Good morning, thank you for joining us for this special webinar, Public Health Ethics During a Pandemic, What the Orthopedic Surgeon Needs to Know. Today's webinar will be moderated by Dr. Casey Humberd, Associate Professor of Orthopedic Surgery and Associate Faculty at John Hopkins Behrman Institute of Bioethics. Joining Dr. Humberd today is Ruth Baden, PhD, MPH, Professor of Biomedical Ethics at John Hopkins Behrman Institute of Bioethics, Jeffrey Kahn, PhD, MPH, Professor of Bioethics and Health Policy at John Hopkins Behrman Institute of Bioethics, Travis Reeder, PhD, Assistant Director of Education Initiatives and Research Scholar at John Hopkins Behrman Institute of Bioethics, Cynda Rushton, PhD, MSN, RNR, Professor of Clinical Ethics at John Hopkins Behrman Institute of Bioethics, and Dr. Matthew Weiner, MD, MPH, Director of the Center of Bioethics and Humanities, University of Colorado. Before we get started, I just want to run through a few housekeeping items. Make sure your speakers are turned on and that the volume is turned up. If you have technical problems, please reference the Help tab. Your best bet is typically to close all of your browsers and log back in the same way you did the first time, especially if you experience buffering issues, logging in and logging out typically helps. Registered physician attendees may earn one hour of AMA PRA Category 1 CME credit by completing an evaluation and CME claim form at the end of the webinar. Information for claiming CME will be provided as an email to all attendees post-webinar. We are recording this webinar and it will be available tomorrow on the Physicians Resource Center at www.aofas.org slash PRC. The recording will be available for free for AOFAS members and non-members. You are encouraged to ask questions during the presentations, which the faculty will address at the end of the presentation. To send your message, click on the question mark icon on the bottom right of your navigation column. At this point, I'll turn the program over to the moderator, Dr. Humberg, to begin. Thank you all for joining us during this challenging time. We are so excited to be able to share a discussion with you about public health ethics during a pandemic, what the orthopedic surgeon needs to know. But first off, I must express my appreciation to the American Orthopedic Foot and Ankle Society for their support of this project. It shows true leadership and I am forever grateful. This is a list of the faculty. These are the disclosures. Dr. Humberg, your screen isn't changing. So, looks to be working now. Perfect. Yep, it's better now. Here are the list of the faculty and here are the disclosures. So to start an introduction, I thought I would give my personal timeline of the COVID-19 crisis. On March 10th, we all found out that the Academy was canceled. And then on Friday the 13th, I did my last two elective cases, both of whom had severe Charcot deformities, but I would still classify as elective because we could have kept them non-weight bearing. On Sunday evening, on March 15th, beware the Ides of March, we had a conference call with my department about the emergency and the leadership decided that we would be canceling elective surgery beginning March 18th at my hospital. The next day, I managed to convince the American Orthopedic Foot and Ankle Society to host this webinar. And then on April 1st, this coming Wednesday, I begin my two week rotation on service as our department has decided to rotate faculty two weeks on, two weeks off to try and ensure that some faculty are always available to care for our patients. Clearly this raises so many ethical dilemmas, having a national crisis. What do I do with my patients who are angry about their canceled surgery, even though I feel it's the right thing to do? What is the role of the orthopedic surgeon in a pandemic? What do we do with personal protective equipment shortages in an operating environment where we're used to having saws, drills, and mallets with clear spread of blood and other body products? And should I even let my residents scrub in? I have a fairly limited set of intensive care medicine skills, but I have a desire to do something, anything to help out while also having a desire to not get sick or worse, make my family sick. I went to the Academy website, which has a resource center, but unfortunately it doesn't have much in terms of recommendations on ethical guidance. It does recommend following the American College of Surgeons guidance on suspending elective surgery. And it has quite a bit of information on how to do telemedicine. Therefore the goals of this webinar are trying to fill this hole in knowledge, try and discuss with world experts how a pandemic situation creates moral distress for healthcare practitioners, as well as giving a broad overview of public health ethics versus patient-centered ethics and discussing professional ethical obligations during a pandemic. Once we've had a didactic portion of this talk, we will then move into a group discussion on ways to move forward. With that, I hand it off to Dr. Rushton. Good morning, everyone. I wanna thank Casey for bringing us all together to talk about a topic that for many of us is been sort of a theoretical possibility and now is a reality. I think for many of us and our colleagues across the country, what people are beginning to experience is both psychological distress and moral distress. What we hear from people on the front lines is the very real gap that people are experiencing that sense of distress that comes from knowing what you ought to be doing and what you're actually doing under conditions of constraint or duress. So we are not used to having constraints on our resources in the way that we are currently confronted with. And that leaves us feeling as if we're not actually fulfilling our mandate and our ethical obligations to our patients and their families. What's distinctive about moral distress is that it arises often when we feel like there really aren't any good moral options or it's impossible to actually do the right thing. And I think this is a place where I know in my own career, I've spent a lot of time thinking about this topic, but the consequence of these kinds of situations are really a profound sense of threat or violation of our personal and