northwest is to face it...

Kathryn Schulz, The New Yorker, July 2015, "The Really Big One. An earthquake will destroy a sizable portion of the coastal Northwest. The question is when."

Another long read. Another Pulitzer-winner. Read the entire piece.

That scares the crap outa me. I lived in the Seattle area from 1968 to 1974. Loved it. Both of my girls were born there. Wrote my first song there, in 1969. I still have the dearest of friends there.

There will likely again be clinicians forced to "play God." In the PacNW and elsewhere.

BTW: Just finished another book.

apropos of the foregoing:

Smart Emergency Response Systems 
Keeping its citizens safe in times of emergencies or disasters is a major challenge for smart cities. Groups such as firefighters, paramedics, law enforcement and medical teams are collectively called “first responders”. The ability to coordinate and deploy such first responders after a disaster occurs can save many thousands of lives during what are called the “incident response” (during and shortly after a disaster) and “recovery” (the weeks after the disaster) time periods. 

Challenges for smart cities when it comes to disasters include: 

• lack of integrated planning 
• poor or non-existent communications during a disaster 
• inability of different agencies (federal, state, local) to act together 

The results of these challenges not being met have been amply demonstrated in the last decade during Hurricane Katrina, the Haiti earthquake, the Indonesian tsunami and hundreds of similar disasters. Fortunately, ICT solutions are available to help smart cities in this area. 

Integrated planning requires that different agencies such as fire departments, local police, paramedics, hospitals, city and state governments as well as federal agencies must plan together, using common terminology and assumptions. The norm is for such agencies to each come up with a unique set of plans in what is termed a “silo” (i.e., remote and independent) environment. This consequently leads to chaotic responses when a crisis occurs.

Integrated communications have also been a problem in the past, with each group of first responders having its own analog equipment. In past years, for instance, personnel from the Los Angeles County Sheriff’s Department, Police Department, Highway Patrol and Fire Department could not talk with each other during crises because their equipment sets were incompatible, purchased through different contracts and procurement processes. 

The inability of different agencies to act together has had dire consequences during disasters. During Hurricane Katrina, highway patrol deputies blocked access to New Orleans to technicians who had been called for and were desperately needed by the City Police Department to repair various infrastructures.

King, Brett; Lark, Andy; Lightman, Alex; Rangaswami, JP (2016-05-15). Augmented: Life in The Smart Lane (Kindle Locations 4930-4949). Marshall Cavendish International (Asia) Pte Ltd. Kindle Edition.

'eh?

Interesting note on EHRs in Five Days at Memorial:

MEMORIAL’S FIFTH FLOOR was bathed only in the dim, bluish light from Toshiba Satellite laptop monitors. A night shift nurse, Michelle Pitre-Ryals, quickly typed notes into her patients’ electronic charts before the computer batteries died, despite the fact that once that happened, the electronic medical records system would be useless. Paper was high technology in a disaster. The electronic medication dispensing cart, new to Pitre-Ryals’s unit, would also shut down, its stock of medicines locked securely inside it... [Kindle Locations 2073-2077]

"Paper was high technology in a disaster." Hmmm. Notwithstanding that, much has been made of the complete, permanent loss of paper chart patient medical records throughout the Katrina impact area, in contrast to those of VA patients, who were on the VA Vista EHR system.

More on Augmented shortly. See my 2015 post "AI vs IA: At the cutting edge of IT R&D."

See also my post on Kevin Kelly's work (cited by Brett King et al) "Anything that CAN be tracked WILL be tracked." Inevitable Tech Forces That Will Shape Our Future."
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UPDATE

Interesting: quick, inexpensive, illuminating read on "medical ethics."

"Issues in medical ethics are rarely out of the media and it is an area of ethics that has particular interest for the general public as well as the medical practitioner. This short and accessible introduction provides an invaluable tool with which to think about the ethical values that lie at the heart of medicine. Tony Hope deals with the thorny moral questions such as euthanasia and the morality of killing, and also explores political questions such as: how should health care resources be distributed fairly? Each chapter in this book considers a different issue: genetics, modern reproductive technologies, resource allocation, mental health, medical research, and discusses controversial questions..."

Stay tuned. Will update you once I've finished it. Very good thus far.
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More to come...