# National Ethics Teleconference

# Disaster Medicine: Unique Ethical Challenges

# April 23, 2002

**INTRODUCTION**

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am a medical ethicist with
the VHA National Center for Ethics and a physician at the VA New York
Harbor Healthcare System, and I am pleased to welcome you all to
today\'s ethics hotline call. By sponsoring this series of ethics
hotline calls, the National Center for Ethics provides an opportunity
for regular education and open discussion of important VHA ethics
issues. Each call features a presentation on an interesting ethics topic
followed by an open moderated discussion of that topic. After the
discussion, we reserve the last few minutes of each call for our 'From
the Field' section, and this will be your opportunity to speak up and
let us know what is on your mind regarding ethics related topics other
than the main focus of today\'s call.

**PRESENTATION**

**Dr. Berkowitz:**

Before we start today\'s discussion on the unique ethical challenges
faced in disaster medicine, I would like to briefly review the overall
ground rules for the ethics hotline calls. We ask that when you talk you
please begin by telling us your name, location, and title, so that we
can continue to get to know each other better. We ask, as did the
operator already, that you please minimize background noise, and if you
have one, please do use the mute button on your phone unless you are
going to speak. Please do not put the call on hold as automated
recordings often come on and they are very disruptive to the call. Due
to the interactive nature of the call and the fact that at times we deal
with sensitive issues, we think it is important to make two final
points. First, it is not the specific role of the National Center for
Ethics to report policy violations. However, please remember that there
are many participants on the line. You are speaking in an open forum and
ultimately you are responsible for your own words. And lastly, please
remember that these ethics hotline calls are not an appropriate place to
discuss specific cases or confidential information, and if during this
discussion we hear people providing such information, we may interrupt
and ask them to make their comments more general. As we proceed to
today\'s discussion of disaster medicine and its unique ethical
challenges, I would like to start by thanking Dr. Linda Williams at the
Little Rock VA and her colleagues out in Arkansas for suggesting
today\'s topic and working with us to help make this call relevant to
some of the ethical dilemmas being confronted in VA facilities today.

Disasters. Sudden, calamitous, unpredictable. They may be the result of
misapplied technology or events natural or accidental. Whatever the
cause, disaster situations can overwhelm a medical system by
outstripping general capacity or forcing a sudden imbalance in demand
for certain resources. Effective healthcare disaster response must be
planned in advance, well coordinated, fair and just. At times of
disaster, healthcare organizations and its workers are confronted with
unique ethical challenges. To frame today\'s discussion of these ethical
challenges, I would like to head to uptown Manhattan and call on Dr.
Kevin Chason. Dr. Chason is the Director of Prehospital Care and
Disaster Management for the Dept of Emergency Medicine at Mt. Sinai
Medical Center. Kevin, could you take a few minutes to run us through
some of the ethical issues you\'ve considered in your work in healthcare
disaster preparedness?

**Dr. Kevin Chason:**

Thank you Dr. Berkowitz for inviting me to this discussion. I would be
happy to talk with you about some of the ethical issues in disasters
that we have confronted or thought about in our planning. In the wake of
the World Trade Center and the Pentagon catastrophes and with the
increasing tensions in the various areas of the world, we realize that
the possibilities of disaster and terrorism are more relevant now than
they have ever been. With that, we understand that we have to confront
some of these ethical issues. There are many ethical issues that
encompass all areas of disaster such as response, mitigation, and
planning, and one of the biggest issues we have had to face in the past
was the idea of funding for mitigation and planning programs.

It has always been difficult to ask a CEO or hospital system to incur
costs for events that may only be *possible*. Asking a CEO, city, state,
or federal governments for funding for an event that potentially may not
happen is countered by the argument that there is a need for a new CT
scan, a new MRI machine, pediatric oncology ward, etc. These are issues
that we have to wrestle with and look at. The risks vs. the benefits or
the potential risk that an area may face when they have to plan or
mitigate disasters. It\'s clear that disasters are increasing. Over the
last 20 years, over 3 million lives have been lost, and disasters have
affected over 800 million people. We are talking about costs of 50
billion dollars to mitigate and recover from these disasters. So you can
make the argument that an ounce of prevention may be worth a pound of
cure.

