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Know your potential limits in the event of disaster
Priorities will guide providers
It wasn't years of medical education, AIDS research, and experience that especially prepared Ruth Berggren, MD, to accept her appointment as interim director of the Center for Medical Humanities & Ethics at the University of Texas at San Antonio — it was, specifically, six days in New Orleans.
Berggren, an AIDS and infectious disease specialist, was a faculty member at Tulane University and was the teaching physician assigned to the infectious disease ward of New Orleans' Charity Hospital in August 2005 when Hurricane Katrina's floodwaters ripped through the city and stranded Berggren, her colleagues, and their patients for six days and nights in the flooded, hot, dark hospital.
"That experience was a really profound one for me, and made it easy for me to take this position [as director of the ethics center]," says Berggren.
Many lessons were learned during and after Katrina, she agrees, but perhaps none so profound as the realization that every person "will draw their line — the line they won't cross — in different places, depending on who they are, what their beliefs are, maybe how they were brought up."
"And when you're going into a disaster, it's important to know where those lines are."
Some need to stay, others need to go
The daughter of two public health physicians, Berggren grew up in rural Haiti. She has particular interest in clinical AIDS and viral hepatitis research, and in implementing HIV care in resource-poor settings. "Resource poor" was just one of the conditions at Charity Hospital after Katrina hit.
At Charity, as at other New Orleans hospitals crippled by the storm, health care providers were discovering where their own personal lines were drawn in the ethical sand.
"One thing I observed as the hurricane bore down on us was that there was an incredible diversity of responses among the health care professionals there," she recalls. "Some thought, clearly, that their first priority had to be to their families, their dependents, and that led them in some cases to abandon some commitments they'd made to be on call for the Code Gray [emergency response team].
"Others felt their families were secure, and that they needed to stay even though they were not on the Code Gray team, because they felt an obligation to their patients, their colleagues, and in some cases, to their career-long research."
The latter describes her husband, Tyler J. Curiel, MD, MPH, who at the time was chief of oncology at Tulane University Hospital, just across the street from Charity. Curiel opted to stay at Tulane with the couple's young son not only because Berggren was staying, but also to care for patients and in hopes of saving irreplaceable research cell lines.
Berggren is quick to say that she does not judge clinicians whose commitments caused them to leave the hospital and secure the safety of their dependents. For some, staying at their posts while unsure of the welfare of their families hindered their ability to do their jobs.
"We were there for six days, and by day three or four, those who didn't know where their loved ones were had serious trouble functioning, and were unable to remain the calm, professional decision makers they wanted to be," she points out.
Berggren says Katrina proved that even among the most dedicated and ethical health care providers, "human response is hard to predict."
Some who might have justified leaving "demonstrated unbelievable commitment to staying," she says, while others who might have been predicted to stay turned out to be among those who left the hospital.
These responses have obvious implications for future disaster planning, says Berggren, who along with Curiel (now professor and director of the San Antonio Cancer Institute) is often asked to speak to ethics and disaster planning conferences on what Katrina revealed about health care response.
"One of the things I did at Tulane after Katrina was to work with committees redesigning disaster plans, and there was a consensus agreement that there should be better pre-selection of emergency response team members," she says. "You need to say, 'Don't sign up if you know you have dependents who will become helpless in a disaster.'"
In planning a facility's disaster response, Berggren says potential emergency responders should think carefully about committing to what could be a one-day disaster — or a two-week "cataclysmic response."
"They should ask themselves, 'Can I secure my dependents? Can I commit to staying?'" she says. "If you can do that sort of preparation with your team, you will help people self-select who can be there and who can stay."
Where's your 'line in the sand'?
Katrina and its aftermath — particularly the conditions health care providers and patients found themselves in, and the life-altering ethical decisions some physicians had to make when it came to rationing care and supplies — was a "huge" wake-up call for medical ethics.
"When we have discussions on ethical dilemmas in medicine, there is a spectrum of ethical solutions — right and wrong is not black and white," she suggests. In times of crisis, people's limits are based on their individual ethics and where they draw their lines in that spectrum.
"When you're suddenly in the valley of the shadow of death, which is where some people felt they were [following Katrina], if you don't know where those lines are on those spectra, you become confused and prone to make impulsive decisions that you haven't had time to think through," she says.
Those in training to go into a health care profession should be exposed to challenges that cause them to think through ethical dilemmas that show them where their limits are.
The team approach to facing ethical challenges was particularly supportive to Berggren at Charity, and it's an approach she encourages anytime she's asked to talk about lessons learned from Katrina, she says.
"What sustained me was knowing I was part of a team of professionals I knew and I trusted," she says. "We could go to each other with questions, and so no ethical decision was ever made in a vacuum by one person who had to take complete responsibility."
As Berggren visits ethics centers around the country, she says she notes that medical schools are making progress in training students to consider disaster scenarios and the ethical implications they might hold.
"There's a tremendous amount being done today compared to 20 years ago, and I would like to see it spread and involve all our medical schools," she says. "When medical students discuss dilemmas in a bio-ethics seminar, they not only learn where their lines are drawn on certain issues, they also experience the team approach to decision making.
"It is an experiential learning process — they are learning by doing when they discuss a problem together and reach a solution. My belief is that the more they have been through this process, the more willing they will be to replicate the team approach when pressed into grave decision making in real life."
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