Dr. David Urion - Rationing and Prioritization during CSOC in Covid 19

out here. You know, there's any of a number of people in the audience who would probably be infinitely more equipped to give this talk than I. As a several colleagues from ethics and intensive care are here, but we'll sort of soldier on. I'm going to try and share my screen, which is always, oh, and then to answer the question since, you know, most of us have developed, you know, this huge interest in what people's backrops are and kind of what's on them, you know, kind of squinty and looking at them. And I can't make those sort of fancy things, you know, that show pictures of the Zaykin Bridge or the hospital here. I didn't actually run the Chicago Marathon. That'll save us all one question later in the background there. Like most people, parts of our house had been repurposed for office space and the shrine that was our son's room is now my home office. So, can anybody see that? Is that working? Great. So, I'd like to speak, you know, over the time to give in and leave ample time for questions around issues of rationing and prioritization in the context of right standards of care. And what are the lessons that we've learned as a system to date during the COVID-19 pandemic? And I would start off by saying that none of the lessons learned or things that we'll be talking about today are meant in any way, shape or form as a critique or a criticism of all sorts of people who did an extraordinary amount of work on very short notice when we got hit by the pandemic. But rather what systems, particularly on the basis of this and what can we learn? These things in general tend to be really good teachers and pandemics, I think, show us all of the flaws, cracks and crevices in a healthcare system. And we would be foolish if we chose not to learn from those. So, I've already heard sort of of my job positions. I think the things that add would, when the crisis standards of care came out, I was part of a group that was assembled by leadership at Children's Hospital to come up with some practical responses to the crisis standards of care at the critical level. And then did the same thing again and then in a revision during the second surge that was actually system-wide at the Beth Israel-Lakey health system, again to come up with approaches that might use that. So that undoubtedly influences some of the thoughts that you're about to hear. I don't have any financial disclosures of significance. I'm just not sure how you would have those in the middle of this. But I am one of the authors of a position paper on a prioritization schema as they impact people with neuromuscular disorders, a point to which we'll return later in a more general fashion. So, you don't need to know the entirety of the autobiography, but at least the things that might influence some of the opinions that I'll offer you over the course of the next bit of time. So I have three goals today, maybe three objectives. One is to review the crisis standards of care as they were developed here in Massachusetts and mostly to review process as much as content. The second is to examine the impact of crisis standards of care on pediatric practice and especially on non-urgent and elective procedures as we've now started to roll back to those. And then find me to steer the impact of risk standards of care on the estimation by the public of the trustworthiness of the medical system. So, I'm a basic principal, basically when I think about ethics. And I didn't hear this. First of all, I first heard this from my grandfather who is an architect and very accomplished musician and also an enthusiastic fisherman. I'm certainly sound original with him, but I first heard it from him. And it's something I've actually carried since then. So, I think this is what you do in the dark before the Fish and Game Warden gets there. To make that a little more high-faluten, we know now on the basis of a fair amount of neuroscientific work using functional magnetic resonance imaging that when we give people moral problems over which to reason, ancient parts of our brain that we often think of as part of the so-called limbic circuitry are the first portions that light up and then only later do those transmit to other parts of our cortex. So, while we may give ourselves some reason that we have an ethical opinion on something, you know, that you decide that you're a consequentialist and therefore that's how you like to think about these things or your virtual ethicist. And this is what Alistair McIntyre has taught you, anything along those lines. In point of fact, I think we actually feel most of our ethical decisions and emote them before we then find some logical reason. And it's not that logic is at all a bad thing nor is it bad for us to reason through things. But I think it is important to remember that if it feels wrong, that's actually worth paying attention to. So, let's first talk about crisis standards, not in terms of what the actual details were, but really more from a process and a systems initiative. So, crisis standards of care in general are developed, are developed, and overwhelming threat to the public health. And unlike most of what we all do on a daily basis, which I think is to consider what's best for the patient that's sitting in front of us at any given moment and do everything in our power to make that happen and also to divest ourselves of conflicts of interest that might not operate in the patient's best interest. We make a real pivot in the context of crisis standards of care, because these are developed to maximize benefits to entire populations of patients and not to single patients. And so, if we put that through to its logical conclusion for the vast majority of providers, this is a dramatic shift in what the day-to-day ethical practice... So, I was in there. Harry has all of the emergency drugs. She's also... Of the... The eye-alarm... And I think it's important for us to underline that, because this goes really far beyond what most of us are getting used to in terms of concepts of population health and taking that notion and really putting it on steroids. In addition to that, what's hidden behind the concept of crisis standards of care is that without a pivot and a significant pivot, our entire