The other issues that we talked about in planning and in mitigation, is
the cost of mitigation for equipment and supplies, the complexity of the
multi-organizational preparedness. It\'s not just a hospital that is
preparing. You have to prepare a system. So the cost can become huge.
And now you are seeing large amounts of government funding being
dedicated to this issue. The cost of disasters is one ethical issue that
we need to look at. The idea of response is another issue that we have
to look at. Rescuers that respond to the scene are putting themselves in
harms way. This is always the case of EMS workers, police, fire
departments, but now they are responding to areas where there may be
bomb threats or potential health threats that they may not feel prepared
for or they may feel that are not worth the risk. They have to come to
grips with this; they are employed to do this job and are they going to
go into a situation where they have to get involved in a potentially
unknown event?

Physicians and healthcare workers may have these same issues. When you
had plague and other infectious diseases in earlier times when we had no
antibiotics, there was a choice whether you were going to treat or not.
And physicians are now wrestling with this question again. Rescuers are
going to possibly be exposed to things like biological agents, chemical
agents, possibly nuclear agents and they may have to ask the question of
themselves, are they committed to their response? So it is important
that we educate rescue workers and health care professionals on what the
potential risks are, what the response should be and what their role is
in a disaster. This may avoid the doubt or misunderstanding or confusion
that can be involved in response and cause people to act in an
unpredictable fashion.

The response to a disaster is not the typical day-to-day work that you
do in your health care facility and what you trained to do in the past.
It is different in the VA. You understand the military organization, but
volunteers and people who work in other institutions not affiliated with
government or military response are not used to working in a
paramilitary type structure, and do not understand the idea of a
commander and a structured system where you have to report to others who
are above you, and you have a role and you may be a health care worker
who feels that your role is more important than someone else\'s role,
and you are only a small part of the response. So you have to work
within that structure.

We also looked at the idea of triage in disaster response situations. In
every-day medical emergencies, we try and do what we were trained to do,
and that is, use every resource available to us to take care of a single
patient. In a disaster there is a huge paradigm shift. Triage has
changed so that you try and do the greatest good for the greatest number
of people. That is not what we are used to doing, and it is definitely
something that people are not comfortable doing\--saying that this
person is going to die so that we can use resources to help people who
are more salvageable. This would be a difficult decision for anybody to
have to make. And then there are other possibilities in triage. Do we
use a first come, first served system where the first person to my door
I treat? Do we evaluate societal worth? Am I going to save a teacher? Am
I going to save a scientist? Am I going to save a physician versus
saving someone who is a laborer or someone who is unemployed or someone
who is physically challenged? I am not saying that we should do these
things, but these are proposals that people have thought of. How do we
weigh the distribution of resources?

We have also struggled with patient autonomy and privacy during disaster
responses. Departments of Health in cities and states have been doing
surveillance and have talked about reporting various diseases. Does that
now make it an infringement on someone\'s privacy when we start
reporting that people were exposed to anthrax or exposed to other
chemical agents? Are we infringing on their right and their autonomy? In
addition to that, you have agencies like media, CNN, who want to
disseminate all this information and now information like that may pose
national security issues. It may increase panic. It may increase fear
amongst the public. Where do we draw the line on what information we are
going to provide the public? Should we use a "need to know basis"? Is it
on the physician to try to allow them as much information as can be
provided? Who is going to make the decision about what information
healthcare systems disseminate to the public? These issues are also
things that we are struggling with.

And then when you get into acts of war and marshal law\--you are looking
at crime scene and national security and the issue of privacy may not be
pertinent at all. But in the World Trade Center disaster, there were
papers strewn across miles about a foot high. And these were wills and
financial documents and bank statements and these things need to be
controlled for individuals\' privacy, and plans need to be in place to
make sure that things like documents and patients\' medical conditions
are taken care of and their privacy is protected. But you have to weigh
that with the national security and the ability to mitigate and to
recover from your disasters. So there are a lot of issues that we have
been struggling with.

