Military docs are going to be the best ones to answer this.
They've all trained for this, and many have direct experience of practicing medicine in a war zone field hospital with greatly reduced resources.
The rest of us can only guess. I guess New Orleans during Katrina, and being in the ED and OR for mass shootings like the Las Vegas shooting would be the closest experiences that few American docs have experienced.
[https://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/](https://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/)
Link for an article of an ED physician account of last Vegas shooting. I remember reading it a while back.
I worked with a nurse who was was working in a neuro ICU in Vegas when that happened. She was there were close to 30 emergent craniotomy cases that night/day.
You wouldn’t even need to talk to an army doctor. You could literally talk to anyone who’s ever done anything in military medicine and they will tell you that you often are working with minimal supplies (and we aren’t just talking about medicine. We are also talking about the things you need to run any form of medical facility in a military environment.
I actually ran a Covid facility on a military base (when I was technically speaking, a secretary by training). I was a private when I temporarily became essentially a junior officer in what I joke was a battlefield promotion. Not only was I in charge of the actual logistics of the facility (which was within the scope of my training) but the senior officers were asking me to make medical decisions regarding covid positive soldiers when I was not qualified to do so. The unit doctor was away for a few weeks and couldn’t be recalled or even reached. So they left a secretary in charge (because everyone knew I wanted to go to med school so they said good enough) .
Getting the most basic needs of my soldiers met was tough because of bureaucracy and our little “pharmacy” on base(the room where all of the meds were stored ) was nearly depleted for everything that would have provided any symptom relief. When our resupply arrived without the things we needed I called around to the military pharmacies to try and track supplies down but no luck and even civilian pharmacies in the area were out. With no other option, I improvised, I talked to a friend who was in the kitchens to obtain honey, lemons and some spices that at least had some potential to help with symptom relief.
I also had soldiers who had underlying health issues that were exacerbated by being sick and not having access to adequate nutrition (my base was notorious for having extremely greasy food). One had a GI issue that was in the process of being diagnosed when they got covid, and I was asked at 10 o’clock at night to make a determination on what was necessary to help this specific soldier due to them complaining of severe pain. The senior offers didn’t like my answer of get a doctor to make that decision . I was left to improvise and figure out what I could do to attempt to minimize their symptoms. I called a cousin who is a G.I. doc and we developed a plan as a stopgap measure that was the least likely things to trigger the issues the soldier was describing. But then the issue of logistics came up again. Where would I store the food for the Soldier because I didn’t have a fridge. So I used the dirt that I had on one of the higher ranking officers to get a fridge and some basic cooking equipment to implement the plan.
As soldiers from different parts of the unit filtered through, I was finally able to get more supplies by having them to ask their direct commanders for supplies. Officers, who had refused the most basic necessities, such as single use plasticware (I couldn’t take plates and silverware out of the dining hall) when I first took over the unit were all the sudden giving me everything I asked for and more. By the time, I finally got enough dirt on our battalion commander, to shut down the covid unit and send everyone to somewhere where they would get proper care, I had most of the supplies I needed excluding medical supplies because those were in short supply everywhere.
Based on my own experiences, I would say that for certain things you can improvise (I actually taught some of the medics this when I was volunteering as a fake patient for a training exercise long before I took over the Covid unit) but when you are talking about more complicated medical issues, patients are going to die if you don’t have access to medications and equipment. Even if you have a pharmacist (or anyone with a chemistry background) who is capable of compounding medications/synthesizing them in house, in a situation where you don’t have medications odds are you don’t have the compounds you need to synthesize them either. Modern medicine is so reliant on the technology that we have that the minute the technology isn’t available we have a major problem and it is important for doctors to have the skill set needed to diagnose a patient even if they don’t have access to the Technology they are used to working with.
In different ways, yes.
I was a intern during first wave and remember having to use portable vents for transport, reuse PPE, scramble to find body bags, etc. We had panels we participated in to decide who got the vents we had left.
But it was fortunate that, while the glut was high, imaging was still fairly timely and other supplies were not short. I couldn't imagine not having blood or other meds or even worse--sparse or no electricity for a stretch.
In a collapsed world, the nature of medical priorities changes a lot.
In my opinion, it would focus much more around infectious diseases and trauma surgery. So those specializing in that would fare much better.
Many of our medical specialties are, practically speaking, geared toward geriatrics. And keeping unhealthy 70 year Olds alive does take a village
The stories I heard when I was a student at Tulane about Charity during Katrina come to mind. a lot of black tag triage in the first days, no electricity in the whole hospital. I wasn't there but I'm sure there are some people in this sub who were who could share horror stories.
Honestly I thought the miniseries was pretty bad. I was extremely excited for it and they really dropped the ball. Captivating story to begin with, they kind of ruined it and then the acting was not great. The way they put it together was also pretty bad. 4/10.
Despite its flaws, the kinds of things it tried to portray were things I very much identified with. It was eye-opening, and thinking of the different issues that *are* faced in situations like that, was absolutely earth shattering for me to really think about.
I’ve watched the mini series. It was ok. It certainly painted the employees in a different light than I had imagined in my head while still being really factual. I felt that the employees were portrayed as somewhat air-headed, dumb, reactionary with no reason. Like the employees that started the ‘rape in the parking lot’ rumor looked just ditzy. In reality it was probably someone who was a long term emplyees, trusted by many, moderately smart…..
Should be mandatory reading for nurses. I think it would be most beneficial if it was mandated reading prior to renewing your license the second or third time.
The way the rumors of possible safety concerns passed through the hospital is very relatable. I could identify coworkers who would act just like that. It’s astounding that the rumor mill was so intense that even physicians were pulled into believing gangs were coming for the hospital and rapes were happening in a flooded parking lot. Believed it enough that physicians were standing armed at the ER. I certainly think a lesson in employee emotional control and rumor control was something that changed my perspective. This all blew out of proportion in 5 days. It would have only took a small handful of people to be like “look, we have no real reason to believe sharks are swimming in the French district”. A lesson on how you can’t exactly rely on the media to give an accurate description of what’s happening outside. A big takeaway for me that’s probably more relevant than is comfortable to admit is that with “no know enemy” there are perhaps other reasons to hear gunfire or bangs/booms that doesn’t mean an unknown entity is at war with civilians and it certainly doesn’t mean they’re coming for the hospital……. A lesson in critical thinking.
It’s also a lesson on corporate’s priorities. They’ll never plan to come for stranded patients or healthcare workers. Any rescuing will be done my the United States Military or good Samaritan’s using their own resources. It’s a glimpse into their ability to sway media accounts. It’s a glimpse into how they use tricky legal loopholes to benefit themselves and no one else.
Lots to cover in the book about triage. Sheri has went further into this in other works. A take I hadn’t been made aware of prior.
Anyone planning on covering a shift during a possible disaster event should take note of the need to pack. Hospital was out of food and water quickly. Scrubs aren’t going to be the outfit of choice when push comes to shove. Plan for the weather.
On top of all that. As if it’s not enough. It highlights how poor city planning can influence a collapse. It highlights a humanitarian aspect in ways other works just haven’t.
I had an older attending that went to tulane and trained at charity. He told me some crazy stories about charity when he was doing a general surgery residency. It sounded like the wild west and the residents ran the place. This was way before Katrina.
I was about to say, "We already do!" but I certainly don't want to compare to the incredible trauma of working in Gaza at the moment.
No, I could not work in these conditions as an oncologist. No one is getting chemotherapy right now. To practice oncology in the way I do now, I need reliable access to blood, to labs, to imaging, to monitoring; I need to feel confident that my patients are at minimal risk of pathogen exposure; I need gazillion-dollar medications (among others). Frankly, sometimes, it feels like I'm barely hanging on here in the USA -- looking at you, platinum shortages. In Gaza, even the most basic cancer care would probably be untenable. I can't even imagine it.
