Name: The Coming Coronavirus Critical-Care Emergency
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The Coming Coronavirus Critical-Care Emergency

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When the first began, in December, in Wuhan, China, Ruoran Li, a doctoral student in epidemiology at Harvard, paid particular attention. Li’s research has focussed on tuberculosis, but she is originally from Shenzhen, a city of more than thirteen million people on the southern shore of mainland China, bordering Hong Kong. She gave an online seminar on the epidemiology of the outbreak in February, arranged by a Harvard student organization, and began to closely follow the social-media accounts of people in Wuhan. Li noticed that the stories of suffering she saw often had a particular pattern. There were reports of people trying to get emergency care, or a bed at the hospital, and, in one case, she said, dying before doctors could reach their car. Other reports indicated that patients needing dialysis were being turned away and were dying at home. The issue seemed to be capacity: the hospitals in Wuhan simply did not have enough beds or doctors (or enough of the right kinds of beds or doctors) to treat all of the sick. One day, Li was watching the live WeChat feed of a wealthy, anonymous man in Wuhan who was giving his followers advice on how to access a hospital in the middle of the outbreak, in case they had relatives who needed care. “In China, usually if you have some connections—you know someone at the hospital, or you know a doctor—there wouldn’t be trouble getting in,” Li said. “It was a shock to me, because even those who have a very high social status couldn’t get in. It was just maxed out.”The possibility that this pandemic might max out the hospitals—that there is a hard limit to the number of patients that they can treat at once, and that the number of COVID-19 patients will exceed it—is the preoccupation of everyone working in medicine in the United States. It is the nightmare scenario, and it has led to a shutdown of public life across the country, as a last-ditch effort to “flatten the curve”—to slow the rate at which people contract the virus, in order to slow the rate at which patients are admitted to hospitals. Since the virus first appeared in the U.S., public-health officials have issued warnings about possible shortages of basic medical supplies, including masks and gloves to protect health-care workers from the virus—in large part because much of that equipment is manufactured in China. (This week, BuzzFeed News that Memorial Sloan Kettering Cancer Center, in New York City, one of the preëminent treatment centers in the country, has only a week’s supply of masks left. Three patients and at least five staff members have been diagnosed with COVID-19, though not all of them were infected at the hospital.) On Tuesday, the New York Times and ProPublica both of hospital beds from the Harvard Global Health Institute; per the Times, the data found that, in a “moderate” scenario, hospitals in forty per cent of American hospital markets “would not be able to make enough room for all the patients who became ill with Covid-19, even if they could empty their beds of other patients.” But, as an increasing number of Americans have become critically ill with the virus, public-health experts have raised alarms about what may be the hardest limit on hospitals’ ability to care for such patients: the availability of ventilators, the assisted-breathing devices that are the main tools of intervention in intensive-care units. Some patients who develop pneumonia as a result of COVID-19 need ventilators to breathe for them when they can no longer do so on their own; the assistance gives their immune systems time to develop antibodies and fight off the virus. Run out of ventilators and those patients run out of time.Li found that the Chinese government had created an online database of cases in both Wuhan and the surrounding Hubei Province. She began to plot that data, day by day, so that she could determine how many infected people became sick enough to require hospitalization and how many became so sick that they needed ventilators. During the peak of the epidemic in Wuhan, in mid- to late February, Li calculated that two thousand and eighty-seven COVID-19 patients required intensive care every day, usually including ventilator support. That meant that Wuhan’s medical-care centers needed about 2.6 intensive-care beds for every ten thousand adults in the city.Li took her results to one of her advisers, Marc Lipsitch, who put her in touch with other epidemiologists, among them Eric Toner, at Johns Hopkins, who specializes in studying hospital capacity. Together, in a paper released on March 10th, Li, Toner, and four co-authors, all from Harvard and Hopkins, worked to apply the rates of bed need in intensive-care units from Wuhan to major American cities. According to a 2010 report that they cite, there are 2.8 critical-care hospital beds for every ten thousand American adults, and a separate study, from 2015, suggests that those beds generally have a sixty-five-per-cent occupancy rate. That means a Wuhan-like event in the U.S. would stretch, and perhaps overwhelm, many American I.C.U.s. As they worked through the details, they found good reason to think that the American outbreak could be worse than Wuhan’s. Fourteen per cent of Wuhan’s population is over the age of sixty-five, compared with fifteen per cent in the United States, and the rates of crucial comorbidities, such as hypertension, are higher in the U.S. Li and her colleagues calculated that, in an American city, the outbreak could require 2.6 I.C.U. beds for every ten thousand adults, as it did in Wuhan, but when I spoke to her last Friday she told me that now they believe that figure represents a better-case scenario. The upper bound, they calculated, would be 4.9 critically ill people per every ten thousand. In the paper, Li and her co-authors wrote, “If a Wuhan-like outbreak were to take place in a US city, even with strong social distancing and contact tracing protocols as strict as the