When we discussed some of the issues after our response to 9-11, many of
our employees struggled with the idea that they have families and they
have a responsibility to the institution, and they were conflicted with
the idea that there were children at school they had to pick, they had
loved ones downtown that they needed to make sure were okay. They were
responsible for duties in the hospital, to serve the public, but they
also had duties to their families. How do you prepare and how do you
allow staff the ability to make sure that their family members or loved
ones are okay when you are trying to recover or to mitigate or implement
your disaster plans and respond? These are issues that we are trying now
to put into our plan where we have systems to contact schools or other
people to get school children, bring them back to our facility and have
a place for them to be watched, and possibly make places for workers and
their significant others to come in and stay with them. If staff cannot
ensure that their loved ones are safe, they may not want to come to
work, so we have to make provisions for possibly housing families of our
workers.

So these are things that we are thinking about, and I think we should
all be thinking about when we develop our disaster plans and our
response plan. If you have been involved in a disaster response, when
you do your critique, you need to ask some of these questions about how
people felt about not knowing what was going on with people threatening
their family, their friends, and what they felt their responsibilities
were and how important they were to the response of the institution. So
I think education becomes a huge part where people have to understand
what their role is in the disaster plan, and how the institution views
them as important or essential to the response. These are just some of
the issues that we have looked at and struggled with and have tried to
incorporate into our plan. We now have to motivate and prepare our staff
and train them to respond and understand these issues.

**Dr. Berkowitz:**

Thank you very much Dr. Chason. You have touched on several broad areas
of ethical concern: resource allocation, triage questions, professional
responsibilities vs. duty to one\'s family or community, and safety of
those involved in disaster response. Other things such as loss of
personal liberty, compromises in rights to privacy and confidentiality
or patient autonomy are some of the big issues that we are all coming to
grips with. To continue, I would like to head south to Dr. Kristi
Koenig. Dr. Koenig is the Chief Consultant for VA\'s Emergency
Management Strategic Healthcare Group. She is field stationed in
Martinsburg, West Virginia, and I believe today she is calling from a
meeting of the National Disaster Medical System (NDMS) in Atlanta,
Georgia. Dr. Koenig, please tell us a little bit about how VA is facing
some of the ethical challenges in disaster medicine.

**Dr. Kristi Koenig:**

I\'ve just finished the NDMS meeting. We had close to 2,000
participants, so it was a very successful meeting for us. I am going to
speak quickly so that we can hopefully allow some time for questions. I
would like to just augment a couple of the items that Dr. Chason so
eloquently described, and then I will tell you a little bit about what
we doing within the VA system to address some of these issues.

I think one of the most important things we talked about was the idea of
triage. For those of you who are health care providers, think about
somebody coming in to your facility in cardiac arrest. What you would
normally do is throw all your resources into that individual, start
performing CPR and resuscitation. The teaching in disaster medicine
takes much more of a public health perspective; as Kevin said, do the
most good for the greatest population of people. Therefore, we would
advise that you not do CPR if you have an overwhelming number of
causalities. So it is a completely different mindset than you would have
during normal operations. I have found that when we do our training
courses, it is very, very difficult for people who have gone into
medicine, who have a certain ethic of trying to help somebody who is in
the most extreme condition, to shift gears to help the greatest number
of people. So I did want to mention that.

One other thing that we looked at in terms of special triage categories,
Kevin said that perhaps you would treat a physician before others. You
might want to consider if that physician, once treated (perhaps they
have an arm fracture and you can splint that fracture), can then become
part of the response team. So here again, do the greatest good for the
greatest amount of people. That may be a reason where\--not simply
because a person is a physician, but because that person could assist
with the response\--you might want to triage them a little bit
differently than you would do a citizen who is not able to assist with
caring for other patients.

The other thing I wanted to augment was the idea of individual rights
versus public health type of issues. Again, we have national security
issues coming into some of these types of events, particularly if we are
talking about weapons of mass destruction. The idea of the use of the
military and how they might or might not assist, and that is a very
large issue when we talk about civilian causalities and the use of the
military in some type of homeland security situation.