our professional integrity. And often along with it, a substantial amount of moral residue, the kinds of unmet obligations that come along with not being able to meet the needs of the people we're called to serve and yet having to make decisions in circumstances where we have to make really hard choices. This concept of moral distress is one that has been in the literature for about three decades. It's a concept that was first identified by philosopher Andy Jameton. It's been studied primarily in nursing initially, but now what we know is that all members of the healthcare team experience moral distress. I think the situation that we're currently facing is a situation where moral distress is widespread and expected as we try to recalibrate in this current environment, how we make sense of our primary commitments as clinicians to the wellbeing of our patients. And at the same time being called to consider the wellbeing of the entire population. This is a new and often uncharted territory for all of us. And as a result of that, it requires new ways of thinking, resetting our expectations of ourselves and others, and also beginning to think about how we can find a place of integrity in the midst of the chaos, in the midst of the confusion and uncertainty. I'm gonna turn it over to Dr. Ruth Faden now to help flesh out a little bit more the distinction between what we're used to in our work, focusing on clinical ethics or patient-centered ethics, and now being called to really put that in the context of public health ethics. Ruth? Are other people hearing Ruth? I'm not hearing her. No. Ruth, we can't hear you. Can you hear me now, guys? There you go. Yes, now. Sorry about that. All right, I've been having a little audio problem all the way through, so I apologize to all of you on the webinar. I want to thank Cinda for the segue here, which was perfect, and especially a big shout out to Casey for her leadership in putting this together so quickly and giving us a chance to talk with you. The context that we are in now, the very difficult and indeed often tragic context in which we are in, is calling on clinicians to change to some extent how they understand their ethical obligations. In changing how to think about our ethical obligations, there is a hope that at least some of the moral distress that Cinda has described will be at least manageable, if not diminished. If moral distress finds its source in feeling like it's impossible to do the right thing, maybe it's helpful to think about what the right thing is changes in the context of a public health crisis. To oversimplify a bit, this chart draws out or teases out the main distinguishing characteristics of two ways of thinking about ethics in the context of health and health care. The first, and the one that is most familiar to all clinicians, is clinical or medical ethics. And there, there is one overriding injunction, which is to advance the health of each individual patient one at a time. Do what you can to make the patient in front of you as healthy and as functional and as comfortable as possible. So the focus is, as everyone on this webinar knows, to organize your thinking and to make your decisions around what is in the best interest of each patient. And obviously embedded in that is to minimize harm to that patient to the extent possible. The frame of public health ethics is quite different. Its organizing principle is not to advance the health of each patient one at a time, but rather to advance the health of the population, of the public. So it is a very different moral mission at the core of its foundation. The primary obligation of public health ethics is to advance the health of the public in ways that are efficient and also equitable or just. So public health ethics is all about the just allocation of resources with two primary and in many cases integrated, hopefully always integrated, sub-principles. The first is to try to wring out of whatever resources are available as much health as possible. That's the efficiency aim. But that efficiency aim has to be tempered with considerations of equity, fairness between groups of people, and fairness that recognizes that not everybody comes into an emergency context like a pandemic, similarly situated. To give an example of how the equity context would function, or the equity consideration would function, if you think about the allocation of ventilators, for example, in the context of the current crisis. To the extent that comorbidities become an important feature in determining prognosis. The justice question challenges to ask how we deal with the recognition that comorbidities do not distribute in the population equally, and that people who are disadvantaged in many respects disproportionately come into the COVID-19 situation with comorbidities. So far I've just given the sort of snapshot distinctions between medical ethics and public health ethics. In fact, as everyone on the webinar I'm sure appreciates, it is not always the case, even under regular order, that physicians and nurses can only think about what is in the best interest of the particular patient. And it is not always the case in public health ethics that the interest of individual patients are not taken into account. But what happens in the context of a public health emergency of the sort that we're in, is that the public health ethics frame becomes the dominant frame. It is not the exclusive frame. There are still many context situations in the context of a pandemic, when traditional or dominant medical ethics concerns still appear. If I could get the next slide, please. Elective surgery is one such example. And another, which Dr. Kahn will speak to in a minute, is the blood supply. In the context of elective surgery, we have all now heard the call to reduce, if not eliminate, elective surgery. And Dr. Humbert made the point that at Hopkins on the 18th of March, the I's of March, elective surgery was canceled. We do have guidance that's offered by the American College of Surgeons. And there's a complicated table that tries to identify which kinds of surgeries would be ethically permissible, under what sorts of conditions in the context of the pandemic. This has been provided by the University of Pennsylvania. I didn't put it up here because it's just too complicated to