How The Ethics Of Triage Play Out In Haiti
NEAL CONAN, host:
The government of Haiti now reports the death toll from last month's earthquake at 230,000, and hundreds of thousands of those who survived the quake are in desperate need of medical care. Medical teams from around the world rushed in to help, but with limited resources and facilities, doctors and nurses have been forced to make life-or-death decisions for patients multiple times every day. Not everyone can be saved. Sometimes, heroic measures for one can't be justified with so many others waiting.
If you've provided medical care in disaster situations or if you've practiced triage, give us a call: 800-989-8255. Email is firstname.lastname@example.org. You can join the conversation on our Web site. That's at npr.org. Click on TALK OF THE NATION.
Dr. Michael Millin works as an emergency physician at Johns Hopkins Hospital in Baltimore, recently returned from Port-au-Prince, where he served as medical director for the New Jersey Disaster Medical Assistance Team. And he joined us by phone today from a blizzard in Baltimore. Thanks very much for being with us.
Dr. MICHAEL MILLIN (Emergency Physician, Johns Hopkins Hospital): Thank you for having me.
CONAN: And how were the decisions you had to make in Haiti different from decisions you make every day at Hopkins?
Dr. MILLIN: The decisions that we made in Haiti were very difficult decisions, but in many ways, based on very similar principles that I use in my day-to-day career in Baltimore. We use a process by which we make a decision and allocation of health care resources as to how those recourses are going to best help not just one individual, but the populace as a whole. And often, we make a decision that we categorize the patient as being expectant, meaning we expect that patient to die.
So we're more likely to give resources to someone who is likely to live. The difference that I had in Haiti is there were times I made decisions about a patient potentially being an expectant patient, even with the patient who was talking and alert. And that was something that was a new experience for me and very difficult.
CONAN: And why did you have to do that?
Dr. MILLIN: Though in particular I have one specific patient who I clinically diagnosed with end-stage tuberculosis, he was not known to himself to have tuberculosis, but he came into our medical tent with a syndrome of end-stage tuberculosis. And with a high prevalence of tuberculosis in Haiti, that's what I felt was probably going on with the patient. He needed a vital resource of oxygen, and we had limited supplies of oxygen in our tent.
And we also had a number of patients coming to the tent with potentially reversible diseases requiring oxygen, such as exacerbation of asthma from all the dust flying around. And so I had to make a decision as to would I provide that one individual the oxygen he needed to stay alive, or reserve that oxygen for other patients who may get more benefit out of it?
CONAN: And what did you tell him?
Dr. MILLIN: It was very difficult, and I actually - I do not speak for Creole, so I had a interpreter who was helping me. And so I said to both the patient and his family through interpreter that there was very little I could do for him, and that we would send him out of the tent with medications to control his pain, masks to protect his family. But ultimately, he would be sent out, likely to die.
CONAN: Oh, that's an awful thing to have to tell anybody. And I know that wasnt easy. But does it - and I know you made it for the greater good. Nevertheless, does it cause some disturbance at night sometimes?
Dr. MILLIN: The decisions we have to make as physicians often will cause us disturbance at night. And, you know, one of the things that certainly I feel benefited from - I responded to Haiti as part of the federal government, United States federal government. And when we came back home, we had very strong mental health support that is available to me whenever I need it. As it is, I - well, you know, I'm able to sleep well at night knowing that I did the best I could, and for the greatest number of people possible.
Certainly, we as physicians like to go down and save the world and every patient live, but it just doesnt work that way. The realities just arent such that we can save everyone. So we do the best we can. So does bother me that I couldnt save every patient? Absolutely. But at the same time, I feel very good about the work we were able to do.
CONAN: And doctors, being human beings, you know that as you're categorizing some patients as expected. In other words, they're expected to die and they will not get the heroic treatment that might keep them alive for a shorter - for some more greater period of time, you're going to make mistakes.
Dr. MILLIN: Absolutely, we may make mistakes. I was also fortunate in that there was an excellent support team behind me. My respond, and again as (unintelligible) government what's known as a disaster medical assistance team, and I was one of three physicians in the tent. There was actually a medical officer, a chief medical officer above me - he was a great resource - and then administrative support people above him who are a resource. And so, even though I certainly had a potential to make mistakes, there were people that I was be able to refer to to help make decisions as to what our resources were available at any moment in time so that I can make the best decisions possible.
CONAN: It's also interesting, you pointed out the patient with tuberculosis. Obviously, that is a condition that predated the earthquake. There is such a paucity of medical care there before the earthquake that you were dealing with a lot of people who had - you should excuse the expression - pre-existing conditions.