Moving on to some of the initiatives that VA has taken. We have
definitely been struggling with the issue of limited resources and
looking at how we can protect our own veteran patients and staff from
any type of weapons of mass destruction attack. We have put together
something called a Technical Advisory Committee through my office, the
Emergency Management Strategic Healthcare Group. You can read more about
it on our Web site (http://www.va.gov/emshg/), but essentially we have
divided into a number of task forces and we are looking at issues such
as personal protected equipment, surveillance, quarantine, a number of
different issues. And many of these do go over to some ethical questions
about what we should be providing in order to protect people with the
limited resources that we have. I think, also along those lines, that
our primary mission is to serve veterans. If we get one of these
scenarios (disaster, weapons of mass destruction), we know that
everything starts at the local level, the doctors are local, and we will
very likely (as the literature has shown over and over again) have
people coming to our hospital. They do not care that we are a VA
Hospital or VA Clinic. They see that it is a place they can go for help.
They may not be eligible for care, and we should be providing that care
under our humanitarian act but you can get into some concerns about what
you can and cannot do.

Another issue related to that would be taking care of staff families,
also in terms of treatment. For example, if we had a large biological
terrorist attack, would we be able to dispense prophylactic antibiotics
to the families of staff members, which again might make those staff
members more likely to come in and care for patients? But there are a
lot of issues such as medical record documentation, allergies, etc. We
do, in the VA system, have a new initiative where we are putting out
pharmaceutical caches to the most high-risk VA facilities. There are
about 200 facilities that are targeted to receive these. It is in the
early stages of implementation, but the idea would be to first and
foremost protect our own patients and staff, and assist in the community
as possible, at the local level before any outside help might get in.

Another item I wanted to mention in terms of the education and training,
which is very, very important, is something we have called the Emergency
Management Academy. You may have seen some of the satellite broadcasts
that we have put out through the Academy, and we are also developing a
Web-based standardized training. I have more to say, but I think I will
stop there just so that we could have more of an interactive discussion.

**MODERATED DISCUSSION**

**Dr. Berkowitz:**

Thank you very much Dr. Koenig. And that does still leave us a good 15
minutes for open discussion of today\'s topic. We know there are sure to
be many questions on your mind, so please stick to the ethics of
disaster medicine. Feel free to introduce yourself and let us know what
you\'re thinking.

**Suzanne Ward, Reno, NV VAMC:**

You were talking about allocating the resources for the veterans and the
staff of our facilities; is that really the best use of some of these
resources at the time of a national disaster? To put all of these
resources into a 70- or 80-year-old population rather than in a
community that has 20-, 30- or 40-year-olds?

**Dr. Koenig:**

I think that is a good ethical question. But I would focus on our
primary mission of caring for veterans, but also one of the VHA
strategic goals is building healthy communities. So the important idea
is to think through the scenarios ahead of time, and plan within your
own communities. And I think again, our primary role is to the veterans,
no matter what age they happen to be. If we have additional resources
after we meet that mission then we would definitely want to share those
with the community. We are not talking about going out and responding.
We are talking about patients coming to our facilities. So I would not
expect necessarily that you would have large numbers of, I mean you may
have large numbers of non-veterans, but it is not where you are going to
have to go out and sort out who is who. You are going to have to figure
out how to care for people who are coming to you. We do have one team
called the Medical Emergency Radiological Response Team that is
available to go out and respond. But what I am talking about is in your
own community, having a plan for triage if you have casualties coming to
your door before any outside help can get there.

**Dr. Chason:**

Along the lines of your question, in your disaster planning I think you
should address the idea of mutual aid, and that is when your facility is
overwhelmed or another facility is overwhelmed, what kind of contingency
plan do you have? Are you going to assist another facility if you have
the means to do so? Are you going to allow patients to be transported to
your facility? Are you going to allow supplies to be transported to and
from your facility? You need to ask these questions now of yourself, and
of your institution, and the other organizations in your community, so
that in times of disaster you have agreements in place that are capable
of answering these questions. Otherwise you will have to go through the
huge ethical, political, and legal problems that you may have to
encounter trying to figure out what goes where and when during the
disaster response. So thinking about this now, discussing it with other
institutions now, is what you should be doing.

**Dr. Koenig:**

Let me just caution. I would advise *against* making a triage protocol
that is based strictly on age. It could be based on expected outcome
where you have an 80-year-old patient with multiple medical problems and
two 20-yearold patients with no medical problems and enough resources to
treat two of the three. But if you had a healthy 80-year-old and a very
sick patient with underlying medical problems who was 20, then you might
actually reverse that decision. So I think you really need to
concentrate on how you can do the most good for the most number of
people, and not focus on age. For example, we have some good data from
heart attack (MI) patients that elderly people may do better with
thrombolytic agents (clot busting agents) because you have a greater
chance of making an impact. So I figure it is a little bit of a slippery
slope to think about this strictly in terms of age.