see. But it is simply not easy, in all cases, to determine when a surgery is elective, what elective means, when it's essential, or when it's an emergency. I wish I could blow up, but I can't, the very last line of the news article to the right. But what it says is, examples include knee replacements or nose jobs. There's something profoundly disturbing about that presuming moral equivalence. But both are presented in this news piece as illustrations of elective surgery. But we know that there are many difficult decisions that will need to be made in the context of elective surgery. And I want to leave you with, in the context of the ban on elective surgeries, that I want to leave you with a case to think about, which actually comes from Dr. Humberg, that hopefully we can return to in conversation. And this would be, and the case involves, a massive rotator cuff injury in a manual laborer. If the surgery is done now, this person has an excellent chance of being able to return to work in the future. However, in a few months, the tendons will likely have retracted and it will no longer be repairable, with arthritis nearly certain to result in the need for a particular type of shoulder replacement that would prevent future manual labor. How are we supposed to think about this case? Is this elective surgery? The concerns about elective surgery are pretty straightforward. We have to be very careful now to conserve essential equipment, equipment that is critical for the management of COVID patients, COVID-19 patients and the protection of health care workers who are providing that care. These include ICU beds, personal protective equipment, terminal cleaning supplies and ventilators. How do we weigh that public health concern with this particular patient's prospects and what that patient will lose if the patient does not get his surgery? With that, I'll turn to the next example. Dr. Khan. Thanks, Dr. Faden, and thanks, Professors Rushton and Humbert and Faden for so far, the comments on the webinar, and thanks, Professor Humbert, for organizing us today. I'm going to talk briefly about a particular concrete example of the kind of challenge that Professor Faden just articulated, which I think brings into some relief the challenges of public health ethics thinking versus patient-centered thinking in the context of this particular pandemic, and that's related to the blood supply. As this slide indicates, there is some background here, and I'll go through this relatively quickly. This quoted information comes from a directive that came from the American Red Cross now about a week ago where they said at that time they were experiencing a severe shortage. As you see here, estimates of 6,000 donor drives having already been canceled, reducing the blood supply substantially, and supplemental blood suppliers, those that help add to the Red Cross's collection, experiencing similar disruptions. So they were messaging, as it says here, and these are just quoted directly from the email that went out nationally. So let clinical staff know about this strain on the supply. Set goal to reduce utilization by at least 25%, and that number has even moved to higher levels of restriction, as I'll talk about in a second. Implementing targets to reuse blood to the extent possible and minimize transfusions, as it says here, for those where you can do so. So hospitals are acting in ways that are in concert with these recommendations, and you already heard from Casey and Ruth just now talking about cancellation of elective surgeries, and that's been, I think, fairly consistent across the board. In addition, high utilization blood kinds of therapies are being canceled or postponed, most notably stem cell transplants, which can be very high use over time. Thinking about blood now is among the critical supplies that need to be assessed, and setting up a process by which supply is assessed frequently and thresholds established from when limits of use would be triggered. Next slide, please. So just to drill down a little bit about some of the special challenges related to blood during this and presumably other pandemics as well. So just to remind everybody, it probably goes without saying, blood is in particular because it's perishable, so that means it needs to be replenished in an ongoing way by altruistic donors, and at the moment we're telling all those altruistic donors to stay at home. That's having the sort of obvious but maybe somewhat unexpected consequences had not been planned for in the way that other kinds of shortages had. Unlike other kinds of strains on the system, say when there's been a natural disaster or a mass tragedy, where blood can be moved around to where it's most needed, this is a shortage that is rolling across the country, so that's putting added strain on the system. Unlike in other kinds of shortage situations, and there have been, of course, lots of reports and lots of discussion about how to manage triage for things like ventilators and ICU beds, blood is variable in its usage, so ventilators, of course, are one-to-one, one per patient, or maybe we can split them into two patients to one ventilator. Blood has a much more variable kind of usage, and in particular, the things that are causing the most strain to the system are the cases that invoke what are called massive transfusion protocols, and I'm sure you all know this, but let me just say out loud the three big users that invoke massive transfusion protocol are trauma, mostly gunshot wounds, transplant, mostly liver transplant, and postpartum hemorrhage, and those can use sometimes literally hundreds of units for a single case over a very short period of time. Next slide, please. So that raises particular ethics challenges, and so I want to just sort of be really specific here. So unlike the challenge related to ventilators where the question is really how to decide which patients get the ventilator to potentially save their life, and that's a choice between individual patients. It's a one-to-one kind of choice. This is a different kind of allocation problem where the choice is really between allocating most or sometimes even all during a certain period of time of the supply of a life-saving resource, blood in this case, to a very few or even a single patient versus allocating less of that