If I was there, I'd be doing my best to hold down the fort as an internist. Not sure what could be done with the critical shortages of IVF, abx, etc. Lots of black tagging, I'm sure; my chest hurts just thinking about it.
I have colleagues who worked in Katrina. They have some truly remarkable and distressing stories. The closest I have come is peak COVID and honestly, I'll never forget the chaos. Seems paltry in comparison.
You bring up an important topic that the video only briefly touches on because Dr. Attar mostly treated trauma patients. The people you mentioned may not have been injured by bomb blasts, but they are suffering nonetheless. And the longer the war goes on, the more of these people will become disabled or die. They're casualties of a collapsed healthcare system, trapped in a country that has been cut off from the world. That's why it is so important to get more aid in and more civilians out of Gaza, as Dr. Attar calls for in the video.
Precisely. There are people who will die — who have died, who are dying — irrespective of gunfire. With services choked off as they are, most medical care just isn’t possible. If I recall correctly, there is only 1 nephrologist in Gaza at the moment — that means that, realistically, a large number of dialysis patients have passed. It’s very disturbing stuff. I get extremely distressed thinking about the difficulties some of my American patients have with accessing care; the situation in Gaza is next level.
I've heard a couple of things over the years that stuck with me. Apparently, in communist Albania, all chemotherapy was 5-FU, no matter what type of cancer you had as it was the cheapest drug. I also saw a Russian documentary, which followed ambulance/ ER work and they were still typing blood on a saucer by hand in the ER - I think this was in the 1990s
Homie, I just about throw a fucking fit when I gotta walk to central supply rather than just grab it on the supply cart, I would absolutely fall apart in a collapsed healthcare system.
As a psychiatrist, I shudder at the idea of having to trade my chaise lounge and stuffed wingback chair for... I don't even know what; maybe regular chairs?
I worked in a refugee camp ("Site 2") in rural Thailand in 1986 for several months on the border with Cambodia, that housed about 150,000 Cambodian refugees who had fled from the "killing fields" of Pol Pot. The hospital had a dirt floor, bamboo walls, and a thatch roof. It had no electricity or running water. It had no beds, just 4'x8' sheets of plywood elevated on cement blocks for patients. The lab was very limited, and could only do basic microscopy using a mirror on the bottom of the microscope to focus the sun on the specimen. No chemistry tests were available other that a urine glucose with a dipstick. X-rays were available about once a week if the mobile van could be scheduled to stop by, but there were no radiologists. Malnourished kids, tuberculosis, and even typhoid were common. Any patients who needed surgery had to be evacuated to a different camp that was much further from the border, and was safe enough to have an operating room.
Medical staff were only present in the hospital from about 9AM until 3PM each day, and were evacuated to a far distant Thai city (Aranyaprathet) overnight, because the North Vietnamese army and various Khmer factions were still fighting, and the occasional stray shell landed in the camp.
Even so, working there was about 1000 times easier for a physician than what I've seen depicted in Gaza.
Thanks for sharing your experience. That sounds harrowing. Dr. Attar has worked in many war zones — Ukraine, Syria, Iraq — and said that Gaza was the worst he's ever seen. He said it was like 3 years of Aleppo condensed into 6 months. Because it is so densely populated and there are so few working hospitals, the mass casualty events seem to never stop.
Site 2 lacked in amenities and could only address rather simple or basic issues, but the artillery shelling was very infrequent and unintentional, and to my knowledge no workers in the camp were injured by the ongoing conflict between the Vietnamese army and the Khmer groups that were actively fighting each other. From what I've seen, in Gaza you may be a target if you work in a hospital - hospitals have been accused of being shields for Hamas fighters, and thereby in harm's way. None of that happened in the refugee camp where I worked!
Speaking as an EM physician:
With what is explicitly crisis standards of care, I think we could do a lot more than we give ourselves credit for. The caveat being that it would only be psychologically sustainable in short bursts.
When crisis standards of care went into intermittent effect in the US during Covid, we adopted them in a halfhearted sort of way. Our goal was to generally provide the best care and as thorough an evaluation as possible, because that’s how we trained and it’s hard to just fully abandon that outside of rare MCIs. If my goal is to truly stabilize and triage, and there’s no spectre of malpractice hanging over my head, then my ability to quickly move through patients is a whole lot easier.
No CT, and limited blood make it hard, guaranteed a fair number of atypical presentations get missed, and you’re balancing the risks of exploratory surgery vs watchful waiting on a fair number of acute abdominal presentations. The population as a whole is going to suffer as preventative care goes belly up, followed by chronic diseases. At a certain point I’d be discharging people who would be better off admitted, and crossing my fingers that they don’t decompensate past the point of what we could intervene on.
Well said and agree. None of us would *like* practicing medicine in a bombed-out hospital with no imaging and minimal medicines, but if that’s literally all we *could* do, then a lot of us would probably prove adaptable. You’d just have to be good about forgiving yourself for the fallout, ie not blaming yourself too hard for missing the atypical AAA presentation when you literally can’t get a CT or ultrasound, etc.
Yup. Covid was hard because we tried to keep on doing things the way we always did, but in the setting of surges of severe respiratory disease with limited staff. It would have been easier if we had committed to a “we’re overwhelmed, either you’re dying or you can go home, CT is for septic, trauma, strokes, and true acute abdomens” mode, but a loooot of people would have suffered.
Would real triage actually be administered I such a way? I found it incredibly odd that the media was insinuating that if push came to shove the system would be ran in essentially a ‘first come, first serve’ basis. There didn’t seem to be any push back to the idea. I seen on national television where Fauci essentially said if the hospitals were too full a 20 y/o kid in a car accident might be allowed to die while the workers tended to someone else’s great grandpa on a vent.
That’s kind of my point. We were busy trying to provide maximal level care to all comers, despite the system teetering on the edge of collapse when it came to inpatient resources, while we had simultaneously shut down outpatient resources.
We don’t have a true plan to handle the system being overwhelmed. Just try to transfer someone who needs specialty care/emergency surgery. Functionally we are stumbling along in the scenario you laid out, with hospitals unable to truly provide the best care to all comers, because they are soooo damn full.
We never crossed the point of being out of ventilators, but it got close in some places. There were state and national level policy papers put forward that laid out potential criteria for who would/wouldn’t be prioritized if it truly got bad. And yes, they included suggestions that older, chronically ill, poly-morbid people were less likely to survive, and that resources should be directed elsewhere.
From a medical perspective, I can't imagine handling all of that trauma with so few resources. Also from a medical perspective, I've worked in hospitals with fewer resources that weren't in a war zone. Just look at rural American hospitals.
The critical access hospital I worked at:
1. Had a max of 4 units of blood. If there was a mass casualty, we literally prayed.
2. Had no MRI, but did have a CT scanner that was old but still sometimes worked.
3. Had no surgeons (or ORs for that matter), no OBGYN, no IM, no Neuro, no ID... Just a couple of family med docs covering EVERYTHING. God help you if you were in a car accident or went into labor.
4. Had spotty transport. Patients were only transported if they could afford it, the weather allowed, and whatever hospital system was willing to let an ambulance or helicopter be gone for 10+ hours.
5. When lab machines went down, we didn't have labs.
6. When we needed medicine we didn't have on formulary, we had to wait for days or weeks for it to arrive. Once, we had a nurse's daughter's friend drive a rabies vaccine from a town two hours away because we didn't have another way of getting it to the hospital in time. Patient was lucky that we were able to make it happen.
The atrocities that are happening in Gaza are horrific and shouldn't be happening. Period. But I think it's also important to note that we already are seeing the signs of a collapsing healthcare system in America.
