When a person catches the flu, the infection can affect the lungs and cause difficulty breathing. In serious cases, people need a breathing machine, or ventilator, to help them stay alive.
But if there was a worldwide outbreak of the bird flu among humans, the number of people who need a ventilator could far exceed supply.
A "medium-level" flu pandemic would likely cause between 89,000 to 207,000 deaths and about 314,000 to 734,000 people to be hospitalized in the United States, according to the Centers for Disease Control and Prevention. A large percentage of these hospitalized patients could be critically ill and require a ventilator.
With that in mind, doctors throughout the country are debating how to parse out a limited supply of ventilators in the event of an outbreak.
Dr. John Hick, an emergency physician at Hennepin County Medical Center in Minneapolis, has been working on a plan where the limited number of ventilators would be used for healthier patients, while the sickest patients would not receive them unless one became available.
His plan attempts to do the "greatest good for the greatest number" because the healthier patients would be more likely to benefit from ventilation and ultimately have a better outcome, he said. His proposal was published in the February issue of the journal Academic Emergency Medicine.
"In a disaster where we are were short on resources, and are not going to be able to receive resources from other sources to fill the needs, we would have to prioritize patients that have a better chance of survival," he said. "For example, deciding to take a very sick patient with multiple organs failing off the ventilator in order to give it to a patient with a better chance of recovery."
Another proposal would give priority for ventilators to patients who are health care workers. The plan also would give priority to health care workers' family members and key health system leaders, such as hospital chief executive officers.
"It is a really controversial topic, but if you look at an overall goal of achieving the maximum benefit for the most number of people, it would make sense to put people to work who can help save lives," said the doctor who proposed the approach, Kristi Koenig, director of public health preparedness in the Department of Emergency Medicine at the University of California at Irvine. "We know that in many cases if people cannot assure the safety of their own families, they will not be effective at work."
Doctors also are discussing what to do with patients who are on a ventilator long term and would likely be dependent on it for the rest of their lives. If there's a flu pandemic, some doctors may consider removing these patients from ventilators so that they can be used in other people more likely to benefit from them.
"It is going to be very difficult to justify withdrawing the ventilator from a patient that is chronically dependent on it, even if another patient exists that could benefit more from the ventilator. The fundamental rights of the patient would need to be respected even in a pandemic emergency," said Gerard Magill, a professor at the Center for Health Care Ethics at Saint Louis University.
To illustrate what may happen in the event of a pandemic, Hick detailed a drill where the 27 hospitals in his medical group were forced to take care of 400 patients with pneumonic plague, a severe bacterial infection of the lung. In the drill, the hospitals suffered a severe shortage of ventilators.
While they tried to get extra ventilators from local vendors that sell them, he said, "We were about 50 ventilators short and our local vendors only had 16 available. Thus we would have had to go to regional networks or to the CDC stockpiles in order to have these needs met."
The CDC maintains a supply of 4,000 ventilators for emergency use, but in the event of a worldwide flu epidemic the demand could far exceed their supply.
Hick also noted that a high percentage of the ventilators at the hospitals were in use already before the simulated outbreak began and were unavailable to treat the new patients.
"Our hospitals are usually running about 75 [percent] to 80 percent of their ventilators at any given time, but it's not unusual to be in the 90 percent range, and sometimes 100 percent," he said.
But there are other ways of increasing the number of ventilators available -- ventilators actually can be shared to ventilate two patients at a time.
There would need to be regulatory changes to permit such use, said Dr. Bonnie Arquilla, the director of disaster preparedness for Kings County Hospital at the SUNY Down State Medical Center in New York City. Right now. the rules in place prevent the sharing of ventilators.
The issue will likely remain a hot topic among health care workers. Hick feels that his recommendations are not definitive but are nothing more than "a starting point that needs further discussion, study and refinement."
Koenig agrees it is important that these issues be discussed.
"It's important to think about and talk about a situation in which we exceed our health care resources where people could literally die in the streets, because it is a scenario we've rarely had to face within the borders of our own country. We must address the situation up front if we are to save lives when the event occurs."
Schofer is a chief resident in emergency medicine at the U.S. Naval Medical Center in San Diego. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.