thing, less blood across many patients in a way that's kind of obviously utilitarian, and as it says here, it's a real-life version of the so-called trolley problem, which I'm sure you all remember from your Introduction to Moral Philosophy courses or if you watch The Good Place, that's a prominent storyline in one of the episodes. So the question is how to allocate when you only have so much of a thing and the choice is really not which of the two patients in front of you should get the one thing but rather should you use all of it on a few patients or spread it out across many more. The answer seems to be sort of obvious, but, of course, that will have burdens, consequences, in terms of the restrictions, how they will fall, and will the burdens be equitably shared, as it says here, and I'll say more about that in a second. Next slide, please. So what to do. So there's a little bit of good news in that, of course, when there's reduced supply, there's a way to go at it besides just reducing demand, and that is to put out the word for donation, and you may have seen there have been calls for donors to come out, setting up mechanisms by which that could happen in ways that were safe for donors, so that will help ease the supply side of the problem, at the same time reducing demand. That's happening through postponement and cancellation of elective procedures. There have been efforts to establish frameworks for triggering restrictions, which this would be sort of sub-bullets here, include things like limiting the number of units per case that invoke the massive transfusion protocols, so rather than saying we'll just keep sending blood as the OR calls for it, we will say we'll only send 10, and then we'll reassess, so we'll send fewer in the first container of the MTP cooler, and then assess over time whether to continue or to stop as a way of managing the limited supplies, and doing this, and again, this is a sort of new part of the process, creating and engaging triage teams to implement the framework when restrictions get invoked, as a way of removing the bedside practitioner from the decision about whether to continue or to stop when blood is being called for. The challenge in that, in terms of trying to prioritize sufficient supply, that is a supply that will be available for people when they need it, will have significant implications on who gets blood and who does not, so just to put maybe a finer point on it, if the restriction triggers in place are such that a massive transfusion protocol gets called because of a gunshot wound, and that case is only limited to a fewer number of units, and the patient were to die, how would we think about who was affected by those kinds of decisions versus in a typical normal case, so who are the people who would come in and need massive transfusion versus those who can be spread out over fewer units over more time, and how can we do that in a way that's equitable, so that all of the burden doesn't fall on those who are suffering trauma, and the benefit falling to those only one or two units. So those are the kinds of issues that are being faced. I don't have great answers for you, as you probably can tell, but I should have said at the outset, and I'll say now, Professor Rushton and I are part of a group here at Hopkins that includes a couple of other people who do bioethics, and then a number of clinicians who are trying to work through frameworks for this, and other kinds of scarce resource allocation. With that, I'll say thanks, and I think turn it back to Professor Humbert. Actually, it's... Or is it Cinda? Sorry, I don't remember who's next. My fault. Sorry. So I want to thank Dr. Bain and Dr. Kahn for sort of setting up this context to think about what professional ethics looks like in this context, and I think one of the questions that comes up very quickly is, what is our duty as clinicians, as orthopedic surgeons, as physicians, nurses, to actually practice in a situation where there is significant risk to our own health and well-being? And so when you look at the AMA opinion on this question and what physicians' responsibilities are in disaster situations, it's very clear, as it is for other professions such as nursing, that we have an ethical obligation to provide care in these circumstances. But then that raises the question of, what does that look like when, for example, the kinds of ways that we contribute on a daily basis are changed because of scarcity for the circumstances that you've already heard about, limiting elective surgery so that we can conserve resources for patients who are critically ill and who may need intensive care, as well as those patients who are in need of being cared for with personal protective devices? So it immediately leads to the question of, what is the balance between our own personal health and well-being and our duty to care? And I think this is a question that many clinicians struggle with, of how do we begin to answer that question? One of the caveats has often been that there's a limitation on our obligation if we personally have health risks that put us into a more vulnerable situation than the general public. And so these questions about, you know, how far does our obligation extend? One of the things that I think is important in this, too, and I'm sure as, you know, colleagues thinking about this together, clinicians tend to be pretty selfless in many instances. But one of the things we have to continually think about is the fact that we are a scarce resource in this pandemic. And, you know, self-device is really not a sustainable way of approaching our ability to provide care for the greatest number of people. And so I think these questions are ones that we really are struggling with, trying to find what is the right frame, what are the right exceptions, perhaps, that ought to be included. Are things like people with young children, should they be somehow excluded? What about pregnant women? We don't know what the impact of this virus is on the developing fetus. Do those kinds of factors put us in a different category in a legitimate and ethically justified exceptions? Another question that comes up is how to fairly allocate the risks of practice among our practitioners. So when we think about ourselves, none of us works in isolation. We all work in