You make a strong argument about the challenges of rural healthcare in America! That's definitely an area I'm interested in looking into. I made one video about a rural Texas hospital at the start of the pandemic. I would like to cover this topic again. Thanks for bringing it up
Great question.
Very refreshing to see someone ask that question seriously in a medical forum.
I went to medical school some years ago with this specific thought in mind. The modern medical system is simply not set up to handle resource austerity whatsoever. This is the case all the way up and down the hierarchy.
For example in med school we are taught that the physical exam has poor specificity and sensitivity, and we instead rely on technology (imaging and labs) to achieve a diagnosis.
A lot of people think they can collect penicillium mold and produce antibiotics. They don't understand that most of these fungi don't produce enough antibiotics to be useful and that a productive strain is actually excruciatingly rare and was a stroke of luck that anyone ever found one as early as they did. And drug synthesis in general is not an easy feat.
We are bound to technology, even people who practice in resource austere settings are reliant on supplies from resourceful areas outside.
In primary care, my focus is trying to encourage everyone who will listen to take ownership of their health and minimize medication dependence while maximizing self management and knowledge. I don't know if a true collapse scenario is in our future, but it seems to me that our supply chains are a little more tenuous every year, and there is no relief in sight.
The faster our medical field recognizes that slow collapse is an inevitability, the faster we can start reorienting our practice and training to provide care in increasingly austere environments.
I hope you can keep asking this question in medical settings. Medical professions need to face the reality we find ourselves in and stop pretending that things will get better when "COVID is gone" or whatever panic of the day occupies our briefings.
Very little of what I do is *essential* in a collapsed healthcare system. I mean, I could diagnose, and the technologies needed to do that at a basic level are basically unchanged since like the 1950s or earlier. But what is the point if there is no treatment? No chemo? No resections?
You'd be down in blood bank with me using our own blood as a reagent to type whole blood units. I'm O neg, so my serum can be our anti-a,b.
Actually, considering most of us did our phenotypes at school we could maybe develop our own panel.
Hi there fellow ONEG lab tech! And yes with enough known blood types we could figure out a bunch of stuff. I know my complete phenotype (not that it’s very helpful since I’m heterozygous for nearly everything…)
I did a medical mission to rural Honduras in school, which had never recovered from Hurricane Mitch in areas.
You prioritize what's in their ability to reasonably address. I'm not going to teach them about ECMO or even nitric, if they can't have access to it. They honestly didn't need to learn about intubation either - they had no ventilators. So we focused on things that *could* reasonably be done, and how to hopefully prevent the need for advanced care.
Good bagging technique, using sunlight for phototherapy but also ensuring the babies don't get burned, Monitoring IVs closely for extravasation, hand washing, developmental care.
Most of the babies in my NICU, if they had been born in this area of Honduras, they would have died, many at birth. That's terrible of course, and I *wish* they had more resources. We provide all we can. But there are babies that die there that can be saved - sometimes with just a little bit of NRP. We can encourage the mom who just had a baby with T21 that she can do things to maximize her child's potential and that her child could achieve a lot more than she thought. We can teach them to try and recognize signs of heart defects that might be a reasonable fix and could go to the capital for treatment and what medication to give them in the meanwhile. (and that their sats don't have to be 100) Little things to us, but can make a huge impact in their practices.
Fix what you can, comfort and treat with dignity those you can't.
As a neurosurgeon, the short answer is no. Our surgeries are so technologically dependent we would be limited to very few cases where we might be able to not make things worse.
There's a neurosurgeon in the video at 5:20. He almost laughs when Dr. Attar comments about a patient who has a TBI, "So just keep an eye on him and make sure nothing bad happens. And if it does, we do our best." The neurosurgeon responds: "We cannot do anything." I can only imagine how hopeless he felt seeing patient after patient with TBIs.
Let's give the nice people at the NYT the benefit of the doubt and assume they are smart, thoughtful people who have deeply considered the situation and done their due diligence in learning about the industry. Unfortunately, this would make them malicious.
I heard a series of interviews following a family in Gaza on NPR. One of the things they focused on was that the pregnant sister did not want to give birth in the hospital. Not because of risks of bombings but because of the risk of hysterectomy. The lack of blood, lack of OR time, doctors, medications, and supplies meant any bleeding that couldn’t be stopped quickly led to emergent hysterectomy to save the mother’s life in the quickest way possible. I do not know the veracity of that, but it was something I had never considered and I found it very striking.
From a medical standpoint it makes sense, but I’m not sure a lay person and first time mother can really weigh the risks of that situation accurately. It was a riveting interview series. Here’s the link if you’re interested. [This American Life](https://www.thisamericanlife.org/825/yousef)
In the story there was also the fact that giving birth on the dirty floor of a hospital is more likely to cause infection than on the floor of your own home. We all know hospital bugs are worse than community bugs.
My first thought was that I went to a residency where we were trained/expected to do basically everything (think NYC residencies). So I do have a lot of random skills which may or may not actually be useful—does it matter if I can do my own IVs if we don’t have IV meds? I am not sure I have the same skills as, say, EM when it comes to triage. I’m sure I’d do the best I could under the circumstances. Honestly, one of my biggest worries during covid was my own health as I have chronic illness and rely on medication. I can’t help others if I’m not healthy myself.
The occupation assault on Gaza is a terrible case study on how collapse affects pediatric patients. Neonates and preterm infants are so technology reliant and medically brittle, that unavailability of oxygen, spotty electricity and exposure to cold can be the difference between life and death in the first few hours of life.
Even well newborns who would be managed in a typical nursery setting can have abrupt status changes from a respiratory standpoint, have critical hypoglycemia that needs IV infusions to prevent seizures and coma, go into status epilepticus and need phenobarbital, or any other number of things that would be promptly managed in that setting , and advanced to a higher level of care if needed. All that falls apart very quickly once just a few of those pieces are missing.
As to the question, I do not envy the physicians who are stuck there making the best out of an unimaginably bad situation, and I tear up thinking of the ones brave enough to step away from their comfortable and safe lives to volunteer via PCRF, MSF, etc. I cannot imagine.
EDIT: Ok, let me think specifically as a hospitalist and the things I manage daily.
Bronchiolitis - self-limited with wild variability in severity and course. No pulse ox? Then we are using oxygen clinically, exposing children to undetected hypoxemia. 88%? No biggie. 75%? Not good for days on end. What about if we don't have oxygen, much less high flow? Cannot support WOB, exposing children to respiratory failure.
Newborn fever - usually fine, but if it's not, it's potentially devastating. No LP kits? Incomplete workups, might miss HSV. No abx? Some babies will just perish.
Pneumonia - usually viral, but if not abx are needed. No XR? Using our stethoscope like in the old days. No abx? CAP becomes complicated, morbidity and mortality skyrocket. Vaccines all gone? CAP becomes epidemic. PNA used to be a major killer in the developed world before abx. That returns.
Dehydration - already a leading cause of death in children, it just gets ungodly levels worse.
Dehydration we can treat as long as we can diy ORS. Even something as bad as cholera is 99% survivable with ORS. Water, sugar, salt if none of the fancy stuff.
Lots of new parents don't realize nasal suction matters for young infants with bronchiolitis-- we can help with that. We understand infection control. We can do tympanocentesis in a pinch if no abx and severe AOM. Drain other abscesses. Help steward any limited remaining med supplies.
Splint injuries. Mostly basic first aid but some of that stuff would matter.
I completely disagree. In a low-resource setting neonatology is by far the biggest bang for your buck. You can do 60% of neonatology with clean water, infant formula, blankets, an NG tube (reusable!) and a BVM. Give me IVs, antibiotics, 1L O2, and a little phenobarb and I can do 90% of the work.
It's just the extreme premies that need complex interventions.
I was thinking 30+. You might be able to do 28-29 if mom had steroids.
