Point of View: Decisions of Consequence
Last updated 4/27/2020 at 12:38pm
He lay on a gurney with his type & cross-matched blood flowing quickly through an 8-gauge “buffalo” needle; my two-man team, (including a stretcher-bearer) had just completed a femoral cutdown, providing a smooth, straight run up towards his heart. The conveyance had the assistance of an inflatable pressure cuff around the blood bag to pump as much replacement blood as fast as possible.
I was one of less than a dozen hospital corpsmen on 24-hrs on/24-hrs off triage duty, with one doctor and no nurses. He was an 18-year old Marine, just one of nearly 15,000 during the Vietnam war who was in the wrong place at the wrong time. A repeated volley of B-40 rockets had landed in the compound, this one close by, and it exploded, sending shrapnel into his legs, stomach, chest, arms, and forehead. He was breathing on his own but unconscious, and his blood pressure was still low despite tourniquets and clamps at every possible source of blood loss we could find. Near the end of the blood transfusion, his pupils became fixed and dilated. The Quonset hut serving as our triage unit at Da Nang Hospital was, although a rare event, filled to capacity. And there were more Marines awaiting attention outside the hut on stretchers, each with a different extent and severity of injuries. It was announced that more were coming in on choppers.
An ICU nurse stands over a 72-year old grandmother and COVID-19 patient, observant of vital sighs, fluid management, and ventilator status. Her condition has deteriorated, and she’s been on that same ventilator for a week. Her husband, kids, and grandkids can’t visit, but hubby gets updates from a nurse, sometimes the doctor. The doctor’s charge of loved ones was coming dangerously close to his 15-patient limit, that is until two patients died within three hours of the start of his shift. And now, a 32-year old husband and father of 3 is wheeled in and needs a ventilator. Stat. But all the working ones are in use, including the ones adapted for dual use. The first account is true, the second pure fiction. But whether it’s in a wartime medical triage unit or a stateside hospital ICU, it’s still the same – disciplined chaos. And in both cases, a decision will have to be made – who lives and who dies – based on very few if any emotional factors.
Many doctors will soon find themselves in the position of calculating how far up the ladder of statistical probability they must climb to perhaps only extend the death of one patient in order to probably save another, having to make it for the simple reason that both patients can’t be saved. That tipping point decision cannot be made based on emotion, but rather on experience with facts on the ground, and judgment.
I was 20 years old when I made that call, and while making it within a mere 60 seconds of observing the Marine’s fixed and dilated pupils, it was difficult. But it was backed up by the doctor on duty, and I moved on to another patient.
While I gave thought at the time to the Marine’s anticipated family grief, and over the 50+ years since, I’m satisfied it was and remains the right call. I deem acceptable any minor consequences for my psyche.
And doctors across the country will, if the ventilator supply runs short in April, be faced with either a lifetime of second guessing their decision, or else one with the grim satisfaction that they, like me, weighed the options and made the very best decision they could under extraordinary circumstances. I can still sleep soundly with my call in 1969, and I hope they can with theirs in 2020 and beyond.