Thread by @WesElyMD

1/🧵Is my LIFE WORTH MORE than yours if I get #VACCINATED & you don’t? Or if I’m a COVID nurse?

ECMO is advanced life support in short supply that can save lives in extreme #Covid19.

Q 1 of 4:
If a #DeltaVariant surge creates too much demand…WHO GETS MY LAST ECMO MACHINE?

2/ How about essential worker status?

Q 2 of 4: Two #Covid19 patients are admitted on the same day & the virus has destroyed their lungs equally. You only have 8 ECMO machines & 7 are already in use. If forced to choose, WHO DO YOU PRIORITIZE?

3/ THE TWIST:

Q 3 or 4: Two #Covid19 patients are admitted on the same day & the virus has destroyed their lungs equally. You only have 8 ECMO machines & 7 are in use. If forced to choose, WHO DO YOU PRIORITIZE?

4/ Who do you choose to get a scarce resource in the COVID PANDEMIC if there is simply not enough to go around? Should it matter if the person is an essential worker on the front lines vs someone who isn’t a HCP (healthcare professionals)?

5/ Should it matter if the person chose to help society by getting the vaccine vs someone without medical contraindications who said no? I hate asking these questions, but due to the recent surge of #DeltaVariant, we are forced to deal with ethically complex situations.

https://twitter.com/weselymd/status/1417012047007686656

6/ Should #Vaccination be a condition of employment for #healthcare workers? Many hospitals already do this with flu & other vaccines (exceptions made for medical & religious reasons). Why not with #COVID?
 
bit.ly/3z8gnj3

7/ again…Should #Vaccination be a condition of employment for #healthcare workers? I have a🧵on this.👇

8/ Some medical resources are finite. Like lungs for transplantation. The new surge of #DeltaVariant #COVID from #unvaccinated people has some hospitals scratching their heads these days due to pts whose lungs are destroyed & need a machine called ECMO to live.

9/ TIE-BREAKERS: If all else is equal, does being a nurse or being vaccinated help break the tie when only 1 person can be chosen? Don’t forget, we use ECMO for non-COVID pts as well, so it is realistic that there are simply not enough resources to go around.

10/ THE TWIST: How did you answer this third poll question above and why? What if the nurse is an anti-vaxxer who subsequently got COVID at a party and then took it into the hospital? See my other THREAD about mandatory vaccination for HWP…

11/ Is it my job to “punish” people for bad choices by withholding treatment? If so, the MICU would be an empty place. People forgive to me for the gazillion bad choices I make. Still, we in medicine do face real limitations in the resources we can provide.

#Compassion #Reality

12/ Normally we prioritize people most likely to benefit, but ethicists tell us there are grounds for thinking 1 person “qualifies” more than another. COVID RNs & vaccinated people have been suggested. In kidney transplant, they prioritize previous donors:
bit.ly/3inUxkK

13/ There was loads written on this anticipating pandemic #ventilator #rationing. You separate the pts’ doctors from the decision & use a separate team of doctors # ethicists, etc. But this vaccine stuff is super-charging the situation right now.
 
bit.ly/36ORU61

14/ ECMO can get someone through initial catastrophic illness when lungs are so destroyed by virus that we bypass them & remove blood from the body, give it oxygen through an ECMO machine, & return it through plastic tubing so that the brain & other organs can stay alive.

15/ Once a person gets through ECMO & off the vent, lungs can be so trashed that people can’t live well and are highly at risk for another pneumonia that would end their life. Those pts are candidates for a lung transplant. Be clear, we ration lungs daily.
yhoo.it/3ktDJvi

16/
Q 4 of 4:
If all else is equal, which patient should get the precious resource of new lungs from a brain-dead, heart beating donor?

17/ My opinion is that neither essential worker status nor vaccine status should factor into triage prioritization for scarce life-saving resources like ECMO or lungs. Prioritization should be based on likelihood of survival & effectiveness of the resource.
@CCamosy @NIHBioethics

18/ I’ve been surprised how many prominent ethicists think essential workers are a tiebreaker or get priority.  I don’t buy it. Despite the rationalization, it’s saying their lives are worth more than others. See👇@AmerGeriatrics on pillars in medical reasoning in COVID.

19/ That would only make sense to me if a nurse/doc gets better soon enough to help out again, which is why one might prioritize them for vaccination. But a nurse or doc on a vent w COVID won’t be working for months or even a year. All lives are priceless and of equal value.

20/ fin
So what do you think? Who do we choose? If we only have 1 more ECMO Circuit, which patient gets that circuit? Or, more importantly…who doesn’t?
 
#Medtwitter #NurseTwitter

Oops…I forgot to add in this 🧵…others are asking for it so hear you go…

https://twitter.com/weselymd/status/1417012047007686656