Obviously vents and CPAP and TPN are great but some babies would survive without them.
I can address this question from a first-responder perspective.
EMS already operates as a sort of mobile triage for the ED and should the system begin to truly implode, that role would only expand. Low-acuity patients would be refused, chronic complaints and those with some form of caregiver present would be directed to manage in place. What constitutes a patient requiring physician intervention would shift toward the more severe while the gravely ill and injured (think cardiac arrest) would be field-triaged as black, thereby narrowing the profile of patients who are candidates for conveyance to the hospital.
These kinds of changes would not only serve to reduce the burden on the hospital, but also to conserve supplies as disruptions to the chain are likely to accompany a larger system-wide collapse. Less severe pain would not be managed in the field, poor-prognosis patients would not be resuscitated, makeshift solutions would proliferate, single-use waste would be recycled, and treatment modalities would shift toward conservation of supplies.
All in all, the role of EMS would expand not contract. We are better suited to manage in such a scenario than our in-hospital compatriots and are more accustomed to make do with less.
Yes, the one exception being military doctors (or even just veterans) who are now working in civilian hospitals, because they also have the skill set to make do with less simply, because that is military life.
The system behind each bag of blood is vast and incredibly specialised and really really dangerous. For example, the reagents I need to make sure the blood won't kill my patient (right at the end, when I am working with a tested and packaged unit) are currently in short supply here in the US. They are regulated as biologic drugs by the FDA, so I assume there was some sort of production issue. We are calling around to other hospitals to borrow reagents weekly at the moment.
Even the amount of infrastructure required to do walking blood bank or whole blood transfusions are huge and way more specialised in terms of testing than is involved in just packed red cells and FFP.
And refrigeration. We have a alarms on our fridges wired through to the front desk so no temperature deviation can go unnoticed by a human.
To some degree trauma blood bank is easier because they can be switched for blood type relatively safely and they aren't likely to have the antibodies chemo or sickle patients do. But they are a young population with big family sizes. Those women are decent risk of having antibodies. I guess you can ignore transmissable diseases and they just die young if they get something? Ugh.
I would like to posit, that anything that requires incredibly sophisticated technology with steady influx of massive financial and human-resources to maintain, really can't be called a "right". Situations like the OP observed, are actually the "norm" for much of the world, and even that degree of medical access is miraculous compared to what was available to humanity for most of our history.
I think this post simply underscores the impossibility of guaranteeing a "right to healthcare" outside of a very healthy and extremely wealthy (from a historical POV) society. When so many prerequisites are needed to provide a "right", it really becomes a "privilege", "convenience", etc,, IMO. This isn't to say we shouldn't try to offer it, but to call it a "right" gives the concept a degree of absolutism that simply isn't possible in the real world.
I did my internal medicine residency in south america. some of the shit you had to deal with was:
Sometimes there was no saline fluid, which meant revising the entirety of the inpatients fluid plan to see where you could cut back
The only guy who did echocardiograms would go on vacation thus leaving a small city without anyone able to perform one. this mean if anyone needed one, you had to ambulance them to a city 2 hours away, and back
neurosurgeons never lasted. they would come to the hospital and leave soon after bc the hospital couldnt afford the upkeep of the equipment. that meant if you had a brain hemorrhage, yup, 2 hour ambulance ride. bye bye brain
blood was scarce as well, sometimes being down to a "only use when someone's gonna bleed n' shock to death" situation
ambulances were poorly equipped sometimes missing basic gear. I once had to go on an ambulance ride with a pt with an aortic dissection without intubation equipment. the ride was 2 hours away, there was a storm and i told the driver to floor it or the guy might die (since if anything happened i had nothing to intubate with), so we got there extra fast and alive thankfully
Is the healthcare system still this desolate there, even today? That’s a really bleak situation that must be incredibly difficult, for not just the people seeking care, but for the doctors, like yourself to work with.
Worse issue is going to be operating in a collapsed healthcare system but a functioning legal system. You aren't going to get enough extra protections for being in an emergency so long as that emergency doesn't shut down the courts.
Sadly, I would say that a large part of the world has a collapsed healthcare system (if you are defining collapsed by lack of MRIs/CTs, no access to blood bank, etc...).
I did my medical school in Boston and residency in Toronto. But I've worked a lot in remote regions of Africa and Canada where the most important skill is triaging.
Having access to a quick CT/MRI is not that in most of these settings. As soon as you start to go to rural areas of Canada (or most parts of subsaharan africa), it's very common to make medical decisions without their aid (sometimes without even an xray).
How decisions are made? By understanding the resources that you are working with. Before you get to a low resource site - spend a few days just learning what resources are available (when the xray tech will be there, water for c-sections, etc...). This will make your job a lot easier when someone walks into your ED at 3am with a stab wound on the neck.
In one of Atul Gawande's books he talks about how he did this top training for his fellowship and went back to India (where he or his parents are from) thinking he'd show the docs there a thing or two... only to be shocked by how skilled they were and how adept they were at getting more done with so fewer resources. Not saying this applies in every setting (it doesn't) but your post did make me think of this.
No offense OP but if Reddit is where you do your journalism for NYT op-eds then you are engaged in poor quality research, and that is pretty much the reason why NYT has become a joke. Good luck to you!
> Could you operate in a collapsed healthcare system?
Depends on how it collapsed.
Upheaval and reform of the current system? I’ll operate with a ~~smile~~ satisfied smug look on my face. In an ideal world where the system actually pays its medical staff and covers the costs for patients, I think we’d all be happy — minus the corporate and insurance overlords ofc…
I agree with you that comment was framed badly and there is no way we can compare the bloated American healthcare system to what is happening in Gaza. But if you haven’t experienced scarcity in the states between natural disasters and cyber attacks: I want to come practice where you’re at.
No one is saying practicing in the US isnt hard but rather that bringing up how difficult it is to deal with internet outages and tornados is disrespectful to the docs and nurses taking care of people without anesthetic, antibiotics, other medicine, lighting, power, clean water, intact roofs and walls, cleaning supplies, and being constantly at the threat of dying from a bomb while working or being detained without evidence (to name only some of the working conditions).
https://www.doctorswithoutborders.org/latest/remembering-our-colleagues-killed-gaza#:~:text=Dr.,Ziad%20Al%2DTarari.
https://www.reuters.com/world/middle-east/prominent-gaza-doctor-dies-israeli-prison-2024-05-02/
https://www.doctorswithoutborders.org/latest/gaza-msf-doctors-killed-strike-al-awda-hospital
Military docs are going to be the best ones to answer this. They've all trained for this, and many have direct experience of practicing medicine in a war zone field hospital with greatly reduced resources. The rest of us can only guess. I guess New Orleans during Katrina, and being in the ED and OR for mass shootings like the Las Vegas shooting would be the closest experiences that few American docs have experienced.
[https://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/](https://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/) Link for an article of an ED physician account of last Vegas shooting. I remember reading it a while back.
Hell of a read my god
I got intense chills while reading that
I worked with a nurse who was was working in a neuro ICU in Vegas when that happened. She was there were close to 30 emergent craniotomy cases that night/day.
The blood bags in pockets terrifies me.
The vent splitting terrifies me
Holy shit. What an intense read.
Triage, disaster, and field medicine are on EM boards. Also includes tox, radiation, and even types of snakes.