Dr. MILLIN: And that is absolutely correct. There were a number of patients we saw in our tent that were earthquake-related. And we took care of a lot of really bad wounds. I spent most of my time cleaning out wounds. But at the same time, I had a fair number of patients who had medical conditions that had not received any treatment.
There was one patient I took care of who likely had previous strokes related to uncontrolled hypertension. And he came into our medical tent with very high blood pressure and there really wasn't anything I could do for him, even though we actually do carry medications for hypertension in our tent. I felt like it wasn't really a great idea to start him on those medications because he would get them for the week that I could provide him but then after that would not get any further medical care because the health care system in Haiti is virtually nonexistent. And so, there really is no primary care, if you will, as we have in the United States.
CONAN: So in an odd way, for somebody like him, the presence of all of these physicians from outside there for the emergency, gave him a prospect but in the long run it wouldn't have helped.
Dr. MILLIN: Yeah. You know, the short time we were there, we did some fantastic stuff. We saw up to 600 patients a day in our tents. We did some great work. But the long-term care and long-term health needs of the country of Haiti is a question that is beyond my capacity, but certainly...
Dr. MILLIN: ...is a very challenging question. I don't have the answer as to how they're going to fix that problem. But there are great challenges to the long-term needs of the country.
CONAN: You and the other members of your team were there, obviously, in response to the crisis of the earthquake. Did you make any distinction between patients who came in with, for example, you know, some pre-existing conditions - the tuberculosis you mentioned - or did you say, wait a minute, we're here to treat earthquake victims. We're going to have to treat them first.
Dr. MILLIN: No. Not at all. We took care of every operation in our tent regardless of what the condition was to the best that we had the ability to do given the resources and what was going on with the tent or the patient. Now, as it turns out, we really are designed as an acute response group. We are all trained disaster health care providers that are trained and equipped for acute needs based on a disaster and aren't as well-equipped for long-term health care needs. And so we really were better equipped to deal with the wound care issues we had in the tent than the long-term medical needs. But certainly, we took care of everyone who came in to the best that we had ability to do so.
CONAN: And we'd like to hear from callers who've themselves been part of an emergency relief medical teams and had to make some of these same kinds of decisions. 800-989-8255; email email@example.com. Of course, as we mentioned, some of these same decisions get made everyday in emergency rooms. So let's go to Scott(ph). Scott calling us from Yuma, Arizona.
SCOTT (Caller): Hi.
CONAN: Go ahead, Scott.
SCOTT: I'm a retired military physician assistant. Fifteen years ago, I went with an air transportable clinic team down to Guantanamo during a refugee crisis. We had oh, I don't know - 32,000 people down there living in tents. And it was interesting for us because we were in a supply difficulty. We got down there, and when we set up - we were ready for combat casualties. I've never seen quart bottles of morphine before that experience. We had body bags.
And I - but there was no way for me to - treat a kid with an earache. I had a man with malignant hypertension and until supplies came in I had to give him an aspirin a day and tell him: If you're still alive tomorrow, come back and I'll give you another aspirin. I made a comment while I was there: We're going to get decorated. We're going to get medals for doing things here. If we did them at home, we'd be court-martialed for it.
CONAN: And what did you mean by that?
SCOTT: We were making stuff up because, like, I had a man with tinea cruris, industrial jock itch. And what I had to do for him was take a bottle of petroleum jelly and mix in foot powder and give it to him and say, come back and see me next week if you're better. And if you're worse, we'll probably see you in the emergency room. We weren't having the kind of catastrophe - catastrophic patients that they had, you know...
CONAN: Anticipated. Yeah.
SCOTT: Right. Yeah.
SCOTT: We went down equipped for combat casualties. We probably would have set up and been ready for the kind of casualties that they saw the first week - even now in Haiti. And as it was, we were seeing family practice in tents.
SCOTT: You know, you have to do the best you can with the supplies you've got and then make it up as you go.
CONAN: Dr. Millin, I wonder if Scott's experience resonates with you in any sense.
Dr. MILLIN: Well, certainly. Actually, I do agree with something the caller alludes to, and that's the requirement to be creative. One of the things that we are really trained well to do in disaster medicine is to be creative and to use the resources available to us. When I work in emergency department in Baltimore, I have virtually any technological, advanced medical - whatever you want, it's there when I need it. And that's just not the case during a disaster.
And so, we - and the caller says he made up as he went along, I would say we are creative as needed. There was another patient that I took care of in Haiti who I clinically diagnosed with what's known as PCP pneumonia, which is a complication of (unintelligible) AIDS. And the treatment for PCP pneumonia is generally thought to be Bactrim, Bactrim, Bactrim - meaning the first choice of medication is Bactrim, the second choice is Bactrim, the third choice is Bactrim.