teams. And so one of the issues is currently in the midst of shortage. And we are hearing on a daily basis the shortages of personal protective devices, people being asked to reuse their masks in ways that they would not do under normal circumstances. There are shortages of gloves and gowns and all kinds of protective devices. And so how that influences our decisions around conservation, and I think it directly impacts the question about elective surgery, how do we decide what is most urgent? And also to consider who's at most risk in terms of transmissibility of the virus. One of the debates that's going on very actively right now is the risk of CPR. And how do we allocate our protective devices during situations of cardiopulmonary arrest? Are we obligated to, for example, resuscitate every person? And what is the risk to the healthcare providers who are engaged in that resuscitation attempt? What measures ought to be taken? And are there any limitations that we ought to put on the expectation that everyone will receive CPR in situations of cardiac arrest? The other issue around how to fairly allocate is also determined by scarcity of specialties. So one question is, if there are only limited numbers of particular kinds of specialists, should we be prioritizing their health and well-being above other types of clinicians? So in some instances, we find that maybe there's only one surgeon in a community hospital. Should we be prioritizing that individual's health and well-being above others? The reality of all of this is, as Dr. Faden pointed out at the very beginning, is that this is a very significant shift in the way in which we have seen and thought about our roles as clinicians. It's requiring us to recalibrate, to enlarge our ethical framework, not only to include individuals, but to prioritize the health of the entire population. And so that means that we are all called to be stewards of scarce resources. So how we make the distinctions between non-essential and essential care in elective and urgent and critical care, all of those boundaries are being re-evaluated. And when you look at the guidance from the American Medical Association and the Code of Ethics, calls on physicians to choose the course of action that requires fewer resources when alternative courses of action offer similar likelihood of benefit and the degree of anticipated benefit compared to the anticipated harm for the individual patient, but require different levels of resources. So I think in a time when resources are plentiful, these questions don't come up in the same magnitude. But now we're faced with situations where we really have to carefully consider, are there alternatives? What is the balance of benefit and burden for the individual patient? And what are the implications for all patients who are in need of health care at this particular time? Another way that our practice patterns are changing is the introduction and intensification of using telemedicine. How do we begin to think about, as Dr. Faden pointed out, the equity of access to clinicians such as yourselves? What is the impact of using technologies like telemedicine on our ability to accurately diagnose and treat patients? But also, how do we do that in a way that doesn't, in fundamental ways, compromise our professional standards? So those are questions I think that we have to spend time exploring very intentionally. And the last one is practicing at the edge and perhaps beyond what we believe to be our area of competence. All of us are trained in basic elements of our professions. So the question might be, as an orthopedic surgeon, I may not be able to do surgery in this context, but what are the ways in which I can still contribute to the overall health and well-being during this pandemic? So I think we're going to turn it over now to Dr. Humbert to talk about some cases. Thank you so much. And we had had a few cases submitted before the webinar in case nobody else had questions. But we will also request that anyone with ethical dilemmas or questions, that you please submit them to us and we will be answering as many as we possibly can. At this time, the presenters are going to begin sharing their webcams so you can see everybody in their home. And I'm going to present the first two cases. So the first case which was presented was that the CDC guidelines recommended 14 days of quarantine for all who were exposed to a COVID-19 positive patient. A residency program has residents working at multiple hospitals. While Hospital B stated it was unclear what a negative test means in an asymptomatic patient and they wanted everyone to stay out of work for the 14 days of quarantine. While Hospital B stated that exposed patients, I'm sorry, exposed providers with a negative test are allowed to return to work. While Hospital B stated it was unclear what a negative test means in an asymptomatic patient and they wanted everyone to stay out of work for the 14 days of quarantine. What should the residents do and what should the program director advise? I'm going to ask Matt Winia to give me his thoughts here. Sure. Can you guys hear me? Yes. Well, so this is a terrific example of a real tension that arises because ideally, one might think what ought to happen is there should be a statewide standard. Rather than having individual hospitals making up their own public health rules, right? This is the kind of a situation where it would be nice if hospitals A and B both had roughly the same kind of policy and either of these policies is defensible. Here's the problem. Either of these policies might seem more or less defensible depending on the particulars of their situation, right? So if you're looking at a hospital that is overrun with patients, there is a much stronger argument to say, look, we know you've been exposed. We don't know exactly what a negative test means, but you're asymptomatic. We think it's a relatively low risk in consideration of the potential benefit of having you at work right now because we are swamped. Whereas hospital B might have, you know, open ICU beds. They've cleared out all of their cases. They're waiting for the surge to arrive. And in fact, I saw an email this morning from the Surgeon General to a group of bioethicists asking about exactly this problem. That there are in certain