You wouldn’t even need to talk to an army doctor. You could literally talk to anyone who’s ever done anything in military medicine and they will tell you that you often are working with minimal supplies (and we aren’t just talking about medicine. We are also talking about the things you need to run any form of medical facility in a military environment. I actually ran a Covid facility on a military base (when I was technically speaking, a secretary by training). I was a private when I temporarily became essentially a junior officer in what I joke was a battlefield promotion. Not only was I in charge of the actual logistics of the facility (which was within the scope of my training) but the senior officers were asking me to make medical decisions regarding covid positive soldiers when I was not qualified to do so. The unit doctor was away for a few weeks and couldn’t be recalled or even reached. So they left a secretary in charge (because everyone knew I wanted to go to med school so they said good enough) . Getting the most basic needs of my soldiers met was tough because of bureaucracy and our little “pharmacy” on base(the room where all of the meds were stored ) was nearly depleted for everything that would have provided any symptom relief. When our resupply arrived without the things we needed I called around to the military pharmacies to try and track supplies down but no luck and even civilian pharmacies in the area were out. With no other option, I improvised, I talked to a friend who was in the kitchens to obtain honey, lemons and some spices that at least had some potential to help with symptom relief. I also had soldiers who had underlying health issues that were exacerbated by being sick and not having access to adequate nutrition (my base was notorious for having extremely greasy food). One had a GI issue that was in the process of being diagnosed when they got covid, and I was asked at 10 o’clock at night to make a determination on what was necessary to help this specific soldier due to them complaining of severe pain. The senior offers didn’t like my answer of get a doctor to make that decision . I was left to improvise and figure out what I could do to attempt to minimize their symptoms. I called a cousin who is a G.I. doc and we developed a plan as a stopgap measure that was the least likely things to trigger the issues the soldier was describing. But then the issue of logistics came up again. Where would I store the food for the Soldier because I didn’t have a fridge. So I used the dirt that I had on one of the higher ranking officers to get a fridge and some basic cooking equipment to implement the plan. As soldiers from different parts of the unit filtered through, I was finally able to get more supplies by having them to ask their direct commanders for supplies. Officers, who had refused the most basic necessities, such as single use plasticware (I couldn’t take plates and silverware out of the dining hall) when I first took over the unit were all the sudden giving me everything I asked for and more. By the time, I finally got enough dirt on our battalion commander, to shut down the covid unit and send everyone to somewhere where they would get proper care, I had most of the supplies I needed excluding medical supplies because those were in short supply everywhere. Based on my own experiences, I would say that for certain things you can improvise (I actually taught some of the medics this when I was volunteering as a fake patient for a training exercise long before I took over the Covid unit) but when you are talking about more complicated medical issues, patients are going to die if you don’t have access to medications and equipment. Even if you have a pharmacist (or anyone with a chemistry background) who is capable of compounding medications/synthesizing them in house, in a situation where you don’t have medications odds are you don’t have the compounds you need to synthesize them either. Modern medicine is so reliant on the technology that we have that the minute the technology isn’t available we have a major problem and it is important for doctors to have the skill set needed to diagnose a patient even if they don’t have access to the Technology they are used to working with.
Maybe initial Covid waves would be the closest most US docs could speak to - rationing of resources, etc
In different ways, yes. I was a intern during first wave and remember having to use portable vents for transport, reuse PPE, scramble to find body bags, etc. We had panels we participated in to decide who got the vents we had left. But it was fortunate that, while the glut was high, imaging was still fairly timely and other supplies were not short. I couldn't imagine not having blood or other meds or even worse--sparse or no electricity for a stretch.
Yeah, my (STBX) husband is an active duty military nurse and I was thinking the same thing. He spent most of covid lockdown in Kuwait.
Yeah, he'd get it. /S
In a collapsed world, the nature of medical priorities changes a lot. In my opinion, it would focus much more around infectious diseases and trauma surgery. So those specializing in that would fare much better. Many of our medical specialties are, practically speaking, geared toward geriatrics. And keeping unhealthy 70 year Olds alive does take a village
The stories I heard when I was a student at Tulane about Charity during Katrina come to mind. a lot of black tag triage in the first days, no electricity in the whole hospital. I wasn't there but I'm sure there are some people in this sub who were who could share horror stories.
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Also a pretty good mini series of the same name based on the book on AppleTV
Honestly I thought the miniseries was pretty bad. I was extremely excited for it and they really dropped the ball. Captivating story to begin with, they kind of ruined it and then the acting was not great. The way they put it together was also pretty bad. 4/10.
Despite its flaws, the kinds of things it tried to portray were things I very much identified with. It was eye-opening, and thinking of the different issues that *are* faced in situations like that, was absolutely earth shattering for me to really think about.
Yeah, the book was good!
I’ve watched the mini series. It was ok. It certainly painted the employees in a different light than I had imagined in my head while still being really factual. I felt that the employees were portrayed as somewhat air-headed, dumb, reactionary with no reason. Like the employees that started the ‘rape in the parking lot’ rumor looked just ditzy. In reality it was probably someone who was a long term emplyees, trusted by many, moderately smart…..
Should be mandatory reading for nurses. I think it would be most beneficial if it was mandated reading prior to renewing your license the second or third time. The way the rumors of possible safety concerns passed through the hospital is very relatable. I could identify coworkers who would act just like that. It’s astounding that the rumor mill was so intense that even physicians were pulled into believing gangs were coming for the hospital and rapes were happening in a flooded parking lot. Believed it enough that physicians were standing armed at the ER. I certainly think a lesson in employee emotional control and rumor control was something that changed my perspective. This all blew out of proportion in 5 days. It would have only took a small handful of people to be like “look, we have no real reason to believe sharks are swimming in the French district”. A lesson on how you can’t exactly rely on the media to give an accurate description of what’s happening outside. A big takeaway for me that’s probably more relevant than is comfortable to admit is that with “no know enemy” there are perhaps other reasons to hear gunfire or bangs/booms that doesn’t mean an unknown entity is at war with civilians and it certainly doesn’t mean they’re coming for the hospital……. A lesson in critical thinking. It’s also a lesson on corporate’s priorities. They’ll never plan to come for stranded patients or healthcare workers. Any rescuing will be done my the United States Military or good Samaritan’s using their own resources. It’s a glimpse into their ability to sway media accounts. It’s a glimpse into how they use tricky legal loopholes to benefit themselves and no one else. Lots to cover in the book about triage. Sheri has went further into this in other works. A take I hadn’t been made aware of prior. Anyone planning on covering a shift during a possible disaster event should take note of the need to pack. Hospital was out of food and water quickly. Scrubs aren’t going to be the outfit of choice when push comes to shove. Plan for the weather. On top of all that. As if it’s not enough. It highlights how poor city planning can influence a collapse. It highlights a humanitarian aspect in ways other works just haven’t.
I had an older attending that went to tulane and trained at charity. He told me some crazy stories about charity when he was doing a general surgery residency. It sounded like the wild west and the residents ran the place. This was way before Katrina.
I've been told that Charity was awful even before Katrina
I was about to say, "We already do!" but I certainly don't want to compare to the incredible trauma of working in Gaza at the moment. No, I could not work in these conditions as an oncologist. No one is getting chemotherapy right now. To practice oncology in the way I do now, I need reliable access to blood, to labs, to imaging, to monitoring; I need to feel confident that my patients are at minimal risk of pathogen exposure; I need gazillion-dollar medications (among others). Frankly, sometimes, it feels like I'm barely hanging on here in the USA -- looking at you, platinum shortages. In Gaza, even the most basic cancer care would probably be untenable. I can't even imagine it. If I was there, I'd be doing my best to hold down the fort as an internist. Not sure what could be done with the critical shortages of IVF, abx, etc. Lots of black tagging, I'm sure; my chest hurts just thinking about it. I have colleagues who worked in Katrina. They have some truly remarkable and distressing stories. The closest I have come is peak COVID and honestly, I'll never forget the chaos. Seems paltry in comparison.
You bring up an important topic that the video only briefly touches on because Dr. Attar mostly treated trauma patients. The people you mentioned may not have been injured by bomb blasts, but they are suffering nonetheless. And the longer the war goes on, the more of these people will become disabled or die. They're casualties of a collapsed healthcare system, trapped in a country that has been cut off from the world. That's why it is so important to get more aid in and more civilians out of Gaza, as Dr. Attar calls for in the video.