Wuhan lockdown, hospitalization and ICU needs from COVID-19 patients alone may exceed current capacity.”The Chinese government placed Wuhan on lockdown on January 23rd and rapidly built two new hospitals in the city; one began operating on February 3rd, the other less than a week later. The outbreak in China was still largely concentrated in Wuhan, which gave medical authorities more options. Qi Tan, one of Li’s co-authors, is a postdoctoral fellow at Harvard and, until two years ago, was a pulmonologist working at a hospital in Nanjing, a city of eight million not far from Shanghai. She told me, “There are thirty or more doctors in the I.C.U. at my home hospital, and ventilators, and in early February all of it”—including the doctors—“went to Wuhan, to Hubei Province.” Chinese officials have said that ten per cent of the country’s critical-care capacity was sent to Wuhan to fight the outbreak. In the United States, the outbreak is already diffuse, which makes any similar reallocation unlikely. (Ventilators will probably not be sent from Boston to New York, because they are needed in Boston.) John Hick, the medical director for emergency preparedness at Hennepin Healthcare, in Minnesota, has been studying how ventilator capacity might be increased during a pandemic since 2002, when he participated in a disaster-planning exercise that simulated a “very bad disease” outbreak in Minneapolis. “We realized very quickly that there is just a really hard stop on the number of ventilators we have in a city,” Hick said. “There just isn’t a lot of slack in the system.”As the crisis has escalated, Eric Toner has tried to work out how many more breathing machines are available nationally. There is a federal stockpile of ventilators, for use in emergencies, which Anthony Fauci, the director of the National Institute for Allergy and Infectious Diseases, has put at twelve thousand and seven hundred. When President told a group of governors, on a conference call on Monday, “Respirators, ventilators, all the equipment—try getting it yourselves,” he was presumably holding this stockpile in reserve. Anesthesia machines, normally used in surgeries, can provide some similar functions to ventilators, though using one for a patient with pneumonia would mean that it could not be used for a surgery. Transport ventilators often used in ambulances could, in theory, be repurposed to be useful for some less severe I.C.U. patients. “A very ballpark number: maybe you could get up to a hundred and fifty thousand ventilators,” Toner told me on Monday. “That would mean cancelling almost all surgeries and all procedures, and taking very dramatic and drastic steps that would create a great deal of difficulty. I think that is the absolute limit, and I’m not sure we could get to that number.”Toner, Li, and their co-authors had estimated that, in cities with major COVID-19 outbreaks, between 2.1 and 4.9 ventilators would be needed per every ten thousand people. I asked Toner what those numbers would mean for American cities. “Those cities and hospitals that are on the low end of that spectrum, they will be extraordinarily stressed, like they’ve never been stressed before,” Toner said. “On the upper end, that would be something like they’ve never imagined before, where, no matter what we do, we don’t have enough mechanical ventilators for everyone who needs them, and we will need to make allocation decisions—rationing decisions.”So far, the pressure of this outbreak has been on public-health systems and administrators to “dig under the couch cushions,” as Hick put it, to try to increase their capacity as best they can. But some doctors are also beginning to think about what might happen if there is not enough capacity. In Italy, as pressures stemming from the coronavirus rose, guidance published by that country’s national association of critical-care doctors suggested that, if rationing was needed, ventilators should be reserved for patients with “the greatest life expectancy.” The practical problems—finding more breathing machines—lead directly to ethical ones about what to do if there are not enough ventilators and care has to be rationed, with some patients chosen over others. Those decisions would belong not to the system, in some general way, but to doctors, and in particular the pulmonologists running the I.C.U.s.My wife, Heather Parsons, is an oncologist who works at the Dana-Farber Cancer Institute, on the western edge of Boston. Several other large hospitals (Brigham and Women’s, Beth Israel Deaconess, Boston Children’s) are situated within a few blocks, as is Harvard Medical School, with which all of these institutions are affiliated. We live about fifteen blocks away from the medical campus, in the Coolidge Corner neighborhood of Brookline, in what must be one of the world’s densest concentrations of doctors and medical scientists, talent drawn from all over the planet. They are impressive people, and they are perhaps especially impressive to one another—no one wants to be the weak link. In my experience, doctors think about their patients but also about their fellow-doctors and nurses and medical staff—about the vast, collaborative, intricately organized enterprise of professionals of which they are part. “Everyone tries so hard,” Heather told me once, when she was in medical school and starting to work in hospitals, and she has said it hundreds of times in the years since. Everyone is always trying so hard.This past week, everyone has been trying even harder. Each time I dropped our son off at the medical-faculty day care, it was awash in weighty new rumors. Certain surgeries, less acute ones, were said to be postponed. Some doctors were said to be quarantined at home for fourteen days, uneasy and anxious at being sidelined. Only the Massachusetts State Public Health Lab was certified to test for COVID-19, which made it all but impossible to have a suspected case confirmed. Doctors were having to make decisions about what precautions to take without knowing for sure who had the virus. Even the mundane workings of the hospital, such as the waiting rooms and elevators, carried