**Dr. Berkowitz:**

I think that is a great point, Dr. Koenig.

**Dr. Michael Cantor, National Center for Ethics:**

I have a question for Dr. Koenig. I think I have a different
understanding of what happens when there is a big disaster like in New
York or when there is a hurricane in Miami or flood in Houston or
earthquake in California. The role of the VA in that circumstance is not
just to care for veterans who come in, but isn\'t there usually a plan
where VA coordinates with other local, federal and state agencies so
that there is a larger response? Then as the event unfolds over time and
less acute services are needed there is a sort of reconsideration of the
role of the VA. Isn\'t that usually how it works?

**Dr. Koenig:**

Yes. I didn\'t talk too much about that because I didn\'t think it had
that much to do with the ethical considerations. But just to be brief,
we have essentially two roles. We have our role in the local level,
which I\'ve talked about including humanitarian assistance and building
healthy communities and participating within the community plan. But we
also have a national role where we support the federal response to the
disasters by supplying personnel. If you are interested in that you will
want to look at a program called DEMPS (Disaster Emergency Medical
Personnel System). You can also find that on our Web site, and through
supplying pharmaceuticals. In fact, since every major presidentially
declared disaster occurred since 1992, when the Federal Response Plan
first came into place, VA has been requested and has provided assistance
through the federal level deploying over 1,000 people, for example.

**Dr. Cantor:**

In terms of the ethical issues about rationing of care and access to
care, really it is within a much larger context. It is not just VA, but
there is a regional or local plan or a national plan, depending on the
program, and so those sorts of decisions are worked out not just within
the context of our own agency, but in the context of many other agencies
and organizations.

**Dr. Koenig:**

That is correct. And in terms of federal assistance, it is not required,
it is requested; we only provide it if it does not degrade our ability
to care for veterans.

**Dr. Cantor:**

And that primary mission of caring for veterans doesn\'t go away just
because there is a disaster. That still remains our primary focus,
unless we are overwhelmed or other circumstances. Correct?

**Dr. Koenig:**

That is correct. That always remains as our primary focus.

**Dr. Cantor:**

Then that in a way sets the standards, or the terms of what the
underlying values are for our mission. That is clearly set, and it
establishes for the VA sort of the order in which we might triage people
or might respond to disasters.

**Dr. Koenig**:

That is an excellent point, but I do think if you are dealing with a
life and death situation, if you have a veteran with a more minor
problems and a non-eligible person in extremis, and you have the
resources, that you would still triage the non-veteran in an emergency
situation to receive the acutely required medical care.

**Dr. Cantor:**

Thank you

**Dr. William Nelson, National Center for Ethics:**

This question is for both of you because you did a very nice job of
listing and delineating many of the ethical issues in establishing
either a facility plan or more of an agency-wide plan. But I am
wondering in the development in your protocol or guidelines or
procedures, either at a facility level or agency level, who do you use
to help address these ethical issues and these value conflicts? Like in
a facility level, Kevin, is the ethics committee called in as a resource
to help you in some of that dialogue reflection, and at an agency level,
in other words, are there ethics experts brought in to help reflect on
some of these issues?

**Dr. Chason:**

I can speak about our institution. We actually had a lecture series on
some of the ethics of disasters and we spoke about many of these issues
and had discussions amongst our staff and our psychiatrists. I talked to
social workers and ethicists in our hospital and am trying to use some
of their input to add these ideas and issues to our plan. So you also
have to involve the people who are doing the disaster planning for your
institution as well. Then you have to decide whether you want to look
outside of the institution and incorporate other services such as EMS,
fire, police and institutions that support you in your ability to
respond and some of the issues may involve them as well. So you think
locally, you may have to act globally, and I am not trying to be trite,
but you want to protect your institution and make sure it is capable of
fulfilling its primary function. After that, you want to make sure that
if you are capable of doing that, you provide these other resources to
the rest of the community as well, perhaps incorporate these ideas into
the plan and get their input too. That would be my response.