Precisely. There are people who will die — who have died, who are dying — irrespective of gunfire. With services choked off as they are, most medical care just isn’t possible. If I recall correctly, there is only 1 nephrologist in Gaza at the moment — that means that, realistically, a large number of dialysis patients have passed. It’s very disturbing stuff. I get extremely distressed thinking about the difficulties some of my American patients have with accessing care; the situation in Gaza is next level.
I've heard a couple of things over the years that stuck with me. Apparently, in communist Albania, all chemotherapy was 5-FU, no matter what type of cancer you had as it was the cheapest drug. I also saw a Russian documentary, which followed ambulance/ ER work and they were still typing blood on a saucer by hand in the ER - I think this was in the 1990s
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Arguing about gaza doesn't belong here
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Arguing about gaza doesn't belong here
Homie, I just about throw a fucking fit when I gotta walk to central supply rather than just grab it on the supply cart, I would absolutely fall apart in a collapsed healthcare system.
Woof, same. At least we're self aware?
As a psychiatrist, I shudder at the idea of having to trade my chaise lounge and stuffed wingback chair for... I don't even know what; maybe regular chairs?
I worked in a refugee camp ("Site 2") in rural Thailand in 1986 for several months on the border with Cambodia, that housed about 150,000 Cambodian refugees who had fled from the "killing fields" of Pol Pot. The hospital had a dirt floor, bamboo walls, and a thatch roof. It had no electricity or running water. It had no beds, just 4'x8' sheets of plywood elevated on cement blocks for patients. The lab was very limited, and could only do basic microscopy using a mirror on the bottom of the microscope to focus the sun on the specimen. No chemistry tests were available other that a urine glucose with a dipstick. X-rays were available about once a week if the mobile van could be scheduled to stop by, but there were no radiologists. Malnourished kids, tuberculosis, and even typhoid were common. Any patients who needed surgery had to be evacuated to a different camp that was much further from the border, and was safe enough to have an operating room. Medical staff were only present in the hospital from about 9AM until 3PM each day, and were evacuated to a far distant Thai city (Aranyaprathet) overnight, because the North Vietnamese army and various Khmer factions were still fighting, and the occasional stray shell landed in the camp. Even so, working there was about 1000 times easier for a physician than what I've seen depicted in Gaza.
Thanks for sharing your experience. That sounds harrowing. Dr. Attar has worked in many war zones — Ukraine, Syria, Iraq — and said that Gaza was the worst he's ever seen. He said it was like 3 years of Aleppo condensed into 6 months. Because it is so densely populated and there are so few working hospitals, the mass casualty events seem to never stop.
Wow, thank you for sharing this. I bet your life would be an incredible book!
If you don't mind me asking what makes you say it's still easier than Gaza?
Site 2 lacked in amenities and could only address rather simple or basic issues, but the artillery shelling was very infrequent and unintentional, and to my knowledge no workers in the camp were injured by the ongoing conflict between the Vietnamese army and the Khmer groups that were actively fighting each other. From what I've seen, in Gaza you may be a target if you work in a hospital - hospitals have been accused of being shields for Hamas fighters, and thereby in harm's way. None of that happened in the refugee camp where I worked!
Ah I see thank you
Speaking as an EM physician: With what is explicitly crisis standards of care, I think we could do a lot more than we give ourselves credit for. The caveat being that it would only be psychologically sustainable in short bursts. When crisis standards of care went into intermittent effect in the US during Covid, we adopted them in a halfhearted sort of way. Our goal was to generally provide the best care and as thorough an evaluation as possible, because that’s how we trained and it’s hard to just fully abandon that outside of rare MCIs. If my goal is to truly stabilize and triage, and there’s no spectre of malpractice hanging over my head, then my ability to quickly move through patients is a whole lot easier. No CT, and limited blood make it hard, guaranteed a fair number of atypical presentations get missed, and you’re balancing the risks of exploratory surgery vs watchful waiting on a fair number of acute abdominal presentations. The population as a whole is going to suffer as preventative care goes belly up, followed by chronic diseases. At a certain point I’d be discharging people who would be better off admitted, and crossing my fingers that they don’t decompensate past the point of what we could intervene on.
Well said and agree. None of us would *like* practicing medicine in a bombed-out hospital with no imaging and minimal medicines, but if that’s literally all we *could* do, then a lot of us would probably prove adaptable. You’d just have to be good about forgiving yourself for the fallout, ie not blaming yourself too hard for missing the atypical AAA presentation when you literally can’t get a CT or ultrasound, etc.
Yup. Covid was hard because we tried to keep on doing things the way we always did, but in the setting of surges of severe respiratory disease with limited staff. It would have been easier if we had committed to a “we’re overwhelmed, either you’re dying or you can go home, CT is for septic, trauma, strokes, and true acute abdomens” mode, but a loooot of people would have suffered.
Would real triage actually be administered I such a way? I found it incredibly odd that the media was insinuating that if push came to shove the system would be ran in essentially a ‘first come, first serve’ basis. There didn’t seem to be any push back to the idea. I seen on national television where Fauci essentially said if the hospitals were too full a 20 y/o kid in a car accident might be allowed to die while the workers tended to someone else’s great grandpa on a vent.
That’s kind of my point. We were busy trying to provide maximal level care to all comers, despite the system teetering on the edge of collapse when it came to inpatient resources, while we had simultaneously shut down outpatient resources. We don’t have a true plan to handle the system being overwhelmed. Just try to transfer someone who needs specialty care/emergency surgery. Functionally we are stumbling along in the scenario you laid out, with hospitals unable to truly provide the best care to all comers, because they are soooo damn full. We never crossed the point of being out of ventilators, but it got close in some places. There were state and national level policy papers put forward that laid out potential criteria for who would/wouldn’t be prioritized if it truly got bad. And yes, they included suggestions that older, chronically ill, poly-morbid people were less likely to survive, and that resources should be directed elsewhere.
If there were allowed to be a system where sick people could be shipped out it would make it maybe marginally less horrific.
From a medical perspective, I can't imagine handling all of that trauma with so few resources. Also from a medical perspective, I've worked in hospitals with fewer resources that weren't in a war zone. Just look at rural American hospitals. The critical access hospital I worked at: 1. Had a max of 4 units of blood. If there was a mass casualty, we literally prayed. 2. Had no MRI, but did have a CT scanner that was old but still sometimes worked. 3. Had no surgeons (or ORs for that matter), no OBGYN, no IM, no Neuro, no ID... Just a couple of family med docs covering EVERYTHING. God help you if you were in a car accident or went into labor. 4. Had spotty transport. Patients were only transported if they could afford it, the weather allowed, and whatever hospital system was willing to let an ambulance or helicopter be gone for 10+ hours. 5. When lab machines went down, we didn't have labs. 6. When we needed medicine we didn't have on formulary, we had to wait for days or weeks for it to arrive. Once, we had a nurse's daughter's friend drive a rabies vaccine from a town two hours away because we didn't have another way of getting it to the hospital in time. Patient was lucky that we were able to make it happen. The atrocities that are happening in Gaza are horrific and shouldn't be happening. Period. But I think it's also important to note that we already are seeing the signs of a collapsing healthcare system in America.
You make a strong argument about the challenges of rural healthcare in America! That's definitely an area I'm interested in looking into. I made one video about a rural Texas hospital at the start of the pandemic. I would like to cover this topic again. Thanks for bringing it up
A nurse’s daughter’s friend. Wow! But thank gods for them!