communities nationwide right now specific hospitals that are swamped and nearby there are other hospitals that have people standing around waiting to, you know, what to do. And in some instances, those staff are being moved around, which, you know, makes sense. But in other instances, the hospital with staff standing around having nothing to do are reluctant to let those staff go for fear that they may become infected or for fear that the deluge may arrive to their hospital while all their staff are overworking at a different hospital. And so how to organize that, again, is an issue that is larger, ideally, than any single institution. So just as it would be nice if there were some statewide coordination about how to handle people who are exposed but who have a preliminary negative test, there also should be some state guidance on what happens when you've got one hospital that's swamped and other hospitals that are not swamped and have people waiting and literally standing around or staying at home because they don't have work to do. So I know in Colorado we're working on this. I know another number of other states, I assume, are working on how to coordinate the workforce across a region or a state or a city. Right. I don't think this is going to be the same everywhere. New York City probably needs its own plan, which may be a little different from the plan that extends across the entire state, which may be different from a plan that might extend across the region. So this is a policy question as much as it is an ethics question. And it's a very difficult one to answer from the point of view of an individual doctor or a resident. Right. Should I adhere to my institution's policy or should I say, look, I don't think this is the right policy. I'm going to go volunteer at this other place because you've got me standing around right now. And I don't think there's a perfect answer to that. But I would I think you could justify a little bit of civil disobedience if a resident said, hey, you've got me sitting at home and I'm getting phone calls from my friends and colleagues at another hospital where they're being slammed. And if the state will allow it, I'm going to go over and volunteer there. No, I think we were muted centrally, sorry. So I think you've made some interesting points, and among the things I think are really interesting to talk about are what happens to providers who are idled, to use whatever term we like, not because they have nothing to do in their hospital, but because they're in private practice and their practices are effectively shut down. Right. And what responsibility, if any, do those professionals have to come to the aid of hospitals that are being overrun? And it's an interesting challenge. I mean, Jacinda's points about practicing at the edge of your proficiencies, I think is quite relevant. But it's also, I think, an interesting question about what people feel like they are obligated or not obligated to do. And I've heard really varying reactions to that. Some people saying, I'm staying home with my kids and not doing anything, and others saying I've come out of retirement to do whatever I can to help. Yeah, I thought Casey mentioned earlier, I think, the fact that many orthopedic surgeons have some experience in intensive care medicine. And nationwide, at least, there's a lot of conversation that we're worried about not having enough ventilators, but we might be even more worried about the fact that we don't have enough people who know how to run ventilators. And especially if we start seeing a lot of illness among hospital staff, it is very possible that we start doing rapid retraining of people like surgeons who know something about ventilator management, might be a little distant since the last time they had to set vent settings, but they could be retrained pretty quickly. So we're working, and I know the AMA is thinking about this, working with the respiratory therapists to develop rapid training materials to get people to be able to manage vents. Because at our place, for example, we've figured out that maybe typically one respiratory therapist will manage five vents. We think that one RT could probably manage 10 vents. If we remove all of the other stuff that they're responsible for, including documentation, including cleaning, reset up, a bunch of stuff. So there's some very practical things that I think are happening that might allow people to move around at the edge of their capacity, but in a way that would still be better than nothing and might save lives. There was a very heartwarming story on the news yesterday about surgical residents in Los Angeles who were being retrained by ICU nurses to approximate the skills of ICU nurses. And it was very moving, right? And very impressive, but also probably very much the right thing to do. Surgical residents are not busy in most cases. There's tremendous demand for ICU nurses. There's a skillset that could be picked up reasonably quickly. Not as well as an ICU nurse that's been in practice for many years, but there's some transferability of training. And it makes tremendous good sense, practical sense, public health sense, and moral sense. I'm going to do the next question that was presented or attempt to. I might be failing. So the case number two was of blood resources, and I'm going to ask Jeff to start with this one. There is a patient with an impending pathologic fracture of the femur due to metastatic carcinoma. This was thought to be an imminent danger of fracture based upon imaging and exam. He was pancytopenic from marrow involvement, but he was predicted to have at least a 50% chance of surviving six months. This patient will likely require numerous units of blood products postoperatively due to his pancytopenia. Is it appropriate to potentially utilize precious blood products for an urgent but palliative procedure? So this is exactly the kind of case that the sort of general example I was painting might be faced. So maybe I'll ask Cynda to chime in too. I think we've learned a lot in the last 10 days, I mean, it's kind of been a breaking from the fire hose about how to best manage these sorts of rolling scarcity situations. And so, you know, one answer is what's the blood supply look like in the hospital on this day, which will make a big difference in