system, whatever it might be, could collapse and therefore, essential personnel would be eliminated from being available in this instance and in our instance, the medical care system, which would quickly grind society, as we know it, to a real halt. You know, we can think about some of the haunting pictures that came out of Tuscany during the first surge where things really were on the verge of collapse and understand what the impetus behind this is. The other observation I'd make here is that by and large, certainly here in the United States, we've tended to have a system where we don't have a sort of standing set of crisis standards of care that are just sitting on a shelf and we can pull them down and use them in any situation. They tend to be bred in the moment and of the moment. And although there were previous versions of crisis standards of care here in the commonwealth, as well as in several of the other political jurisdictions in the United States that developed these, I think it's important for us to recognize the fact that we tend to operate literally in a crisis when we have to develop crisis standards of care. We'll come back to that in a moment because it tends to therefore drive the process in certain directions and in certain fashions that may not always be advantageous for the larger system as a whole. By and large, we sort of, not entirely improvise, but we confront things each time. Mostly in the United States, these have been developed in response to infectious disease threats and threats of pandemics. But we could easily imagine a situation in which that weren't the case in something else we're going on. So most of these are developed at state levels because of the way that we organize our healthcare system. Most are developed under the authority of departments of public health, which if we think about it as one of the more immensely neglected parts of our overall healthcare system, which is usually both understaffed and underfunded. And then as we can see in the example of New York state, roundly ignored by the heads of government, despite giving, I think really judicious information there. Usually, however, when crisis standards of care are rolled out, the Department of Public Health, which doesn't have on staff, all the people it would need to do a reasonable job of this, find them drafted by ad hoc committees of experts. And as we were talking about a few moments ago, they are usually developed in a crisis mode themselves. Something is bearing down on us and we therefore need to turn this around in a relatively short period of time. As a result of that, the amount of incoming public input is variable. And in many, many instances, the process is reasonably far along before various persons in the public are involved. And we'll talk in a moment about some of the communities that felt themselves in the Commonwealth more afflicted by the original version of crisis standards of care. And therefore, why one had to respond to this. Given that, this often leads to redrafting of original versions of crisis standards of care if the pushback is sufficiently strenuous. And this kind of give and take, push and pull, is pretty typical of many healthcare policies across the United States. I don't suggest that in fact that's an odd or unusual thing. However, in the impetus of the moment and with the perception of crisis, this can make this far more problematic and may not allow us to acquire as many opinions with the same efficiency as we otherwise might need to do this job always in the public interest. And while usually written to be somewhat generic, most versions of crisis standards of care are thought of as being put to use when some critical medical good is in critically short supply. I mean, that's what obviously they need to address. And it tends, however, to focus on technology since that's often in a pandemic perceived as the most critical good. And therefore, ventilators are a good case in point here in the United States fit in large part, I think, because of the Tuscan crisis in the early European phase of the pandemic. In Massachusetts, as you probably know, if you were following this along, there was a point system which heavily used the sequential organ failure assessment score as a way of assigning priority to persons who would or wouldn't get ventilators and or ICU beds in the event of a critical shortage of those goods. There was originally a consideration of co-extant conditions. And as you probably know, children were specifically excluded since the Sophosco was never really validated for them. And freestanding children's hospitals, all one of them here in Massachusetts, were specifically precluded from having to use these. So when a hospital was reaching a critical limit of its capacities, it could, for example, alert the Department of Public Health of the Commonwealth to have crisis standards. If somebody could admit their might because we're somehow getting feedback to invoke a crisis standards of care. One of several important points to recognize within the context of crisis standards of care was that there was an indemnification of the institution from the consequences of its decisions. Obviously, there were some people who would be ultimately disadvantaged by this and would not receive care that they would otherwise be entitled to receive under other circumstances and hospitals were indemnified from those kinds of legal consequences. The system, however, really depended on inter-hospital collaboration so that we wouldn't have the situation that one hospital in a region didn't go into crisis, went into crisis standards of care, went another nearby, still had resources. In a relatively small jurisdiction, such as Massachusetts, that's geographically small distribution. That's easier to pull off than in places where there are long distances between various access to care. Years ago, I was doing some consulting at the hospital at Boystown, you know, Father Flanagan, no such thing as a bad boy and all that. And as a result, I went into have a meeting with the commissioner on public health of the state of Nebraska and there was a big map up on the wall behind him of Nebraska. And it was in it had several colors. There were two little red dots. And then about the eastern third of the state was