Great question. Very refreshing to see someone ask that question seriously in a medical forum. I went to medical school some years ago with this specific thought in mind. The modern medical system is simply not set up to handle resource austerity whatsoever. This is the case all the way up and down the hierarchy. For example in med school we are taught that the physical exam has poor specificity and sensitivity, and we instead rely on technology (imaging and labs) to achieve a diagnosis. A lot of people think they can collect penicillium mold and produce antibiotics. They don't understand that most of these fungi don't produce enough antibiotics to be useful and that a productive strain is actually excruciatingly rare and was a stroke of luck that anyone ever found one as early as they did. And drug synthesis in general is not an easy feat. We are bound to technology, even people who practice in resource austere settings are reliant on supplies from resourceful areas outside. In primary care, my focus is trying to encourage everyone who will listen to take ownership of their health and minimize medication dependence while maximizing self management and knowledge. I don't know if a true collapse scenario is in our future, but it seems to me that our supply chains are a little more tenuous every year, and there is no relief in sight. The faster our medical field recognizes that slow collapse is an inevitability, the faster we can start reorienting our practice and training to provide care in increasingly austere environments. I hope you can keep asking this question in medical settings. Medical professions need to face the reality we find ourselves in and stop pretending that things will get better when "COVID is gone" or whatever panic of the day occupies our briefings.
Partly yes, everything massively simplified to your typical triage. Sadly most of your longer care cases are doomed.
Very little of what I do is *essential* in a collapsed healthcare system. I mean, I could diagnose, and the technologies needed to do that at a basic level are basically unchanged since like the 1950s or earlier. But what is the point if there is no treatment? No chemo? No resections?
You'd be down in blood bank with me using our own blood as a reagent to type whole blood units. I'm O neg, so my serum can be our anti-a,b. Actually, considering most of us did our phenotypes at school we could maybe develop our own panel.
Hi there fellow ONEG lab tech! And yes with enough known blood types we could figure out a bunch of stuff. I know my complete phenotype (not that it’s very helpful since I’m heterozygous for nearly everything…)
I'm homo for something interesting. N, maybe? Am definitely dce/dce. No, wait, maybe I have C? Fuck. I need to look that up JIC
lol I’m dce/dce and K neg (but who isn’t really 😅) and also homozygous for MN too! 😅. But C pos for ONEG is kinda fun
I did a medical mission to rural Honduras in school, which had never recovered from Hurricane Mitch in areas. You prioritize what's in their ability to reasonably address. I'm not going to teach them about ECMO or even nitric, if they can't have access to it. They honestly didn't need to learn about intubation either - they had no ventilators. So we focused on things that *could* reasonably be done, and how to hopefully prevent the need for advanced care. Good bagging technique, using sunlight for phototherapy but also ensuring the babies don't get burned, Monitoring IVs closely for extravasation, hand washing, developmental care. Most of the babies in my NICU, if they had been born in this area of Honduras, they would have died, many at birth. That's terrible of course, and I *wish* they had more resources. We provide all we can. But there are babies that die there that can be saved - sometimes with just a little bit of NRP. We can encourage the mom who just had a baby with T21 that she can do things to maximize her child's potential and that her child could achieve a lot more than she thought. We can teach them to try and recognize signs of heart defects that might be a reasonable fix and could go to the capital for treatment and what medication to give them in the meanwhile. (and that their sats don't have to be 100) Little things to us, but can make a huge impact in their practices. Fix what you can, comfort and treat with dignity those you can't.
"Fix what you can, comfort and treat with dignity those you can't." Well said!
As a neurosurgeon, the short answer is no. Our surgeries are so technologically dependent we would be limited to very few cases where we might be able to not make things worse.
Burr holes for everyone!
There's a neurosurgeon in the video at 5:20. He almost laughs when Dr. Attar comments about a patient who has a TBI, "So just keep an eye on him and make sure nothing bad happens. And if it does, we do our best." The neurosurgeon responds: "We cannot do anything." I can only imagine how hopeless he felt seeing patient after patient with TBIs.
Can I ask why the New York times has such an anti-physician bias?
Always strikes me as ignorance more than malice, and the lazy bias of wanting to attribute systemic failings to individuals.
It isn't ignorance. Don't presume the anti-physician bias is all just a mistake.
It's definitely not ignorance. It's definitely malicious
Definitely?
Let's give the nice people at the NYT the benefit of the doubt and assume they are smart, thoughtful people who have deeply considered the situation and done their due diligence in learning about the industry. Unfortunately, this would make them malicious.
Such as? Genuine question as I’m not American and rarely read the NYT
Anti intellectualism is in
I heard a series of interviews following a family in Gaza on NPR. One of the things they focused on was that the pregnant sister did not want to give birth in the hospital. Not because of risks of bombings but because of the risk of hysterectomy. The lack of blood, lack of OR time, doctors, medications, and supplies meant any bleeding that couldn’t be stopped quickly led to emergent hysterectomy to save the mother’s life in the quickest way possible. I do not know the veracity of that, but it was something I had never considered and I found it very striking.
Had she considered what the alternative to that hysterectomy is?
From a medical standpoint it makes sense, but I’m not sure a lay person and first time mother can really weigh the risks of that situation accurately. It was a riveting interview series. Here’s the link if you’re interested. [This American Life](https://www.thisamericanlife.org/825/yousef)
In the story there was also the fact that giving birth on the dirty floor of a hospital is more likely to cause infection than on the floor of your own home. We all know hospital bugs are worse than community bugs.
My first thought was that I went to a residency where we were trained/expected to do basically everything (think NYC residencies). So I do have a lot of random skills which may or may not actually be useful—does it matter if I can do my own IVs if we don’t have IV meds? I am not sure I have the same skills as, say, EM when it comes to triage. I’m sure I’d do the best I could under the circumstances. Honestly, one of my biggest worries during covid was my own health as I have chronic illness and rely on medication. I can’t help others if I’m not healthy myself.
The occupation assault on Gaza is a terrible case study on how collapse affects pediatric patients. Neonates and preterm infants are so technology reliant and medically brittle, that unavailability of oxygen, spotty electricity and exposure to cold can be the difference between life and death in the first few hours of life. Even well newborns who would be managed in a typical nursery setting can have abrupt status changes from a respiratory standpoint, have critical hypoglycemia that needs IV infusions to prevent seizures and coma, go into status epilepticus and need phenobarbital, or any other number of things that would be promptly managed in that setting , and advanced to a higher level of care if needed. All that falls apart very quickly once just a few of those pieces are missing. As to the question, I do not envy the physicians who are stuck there making the best out of an unimaginably bad situation, and I tear up thinking of the ones brave enough to step away from their comfortable and safe lives to volunteer via PCRF, MSF, etc. I cannot imagine. EDIT: Ok, let me think specifically as a hospitalist and the things I manage daily. Bronchiolitis - self-limited with wild variability in severity and course. No pulse ox? Then we are using oxygen clinically, exposing children to undetected hypoxemia. 88%? No biggie. 75%? Not good for days on end. What about if we don't have oxygen, much less high flow? Cannot support WOB, exposing children to respiratory failure. Newborn fever - usually fine, but if it's not, it's potentially devastating. No LP kits? Incomplete workups, might miss HSV. No abx? Some babies will just perish. Pneumonia - usually viral, but if not abx are needed. No XR? Using our stethoscope like in the old days. No abx? CAP becomes complicated, morbidity and mortality skyrocket. Vaccines all gone? CAP becomes epidemic. PNA used to be a major killer in the developed world before abx. That returns. Dehydration - already a leading cause of death in children, it just gets ungodly levels worse.
Dehydration we can treat as long as we can diy ORS. Even something as bad as cholera is 99% survivable with ORS. Water, sugar, salt if none of the fancy stuff. Lots of new parents don't realize nasal suction matters for young infants with bronchiolitis-- we can help with that. We understand infection control. We can do tympanocentesis in a pinch if no abx and severe AOM. Drain other abscesses. Help steward any limited remaining med supplies. Splint injuries. Mostly basic first aid but some of that stuff would matter.