Well, we didn't carry Bactrim in our cache. And so, I wash creative and used another medication that's sort of a fourth-line Clindamycin. So it's certainly something we often do in disaster medicine, is we make do with what we have and we're creative in our treatment modality.
CONAN: Scott, thanks very much for the call. Appreciate it.
SCOTT: Thank you. Bye-bye.
CONAN: We're talking with Dr. Michael Millin of Johns Hopkins Hospital in Baltimore about some of the difficult decisions he had to make as an emergency physician in Haiti.
You're listening to TALK OF THE NATION from NPR News.
And let's go with Stephanie(ph). Stephanie with us from San Geronimo in California.
STEPHANIE (Caller): Yes. Thank you for taking my call.
STEPHANIE: My father was a physician - triage physician in the Second World War in Leyte and Okinawa on the frontline.
CONAN: Two major invasions by the United States in the latter stages of the Pacific war. Go ahead.
STEPHANIE: Yes. And he - when I was a teen, we'd spoken often about his Second World War experiences - major effects on him, obviously. And when I was a teen, I asked him - we were talking about this, I asked him if he'd ever killed anybody in the war, expecting a no. And he said, yes, hundreds of people, because as a triage doctor, he had to choose life or death.
And I, over the years, have understood him better. He's deceased now, but I understood the pain that he carried his whole life, and which -much of which he transferred to his children...
(Soundbite of laughter)
STEPHANIE: ...and his family. Unfortunately, he ended up being a psychiatrist because he saw the psychological pain and, you know, shell-shocked at that time - people. Anyway, it's not a firsthand experience. It's a second generation experience. But...
CONAN: It's interesting the kind...
STEPHANIE: A major one that has affected people down the line and incredibly difficult thing for him to carry.
CONAN: And, Dr. Millin, obviously, the kind of health care - the mental health care that you've talked about you got since coming back from Haiti, not available for Stephanie's dad.
Dr. MILLIN: Yes. And I would have to say I'm fortunate to have never had to practice medicine in warfare. Although, the stuff we do in a disaster - and there were times we were driving through the streets of Haiti and it looked like there had been a war. There's so much destruction.
The caller also alludes to the word triage and many people throw out that word and don't really understand what triage really is all about. The term triage dates back to the French and Napoleon's time period. And really, in triage, what we're doing is we're creating lists of three different types of patients: patients that no matter what we do will live, patients no matter what we do will die, and patients where we can make a difference as to both whether they will live or die.
The challenge is often finding the difference between those three types of patients. And there are different techniques we use to figure that out. But when we label a patient as potentially that - or most likely, in that going-to-die category, it certainly is very difficult. But it's what you have to do in order to make the most-likely-live-if-we-can-do-something about category as large as we can.
CONAN: Stephanie, thanks so much for the call. We appreciate it.
STEPHANIE: You're welcome.
STEPHANIE: Thank you.
CONAN: Bye-bye. And, Dr. Millin, one final thought. Obviously, the kind of mental health counseling available to you, there is enormous need for that in Haiti, too, and it's not going to be available from us to the people there.
Dr. MILLIN: Yes. And that is absolutely the case. I am not a mental health professional, although I'm fortunate to be married to one. But there are great mental health needs in Haiti. The translator that I helped - or helped me tell this one individual he was going to die, it was very difficult for him as he had just gone through an earthquake himself with his own family and his own needs, and then he was dealing with the shock of having to tell someone that he's going to die. So the mental health needs in that country, I'm sure, will be great for a long, long period of time.
CONAN: Dr. Michael Millin is an emergency physician to Johns Hopkins Hospital in Baltimore, just back from providing emergency medical care in Haiti. He joined us today from - by phone from his home in Baltimore, where I suspect you're getting ready to treat frostbite cases.
(Soundbite of laughter)
Dr. MILLIN: Yeah. Well, we are getting plenty of snow here and we have five-degree wind chills, so yes, it's quite a challenging day for Baltimore.
(Soundbite of laughter)
CONAN: Thanks very much for being with us today.
Dr. MILLIN: Oh, thank you.
CONAN: Tomorrow, we'll talk about some of the trends that will shape the news you get - might be better than you think. Join us then. And if you want more talk, sign up for our email newsletter. Go to npr.org, click on TALK OF THE NATION and scroll down to the newsletter sign up box.
This is TALK OF THE NATION from NPR News. I'm Neal Conan, in Washington.
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