another color. And then the western two thirds of the state was yet another color. And I said, so Kuchik, it's really that map to me. It's kind of interesting. And I said, yeah, those two dots are, you know, the two urban and suburban areas we have really Omaha and Lincoln. And then I said, okay, so that's urban and suburban. And then the eastern third of the state said, oh, that's rural. And I said, okay, what comes after rural? I'm not aware of that. And the western two thirds of the state was was referred to as frontier care. And that meant traveling on dry pavement for 90 minutes under excellent conditions. A first responder could get to you. And I realized that their issues and public health are probably quite different than ours and collaboration in a setting like that is really quite different. This is a is a semi voluntary system that is the identification of resources and during the pandemic as at other times the hospitals have been required to report critical assets in terms of ICU beds, surge bed capacity, et cetera. So the Department of Public Health could keep tabs. It's probably should have said this in the original disclosures during the course of the pandemic. The office of the director of ethics, which I sit now at the Beth Israel is part of the incident command system, which is the equivalent of our AOD system. We don't have a similar representation on children's. You know, crisis managers, the situation for this hospital is different, but it's an interesting observation. I was never quite sure what I was doing there. Others and people would kind of look side long at me when various points were made. And decisions were being made. I think I was supposed to sit there sort of in a black and white striped shirt with a, you know, sort of yellow flag that had a manual cons picture on it or something and throw it if somebody said something that was unethical and call the play. So when crisis standards of care are invoked allocation teams, which had been previously designated would make decisions regarding who received a resource and who did not. And allocation was explicitly determined by stated criteria. The appeals process, imagine this would be very, very limited and really was only questioning the allocation score and not the notion of allocation in and of itself. So crisis standards of care, therefore, focused on high technology goods such as ventilators and specific high technology care locations such as intensive care units. And there's a level we can see from the Tuscan crisis where that's important, obviously. And many things flow through and are dependent upon the availability of ICU beds, including more routine aspects of care, where people can end up for transient periods of time or sometimes. Not such transient periods of time in ICU's. But I want to make a point that this sort of represents what I think of as the ethicist is magpie, you know, really mesmerized by bright, shiny things and not always paying as much attention to where the sticking points really are and what the day in and day out ethical dilemmas of folks are. And I make that observation on myself as much as anybody else. So in the early phase of the pandemic here in the Commonwealth, at least, unlike Tuscan, we appeared to be supplied with at least an adequate number of ICU beds and ventilators and had recently good regional coordination. You know, I think as a colleague and friend said, you know, during the first surge, the water came up to our clavicles, but no higher. What was in short supply and what created a huge amount of consternation at the ground level was personal protective equipment. And I think everybody can think back to those early days, especially if you were working in a multiplicity of Harvard hospitals where there was a bewildering set of differences in terms of what it is one needed to have on when one needed to have it, what you needed to wear. This tended to undermine confidence in the entire system. You know, I'm certain that residents in your programs had exactly the same experience. Our residents in child neurology rotate between MGM, RIGM, MGB hospitals, the Beth Israel Deaconess Medical Center and Children's Hospital, which in the early days of the pandemic had dramatically different kinds of rules for PPE, different approaches to conserving what was perceived as a truly scarce good given the supply chain. Along those lines. And it tended to therefore undermine people's confidence within the system itself and had people very worried about what they were being asked to do on the basis of their job. You know, one of the things I think we could make another sidebar observation from an ethical standpoint is that personal protective equipment has never been defined as a critical strategic national good, at least during the previous administration. It was not as a result. It was permitted that its supply chain could be external to the United States and not surprisingly 90% of the PPE that was being used at the beginning of the pandemic was produced outside the geographic borders of the United States, mostly in Asia, predominantly in China. This left us therefore vulnerable at any of the number of levels. And we continue to see the vulnerability of the supply chain based on the recent events in the Suez Canal. If we think about the second surge at most places, the critical shortage of goods for the expanded ICU surge that the second provided us was actually in skilled nursing, especially skilled nursing for intensive care unit settings. And although we can always ramp down how much a hospital does, we can sort of say we're closing the operating rooms to elective procedures to semi-elective procedures. We're going to close the GI procedure suite. We're going to ramp down in the cardiac catheterization laboratory. The problem is that the nursing workforce that is opened up then is not immediately transferable into an ICU setting. And so the realization that this very human resource was an incredibly critical part of the response. And yet planning for that wasn't really clear. And also the unavailability of transfer, transferred skills, I think also is something that wasn't taken into accounts with sufficient planning beforehand as we go back and think about this. Now, either of these things technically could have