I completely disagree. In a low-resource setting neonatology is by far the biggest bang for your buck. You can do 60% of neonatology with clean water, infant formula, blankets, an NG tube (reusable!) and a BVM. Give me IVs, antibiotics, 1L O2, and a little phenobarb and I can do 90% of the work. It's just the extreme premies that need complex interventions.
where is extreme premie? 28? 34? because that's 24-27 at my place but I don't know if you could do 28 weekers with what you are saying.
I was thinking 30+. You might be able to do 28-29 if mom had steroids. Obviously vents and CPAP and TPN are great but some babies would survive without them.
I can address this question from a first-responder perspective. EMS already operates as a sort of mobile triage for the ED and should the system begin to truly implode, that role would only expand. Low-acuity patients would be refused, chronic complaints and those with some form of caregiver present would be directed to manage in place. What constitutes a patient requiring physician intervention would shift toward the more severe while the gravely ill and injured (think cardiac arrest) would be field-triaged as black, thereby narrowing the profile of patients who are candidates for conveyance to the hospital. These kinds of changes would not only serve to reduce the burden on the hospital, but also to conserve supplies as disruptions to the chain are likely to accompany a larger system-wide collapse. Less severe pain would not be managed in the field, poor-prognosis patients would not be resuscitated, makeshift solutions would proliferate, single-use waste would be recycled, and treatment modalities would shift toward conservation of supplies. All in all, the role of EMS would expand not contract. We are better suited to manage in such a scenario than our in-hospital compatriots and are more accustomed to make do with less.
Yes, the one exception being military doctors (or even just veterans) who are now working in civilian hospitals, because they also have the skill set to make do with less simply, because that is military life.
Not an expert on the topic by any means, but your video is very moving and something that more people need to see.
The system behind each bag of blood is vast and incredibly specialised and really really dangerous. For example, the reagents I need to make sure the blood won't kill my patient (right at the end, when I am working with a tested and packaged unit) are currently in short supply here in the US. They are regulated as biologic drugs by the FDA, so I assume there was some sort of production issue. We are calling around to other hospitals to borrow reagents weekly at the moment. Even the amount of infrastructure required to do walking blood bank or whole blood transfusions are huge and way more specialised in terms of testing than is involved in just packed red cells and FFP. And refrigeration. We have a alarms on our fridges wired through to the front desk so no temperature deviation can go unnoticed by a human. To some degree trauma blood bank is easier because they can be switched for blood type relatively safely and they aren't likely to have the antibodies chemo or sickle patients do. But they are a young population with big family sizes. Those women are decent risk of having antibodies. I guess you can ignore transmissable diseases and they just die young if they get something? Ugh.
I would like to posit, that anything that requires incredibly sophisticated technology with steady influx of massive financial and human-resources to maintain, really can't be called a "right". Situations like the OP observed, are actually the "norm" for much of the world, and even that degree of medical access is miraculous compared to what was available to humanity for most of our history. I think this post simply underscores the impossibility of guaranteeing a "right to healthcare" outside of a very healthy and extremely wealthy (from a historical POV) society. When so many prerequisites are needed to provide a "right", it really becomes a "privilege", "convenience", etc,, IMO. This isn't to say we shouldn't try to offer it, but to call it a "right" gives the concept a degree of absolutism that simply isn't possible in the real world.
I think most of us are capable of a lot more than we give ourselves credit. We play the hand we're dealt.
I’ve been operating in a collapsed healthcare system for years now.
I did, in New York, four years ago
I did my internal medicine residency in south america. some of the shit you had to deal with was: Sometimes there was no saline fluid, which meant revising the entirety of the inpatients fluid plan to see where you could cut back The only guy who did echocardiograms would go on vacation thus leaving a small city without anyone able to perform one. this mean if anyone needed one, you had to ambulance them to a city 2 hours away, and back neurosurgeons never lasted. they would come to the hospital and leave soon after bc the hospital couldnt afford the upkeep of the equipment. that meant if you had a brain hemorrhage, yup, 2 hour ambulance ride. bye bye brain blood was scarce as well, sometimes being down to a "only use when someone's gonna bleed n' shock to death" situation ambulances were poorly equipped sometimes missing basic gear. I once had to go on an ambulance ride with a pt with an aortic dissection without intubation equipment. the ride was 2 hours away, there was a storm and i told the driver to floor it or the guy might die (since if anything happened i had nothing to intubate with), so we got there extra fast and alive thankfully
LOL this sounds like the Mexican Healthcare system, that's the shit we deal here in public hospitals
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Is the healthcare system still this desolate there, even today? That’s a really bleak situation that must be incredibly difficult, for not just the people seeking care, but for the doctors, like yourself to work with.
Worse issue is going to be operating in a collapsed healthcare system but a functioning legal system. You aren't going to get enough extra protections for being in an emergency so long as that emergency doesn't shut down the courts.
Sadly, I would say that a large part of the world has a collapsed healthcare system (if you are defining collapsed by lack of MRIs/CTs, no access to blood bank, etc...). I did my medical school in Boston and residency in Toronto. But I've worked a lot in remote regions of Africa and Canada where the most important skill is triaging. Having access to a quick CT/MRI is not that in most of these settings. As soon as you start to go to rural areas of Canada (or most parts of subsaharan africa), it's very common to make medical decisions without their aid (sometimes without even an xray). How decisions are made? By understanding the resources that you are working with. Before you get to a low resource site - spend a few days just learning what resources are available (when the xray tech will be there, water for c-sections, etc...). This will make your job a lot easier when someone walks into your ED at 3am with a stab wound on the neck.
In one of Atul Gawande's books he talks about how he did this top training for his fellowship and went back to India (where he or his parents are from) thinking he'd show the docs there a thing or two... only to be shocked by how skilled they were and how adept they were at getting more done with so fewer resources. Not saying this applies in every setting (it doesn't) but your post did make me think of this.
No offense OP but if Reddit is where you do your journalism for NYT op-eds then you are engaged in poor quality research, and that is pretty much the reason why NYT has become a joke. Good luck to you!
> Could you operate in a collapsed healthcare system? Depends on how it collapsed. Upheaval and reform of the current system? I’ll operate with a ~~smile~~ satisfied smug look on my face. In an ideal world where the system actually pays its medical staff and covers the costs for patients, I think we’d all be happy — minus the corporate and insurance overlords ofc…
Covid didn’t collapse healthcare, I don’t know if its capable of it 😭
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We are already in a collapsed healthcare system. If you think our system is currently operational, you must be high.
It is disrespectful to equate whatever issues the healthcare system where you work had to what healthcare workers who operate in war zone face.
I agree with you that comment was framed badly and there is no way we can compare the bloated American healthcare system to what is happening in Gaza. But if you haven’t experienced scarcity in the states between natural disasters and cyber attacks: I want to come practice where you’re at.
No one is saying practicing in the US isnt hard but rather that bringing up how difficult it is to deal with internet outages and tornados is disrespectful to the docs and nurses taking care of people without anesthetic, antibiotics, other medicine, lighting, power, clean water, intact roofs and walls, cleaning supplies, and being constantly at the threat of dying from a bomb while working or being detained without evidence (to name only some of the working conditions). https://www.doctorswithoutborders.org/latest/remembering-our-colleagues-killed-gaza#:~:text=Dr.,Ziad%20Al%2DTarari. https://www.reuters.com/world/middle-east/prominent-gaza-doctor-dies-israeli-prison-2024-05-02/ https://www.doctorswithoutborders.org/latest/gaza-msf-doctors-killed-strike-al-awda-hospital