**Dr. Koenig:**

I think that is an excellent question. I again applaud the organizers of
this conference for putting it together because I do not think there has
been enough dialogue. Personally, I have an awareness of the issues and
I will just call Dr. Ellen Fox if I have a question about things, but
probably at the local level there would be more that we could do to
engage in some of these dialogues and look at some of these issues.

**Dr. Berkowitz:**

I think that is especially relevant since we clearly are not going to
cover all the issues or answer all the questions in this brief call.
Facilities should realize that they do have local and national resources
with their own ethics committees, their own ethics leaders, VISN ethics
leaders, and certainly the National Center for Ethics to help address
issues of differences in disaster response regarding patient autonomy,
privacy, confidentiality, allocation of local resources, changes in
triages. These resources can be used especially to help practitioners or
health care workers at the local level to really think through these
issues in advance. There are resources in the VA system to turn to help
you think through these issues, and I think it is much better to think
through them in advance.

**Dr. Koenig:**

Let me just make an offer from my own office, the Emergency Management
Strategic Healthcare Group, for the ethicists on the call who are field
based. If you look at our Web site (http://www.va.gov/emshg/), there is
a listing of what we term Area Emergency Managers and you can see who
the person is closest to your area. If you have specific concerns or
questions about how we have been working on these emergency management
issues, I would invite you to contact that person.

**Dr. Williams Little Rock, AK VAMC:**

If I may respond, I want to thank you all for an excellent presentation
and thank you for putting this on so promptly after I requested further
education on this. It was said that it was a disaster when you weren\'t
prepared for it to happen that suddenly. So as I went to the literature
to try to get ready for this session, I found some materials that I had
no idea were out there, and this is what I was really looking for. I
found a book by Gerald Winslow titled *Triage and Justice: The Ethics of
Rationing Life-Saving Medical Resources*. He goes through the ethics of
the triage systems and starts back with how this began with Napoleon\'s
Chief Medical Officer. And I find this fascinating. These are the types
of resources that I was really looking for. Is there a national source
where we can have them available to us? Does such a source exist?

**Dr. Koenig:**

I am not aware of a national source. I am familiar with the system you
described in Napoleon\'s time, triage being from the French verb
\"triage\" meaning to sort. And again, in that case, in normal
conditions sorting out who we would treat first as opposed to under
disaster conditions, where we sort out who we would not treat. A very
different scenario and again running into some ethical issues of
rationing or withholding treatment. I would also point out that just for
the sake of thinking about it, that in the United States, in my opinion,
since the 1918 flu pandemic, we have not really overwhelmed our health
care resources. What I mean by that, we have had huge amounts of
property damage, at the World Trade Center, we have had huge amounts of
fatalities, but unfortunately we did not have a lot of live casualties
that we could treat. We have not really had a scenario where we have had
more patients than we could treat. Unlike some other countries where
they have had massive earthquakes, for example, with people dying from
preventable causes. So it is very difficult to get people to think about
this because it is hard to conceptualize unless you happen to be around
in 1918, because we are so rich in health care resources in this
country.

**FROM THE FIELD**

**Dr. Berkowitz:**

Thank you. Dr. Williams, if you please send me those references, I will
add them to the follow-up e-mail for this call. Unfortunately, we are
out of the time that is allocated for this part of today\'s discussion.
Please remember, we make provisions to continue our discussions in an
electronic form on our WebBoard, which can be accessed through the VA
National Center for Ethics Web site. We also put on our Web site a very
detailed summary of each ethics hotline call. So please visit our Web
site to review or continue today\'s discussion. Again, you will all be
getting a follow-up e-mail for this call including the links of the
appropriate Web sites, the call summary, the WebBoard discussion, and
some references.

One of the goals of this series of hotline calls is to facilitate
networking among ethics related VA staff and to facilitate communication
between the field and the National Center for Ethics. So we try to
reserve the last few minutes of each call for our 'From the Field'
section. This is your opportunity to speak up and let us know what is on
your mind. It\'s your chance to ask quick questions, make suggestions,
and throw out ideas. Please remember, no consults in this forum. So
'From the Field,' is there anything on your mind?

