Which patient gets the ventilator? Doctors may have tough choices ahead

LOS ANGELES – It’s a choice most doctors never thought they would have to make: Who lives and who dies.

But in coming weeks, if COVID-19 continues to surge, such decisions will be inevitable.

The coronavirus will attack so many people’s lungs that thousands could show up at hospitals gasping for air and will need to be hooked up to machines that breathe for them. But there won’t be enough ventilators for everyone, forcing doctors to make impossible calls about which lives to save.

“You have an 80-year-old and a 20-year-old and both need a vent and you only have one. What do you do?” said Dr. Christopher Colwell, the chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center.

Across the U.S., there could be as many as 31 patients requiring ventilation for every machine available, according to an article published this week in the New England Journal of Medicine. The shortage could be just as severe in California.

Statewide, there are about 9,500 ventilators, a total that includes recent additions made by state leaders and others in anticipation of increased numbers of COVID-19 patients. The federal government’s national stockpile, which states can tap when their local supplies run low, has an additional 16,000.

Gov. Gavin Newsom has not said how many ventilators he thinks California will ultimately require, but studies in China found that between 2% and 6% of people with COVID-19 needed to be on ventilators.

If half of Californians fall sick with COVID-19 and 2% need ventilators, the state would need 390,000 over the course of the outbreak. Even if those cases were spread out over the next year, the state could still require 20,000 ventilators at once.

“It could be catastrophic,” said Dr. Robert Winters, an infectious disease doctor in Los Angeles.

Doctors will have to resort to a wartime-like triage to determine whom to put on the ventilators and whom to turn away. In Italy, hospitals have been forced to deny potentially live-saving treatment to older, frailer people due to a shortage of machines.

These are difficult decisions anywhere, but particularly in America, where families often push for extreme measures to keep people alive even when they are very sick, experts say. And they aren’t choices that medical workers, who trained for years to save lives, want to make.

Colwell, the San Francisco doctor, said he is already considering what to do in such a situation. The city’s hospitals have about 750 ventilators and officials are trying to obtain others from reserve supplies, he said.

“How do I distribute them in an equitable manner that tries to honor the approach of the good of the many versus the good of the few?” Colwell said. “Does it mean lives saved, years of life saved or quality of life?

“There’s not a black and white answer,” he said.

In the New England Journal of Medicine article, a trio of Harvard Medical School experts called decisions about who gets ventilators “the toughest triage.”

“Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and services on this scale,” they wrote. “Of all the medical care that will have to be rationed, the most problematic will be mechanical ventilation.”

Ventilators supply oxygen to people who can’t get enough and also physically push air in and out of the lungs. Infections can debilitate patients and weaken their muscles so they cannot contract and expand on their own.

Rationing such care has been the subject of ongoing discussions at Sutter Health Network, where one of those weighing in said she believes the best model is to allow a panel of doctors, instead of individual physicians, to decide who receives the care, said Dr. Janice Manjuck, a critical care specialist at an Oakland hospital.

“One particular physician does not have the bird’s eye view of what is out there,” she said, adding that as a doctor caring for a patient, “you are probably not the best to make that decision because you always advocate for the patient.”

Ventilators, she said, “can be the difference between life and death.”

With COVID-19, it remains unclear how often that is the case. One small study published in the medical journal the Lancet found that of 37 patients in Wuhan who were ventilated, only seven survived.