how you answer the question. I think the thing that has made us feel like we're most prepared is to set a framework for what triggers decisions about triage, and then having an appropriate team in place to make that judgment and to advise over the course of care about what to do with a particular patient in a particular case. So it's going to sound like waffling, but I think the answer for this particular case is going to be, it depends a lot on what's going on at the time in the hospital when a case like this shows up. And maybe it will be something that go ahead and go forward with a very aggressive limitation on the management of use of blood products, but don't say you can't go forward. But in other circumstances, if the supply is extremely low, then you might say, wait. And so that's going to be one of the challenges that will be faced that isn't about COVID infection per se, but as a consequence of the pandemic and what it's doing to other kinds of life-saving, but increasingly scarce resources as a result. And maybe, Cindy, you can opine. Yeah, I think this is a very interesting case in part because it involves a patient who is, when you look at the subjective data, the long-term survival is limited. And so as Jeff pointed out, when we're in a condition of extreme scarcity, these are the kinds of considerations that will need to be taken into account. And it's really hard for us to think about how do we shift from the do-everything mindset that we often have to being able to confront the reality that there are some patients for whom the investment of scarce resources like blood will not actually provide long-term benefit. And so one of the other questions is, how do we begin to think about integrating things like palliative care into our framework, along with disclosure to the public about the limitations of what we're actually able to do? And I think that's a hard sort of intersection to start with. How do we inform the public that their expectations of what has been available in the past in terms of treatment is severely changed in this environment and expectations cannot be met in the same way? At the same time, I think we can't abandon our patients. And so to be able to disclose to them, we're not abandoning you, but we are going to provide palliative care and to treat your symptoms and to care for you at the end of your life in the same way that perhaps this procedure might offer some benefit in the larger scheme. It may not be the highest priority. And I think as Dr. Kahn has indicated, a lot of it does depend upon what resources are in front of us. But these are the kinds of hard choices that I think are on the horizon for all of us. Can I jump in as well? There are two things. So I agree with all that Jeff and Cinda have said, and in particular, the idea that what you decide or the right thing to do here is going to depend on the circumstances, right? So the same clinical scenario may have a very different right or wrong answer if you've got an adequate blood supply or if you're coming into shortage. So the thing I want to note is, number one, what counts as coming into shortage and who decides that? And this is a conversation that a lot of people are having right now is what would be our trigger for saying we are now entering a crisis standard of care operating protocol. And when you enter a crisis standard of care operating protocol, one of the implications of that is that the clinical, the person at the bedside is no longer the one who gets to make these decisions. And let me not phrase it that way. The person at the bedside should not be burdened with making these decisions. It forces, it would force us as bedside clinicians to choose between our patients. It would force us to take on a different role where we're no longer able to fully advocate for the patient in front of us. It would be so difficult and inhumane, really, to ask a bedside clinician to make these kind of decisions on an ad hoc basis that I think there is very wide agreement that once the trigger is pulled and you know that you are having to ration a scarce resource, be that blood or be it ventilators or ICU staff or ICU beds, whatever the resource may be, when you're in a rationing environment, you need to have a triage team. And that triage team makes these decisions. And they try to make these decisions based on a set of data that is clinically accurate and full but not biased in terms of being blinded to the patient's race, the patient's economic status, whether it's a prisoner or whether it's the mayor. Those kinds of things can be taken off the table when you ask an independent review team to look at these kind of decisions. So when you look at the crisis standards of care protocols that states and hospitals are establishing now and implementing nationwide, there is widespread agreement that this type of decision, this is a life and death type decision. It's a very high stakes decision. And it's a decision where the obvious right thing to do is normal in normal circumstances. But the obvious right thing to do is different under abnormal circumstances. And you shouldn't require the bedside team to make that. So this is a decision, again, I'm waffling as well, like Jeff, on what the right thing to do here is, because I think that's contextual. But I'm not waffling in the sense that this needs to be made by a triage team. Can I just add, I don't think that's waffling at all, Matt, or Jeff. I think that's the way things have to proceed. And we can't answer what to do in that case in the abstract. And of course, what you lay out, Matt, in terms of how things should proceed going forward is absolutely the only way it can and be anything like humane, not only for the patients, but for the physician, the nurse, and the rest of the team. Something we haven't discussed yet, but it was sort of set up by something that Cinda said is, so what do we say to patients and their families? What should be said and who says that? And this is a very, very difficult territory. So even if the triage team makes the call, it's the clinical team that presumably will have to communicate to the patient or to the family member by phone if the family member can't be present, what is and isn't happening. And this is, in terms of what is coming out of Spain and Italy, for example, much