**B.J. Allgood, Prescott, AZ VAMC:**

I recently visited our outlying clinics. I think when we are dealing
with disaster planning, some of our clinics are going to be closer to
the health department than to the VA in case of a disaster. I am
wondering if this is going to be addressed because we are so many hours
away and if they needed, for instance, the pharmaceuticals, I can\'t see
the VA providing it quicker than a local health department.

**Dr. Koenig:**

Yes that is being addressed. I mentioned we looked at some of the most
high risk locations for example, for the pharmaceutical caches, and some
of those are in fact clinics. We also recently did a survey of our
current capabilities and included some of the clinics in remote areas.
Another example would be after September 11, we looked at the fact that
planes were not flying. We are using just-in-time pharmaceuticals and
supplies, and if planes continue to not fly, is that going to impact our
ability to care for veterans? We looked particularly at remote sites
such as Guam, Hawaii, Alaska, Puerto Rico and came up with solutions
such as shipping supplies to make sure that we looked out for those
clinics, which are sometimes the most intensive resource in that entire
community.

**Chaplain George Kelly, VA NJ Healthcare System, East Orange, NJ:**

Kristi, what you just mentioned, you may or may not be aware that other
than the military flying civil air patrols, aircraft were flying blood
and equipment all over the country when no one else was flying. That is
a resource that is available.

**Dr. Koenig:**

Yes, we were aware of that. Thank you for bringing up on the call.

**Dr. Berkowitz:**

One thing that hasn\'t come up is that at times, in a declared disaster,
the level of care that is provided often becomes higher than the
baseline for that community, especially if it is in a poor or indigent
or sometimes otherwise neglected area or even in an under-served
community. What are the ethical responsibilities we have when we start
to withdraw that higher level of care back from that community?

**Dr. Koenig:**

That's one of the items that you and I discussed. To give you a real
live scenario, after some of the hurricanes in Florida when the federal
level sent in what is called DMAT (Disaster Medical Assistance Teams)
which are Health & Human Services, the local population really was
getting a higher level of care than their baseline, and it became a very
difficult decision, "At what point you withdraw those resources?" The
idea is, but for the disaster, they wouldn\'t have had access to routine
tetanus immunizations, primary care types of needs, and it becomes in my
mind a big ethical issue about what to do. And this is something in real
life that we dealt with at the federal level.

**Dr. Berkowitz:**

Was there any reactions from the field on Dr. Koenig\'s suggestion that
CPR should not be offered in disaster situations or the default should
become Do Not Resuscitate?

**Dr. Williams:**

I will respond to that. I certain agree with that as long as you are
putting CPR above life saving measures for other patients there is a
problem. I think that it becomes what is necessary to save the life of
the most patients. If you have someone that is going to die, and you can
give CPR and save the life of another person who will die without it,
then I would put that as a priority.

**Dr. Chason:**

In contrast to that idea of triage, I wanted to echo what Kristi said as
well, that our resources (in the last 20 years of looking at disasters)
have not been overwhelmed. So we understand that triage needs to change,
but we\'ve not really had to practice this so in many of the disasters
that we encounter, we don\'t have the casualty numbers or the severe
casualties, we don\'t have to make these decisions. So it is an idea we
have to think about. But we have not had to do it so frequently.

**CONCLUSION**

**Dr. Berkowitz:**

Thank you Kevin. And I would like to take the last minute to thank
everyone who has worked hard on the conception, planning and
implementation of this call. It is never a trivial task and I appreciate
everyone\'s efforts, especially Drs. Chason and Koenig for their
presentations, and Dr. Williams and her colleagues for helping to
prepare for the call. The next call will be Wednesday, May 22 from
1-1:50 Eastern Time. Please look to our Web site and in your Outlook
e-mail for details and announcements. Again, I will be sending out a
follow-up e-mail for this call with all the e-mail addresses, links and
references, and the summary of the call and WebBoard discussion. If you
don\'t get that or if you know of someone who should be receiving the
announcement and the follow-ups and didn\'t, or if you have suggestions
for topics for future calls, please let us know. Our e-mail address is
vhaethics@med.va.gov or vhaethics on the Outlook system. Thank you all
and have a great day.