new risks, and so decisions that had been easy—say, about whether to have a patient in for a follow-up—became hard. Many of Heather’s patients, people with breast cancer, are on immunosuppressive drugs, and are particularly vulnerable. These decisions had little to do with the limits on ventilator capacity, but they shared the same sharpening realization of trade-offs.A friend of mine suggested that I meet a colleague of his, Emmy Rubin, an attending intensive-care pulmonologist at Massachusetts General and the co-chair of the hospital’s Optimum Care Committee, which she described as the “ethics committee.” We arranged to meet on Friday afternoon, in a pub across the street from Mass General, and though I showed up fifteen minutes early she was already there—a small woman in a green raincoat, with short brown hair, Tina Fey glasses, and an intense and worried look—with the punctuality I’ve come to expect from doctors. Rubin has been involved in planning for the response to the outbreak. When I met her, she was also preparing for a scheduled two-week rotation running one of Mass General’s medical I.C.U.s, beginning on Wednesday, and was trying to weigh what she would do if the I.C.U.s became overwhelmed. Rubin told me that, in some personal ways, she was “totally unprepared.” She said, “Should I be, like, writing letters to everyone I care about? I mean, I guess it can’t hurt, but on the other hand am I realistically going to do that, like, this weekend?”In the Mass General I.C.U.s—the best-resourced units in one of the very best-resourced hospitals in the best-resourced country in the history of the world—the general American assumption of infinite possibility reaches something like an apogee. “Our culture here in the United States is that people who want critical care generally receive it,” Rubin said. “So the idea of not being able to offer it, or saying there are certain people we cannot offer it to, is very new, and a huge departure.” As the stories of strict age limits that were being recommended for ventilator allocation in Italy spread, Rubin had been thinking through the ways in which various ethical frameworks might be applied to rationing care. A strict age cutoff had the advantage of taking all subjectivity out of a doctor’s decision, she said, but it also seemed a little hard to defend, because not all people are equally healthy or equally likely to live a long life. She also raised the idea that some people, based on their professions, might receive preferential treatment, such as “health-care workers or other people who could help save lives or provide a valuable social good that contributes to solving these problems in the future.”In the abstract, it is easy enough to say that a healthier patient with longer to live ought to be prioritized over a sick one. But when a doctor is confronted with two charts of people whom she has never met, it is not easy to quickly make a call. Within the community of medical ethicists, Rubin said, there had been some efforts to define categories of patients—those with malignant metastatic cancer, for instance—who might receive lower priority. But even that seemed too crude: with modern therapies, Rubin pointed out, you could have patients with metastatic breast cancer who would live for fifteen years. “As you try to come up with categories, you really recognize the limitations of those categories and the difficulty of lumping people together who are not all the same,” she said. “Anything but a strict cutoff is going to be extremely subjective.” But extremely subjective measures are still, she said, “probably the best tool.”Eventually, Rubin had to go, and as I lingered, taking notes, I realized that the pub, empty when our conversation started, was now starting to fill up. Schools were being cancelled, and the governor of Massachusetts had just issued an order limiting gatherings to two hundred and fifty people. Beer was being poured, the mugs passed from hand to hand to mouth; plates were being cleared; the men’s room, bar-grimy, was being used, and then people were returning to the bar and eating again. I saw no one with a mask or gloves; surely the disease was spreading.Before Rubin left, we’d chatted for a bit about her plans for the weekend, which had once been to go to Cape Cod and were now to make sure that the ethical plans for the I.C.U. were updated to account for COVID-19. We talked about how Rubin’s I.C.U. rotation might be different than it had been in the past; she mentioned that, because of the risk of contagion, family members would not be allowed to visit infected patients (except, perhaps, in end-of-life scenarios), though technology was being set up to allow for video conferencing. Part of the emotional work of an I.C.U. doctor is to build a quick rapport with a patient’s family, so that life-and-death decisions are understood as joint ones and not as the imposed preferences of the doctors. “It is very hard to build that rapport when you are not in the room with them,” Rubin said. Imagining the scene seemed to clarify what she hoped to avoid. “The horror story is that they are dying alone.” began contributing to The New Yorker in 2006 and joined the magazine as a staff writer in 2015. He writes about American politics and society.Commentary on American politics and society.

When the first began, in December, in Wuhan, China, Ruoran Li, a doctoral student in epidemiology at Harvard, paid particular attention. Li’s research has focussed on tuberculosis, but she is originally from Shenzhen, a city of more than thirteen million people on the southern shore of mainland China, bordering Hong Kong. She gave an online seminar on the epidemiology of the outbreak in February, arranged by a Harvard student organization, and began to closely follow the social-media accounts of people in Wuhan. Li noticed that the stories of suffering she saw often had a particular...

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Benjamin Wallace

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The Coming Coronavirus Critical-Care Emergency

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