of the discussion in their very much crisis-native care context is very reminiscent of the debates we had decades and decades ago around whether rationing should be silent or whether rationing should be explicit and what does that mean at the bedside and how do we think about it. Communication and transparency with the public about what will be determined at the statewide level or the hospital level is very important. It's very difficult to set expectations, manage them among all of us who could have a loved one or ourselves be sick. That said, it doesn't answer the question what should be said to a particular patient or family member in a particular difficult situation. Clinical ethics doesn't go away. I mean, this sort of judgment and clinical sensitivity will be needed more than ever. We and many others are developing essentially scripting to help people with the words here, recognizing that there is no perfect way to tell someone that, you know, something that under normal circumstances we would have been able to do, we are not able to do right now. And that is a terrible tragedy and everyone is experiencing it around the country. Many, many people are having these conversations. These are not normal times, right? I think that's the language that needs to be used is right up front, these are not normal times. This is a very difficult time. There are many people making very hard decisions about how to best use the limited available ICU beds, the limited available blood supply, the limited available intensive care unit resources. It's very unfortunate. But what's happening now is, you know, this disease process is going to be fatal for your parent. And I just want to add to that. We've been doing similar work in developing sort of scripts for clinicians because, you know, in the midst of something like this, fear is the prominent emotion that people are experiencing. And when fear shows up, we become much more rich in our thinking and in our ability to actually be able to come up with the words that we need in this crisis that can be delivered in a respectful, compassionate way. And so one of the other big issues is, at what point do we begin to inform the public of the limitations? Not just in the individual patient who ends up in our emergency room or in our hospital, but prior to that, to begin to reset those expectations of the public before they find themselves in our health care environments so that it's not a surprise. And thankfully, our colleague and some of us were involved in the project with Dr. Bitteson, trying to engage the public in understanding what criteria they would apply to these circumstances. And I think that context gives us some clues about the kinds of fears that the public has that we need to address as we communicate with them about the limitations. And this is really uncharted territory for us, you know, we haven't seen this before. In that project, the one message that we heard, right, above all else is be straight with the public, be honest, right? Tell us what's going on, because we'll need to understand. That plus scripts will help enormously. I just don't want to have it slip by how difficult it's still going to be, even with managed expectations, even with good scripts, and practice with the scripts. It's going to be very difficult for the clinicians to say the words in the script, at least in the first few, many times, and still very hard for people to hear it. But if we don't manage expectations, if we're not transparent about what exactly will be the plan, exactly when, how bad are the shortages, we're lost. Yeah. On the timing of when the public needs to be brought into these conversations, I would say it was about two weeks ago, maybe a month. We have started to see some coverage of this issue in the papers, and that has been the primary mechanism by which the public is now being made aware of what's going on and what is very likely to go on everywhere in the nation over the next weeks and maybe month or so as we face this initial wave of cases. That said, I also want to echo what Cinda and Ruth have said in particular about how difficult this is on the care team. It's also going to be what we know from people who have had to do military triage. Being on the triage team is a scarring experience. People do not walk away from having to make these kinds of decisions, and make no mistake, these are forced choice decisions, so whatever happens, someone is going to die. These are Sophie's choice. Like Sophie, you don't walk away from these kind of decisions unaffected and unaffected in a very deep way. I think all of our institutions should be thinking and planning for how to support the people both at the bedside who may end up in these conversations, who may end up having to implement some of the decisions of the triage team, and also for the triage team themselves. It's hard to imagine what it would feel like to do that, and yet I think many of us are going to be in that circumstance over the next few weeks. I think what you're pointing to is the amount of moral distress that this will create, and the progression of that to what the military has described as moral injury, and the erosion of a sense of one's fundamental core as a consequence of this is likely to really challenge a workforce that has already been overwhelmed with burnout, and a healthcare system that has been teetering for a good while. The real concern about what will happen to our workforce after this is a question that I think we really have to consider and think about how we will proactively address. And I think that's a perfect way to close this webinar. I know we've gone a few minutes past our allotted hour. There have been some questions submitted, and we will be addressing those and email those individuals directly, and if they are comfortable with it, we will then expand that to the conversation to everyone who registered for the webinar. Elena Frey will be immediately emailing everyone the CME claim instructions. Thank you so much for attending our webinar. Clearly a lot that we have to still keep working through. Thanks, everyone. Thanks. Thank you all.

Public Health Ethics

Pandemic

Orthopedic Surgeon

Bioethics

Ethical Dilemmas

Resource Allocation

Expertise

Patient Well-being

Standardizing Policies

Communication