led to the invocation of crisis standards of care. We were in a crisis because there wasn't enough PPE. It appeared in the early days of the pandemic. In the second surge, we had a critical shortage in many health care facilities across the Commonwealth of nursing with ICU capacity. And yet the system itself wasn't really designed for the allocation. It was designed perfectly for the allocation of high technology and high acuity physical resources, but not scarce low technology goods such as PPE or the human resources such as skilled nurses. And so I think that we need to take that into account as we come out of this because I think we're all pretty convinced this is not the last pandemic we'll see. So I think the first lesson is that generals always like to fight the last war. And Dwight Eisenhower, other famously said in preparing for battle, I've always found that plans are useless, but planning is indispensable. And so I think as we consider pandemic responses moving ahead, these are lessons learned and ones that I think we'll need to hold on to. So the crisis standards of care were developed by the Department of Public Health with involvement of multiple different hospital institutions across the Commonwealth and the input of both intensivists and medical ethicists who are perfectly important and prudent people to be on that. But public reaction really wasn't sought until further down, which led to some difficulties because there was significant pushback from communities of color and communities of persons with disability arguing that the allocation rules really doubly penalize both of those communities. We think and we know that social determinants of health and underlying conditions, which were initially factored into thinking about this. And also one of the reasons why people may be more ill with COVID-19 made it more likely for these groups to have more problematic surface scores and therefore be secondarily penalized. There have been some interesting proposals and maybe during the question and answer time we can talk about that of ways to overcome this through things such as weighted lottery systems, although lottery is usually a vast swath of the public health world as well as the providing world in hospitals reflux. But we can think about that as a way of trying to make this a fairer process. And then the ability to arrive at the hospital in the first place has a significant influence on one's prioritization scores because you have to be there in order to be prioritized. We were not thinking across communities entirely, but rather who was within the walls in essence of the building. And so communities of persons with disabilities because it was a harder place for them to get felt doubly penalized and made some pretty significant critiques in that sense. So lesson two I think is something I learned from Judith Johnson, a lawyer and medical ethicist of great renown and here in Boston. Nothing about me without me. I think that we the lesson we learned from this is that we absolutely need to have people who are essential stakeholders in some way, shape or form involved in the process from the get go. This makes it clunkier. This makes it somewhat more difficult. But it also probably makes it more valuable and makes it probably something that is more reflective of larger. That being the case, it would suggest therefore that this is probably not best not done in the midst of the crisis itself. But as we think as best we can beforehand, especially now that we've had the large experience that we've had over the last more than year within the pandemic. So I'd like to shift now and to think about the impact on elective and non urgent procedures and how we can think about that from from an ethical perspective with some particular attention to pediatric since that's where we are. So, Nick, I'm sure but your last name and colleagues developed a model for worldwide cancellations of surgery during the 12 week peak period of the first surge. The design was rather clever. It was a Bayesian regression and it used expert estimates from both the global north and the global south and it conceived of the surge as we think of all epidemics as a rolling process. So it was the 12 week peak period wherever that was happening in your jurisdiction and it defined urgent as cancer surgeries, trauma surgeries and life saving vascular surgeries. And by the best estimates that they could come up with in their work, they estimated that in that 12 week period of time 28 million surgical procedures were canceled across the globe. That's greater than 2 and a quarter million per week. Overall, they argued that about 90% of those procedures that were canceled were postponed would be considered benign under their definition. And they found that by category 82% of the benign operations were canceled or postponed. 37.7% more than a third of cancer operations were canceled or postponed. And although this didn't happen much in American jurisdictions, they found that worldwide about a quarter of elective cesarean sections were canceled or postponed. And the methodology therefore being that if all elective procedures were canceled in a given jurisdiction, when people would need to go into labor women would need to go into labor and then have an emergent section rather than an elective section to measure up to the local regulations. This obviously is hugely disadvantageous and dangerous for both maternal and fetal health, but that was the best number they came up with in their work. So the post surge implications from this work said that if countries were able to increase their post surge capacity by 20% so by a fifth, it would still take 45 weeks or nearly a year to clear the backlog, which is a fairly significant and sobering number to think about. So I think one of the ethical implications here is that while ethicists collaborated with state departments of public health to develop crisis standards of care, that is rationing of perceived shortages of critical goods of a certain type during the surge, no such collaborations occurred generally during re-opening. In which arguably I think we have a real shortage is this demonstrates we have a lot of backlog for this and prioritization, which is I think a nice proxy for rationing because Americans don't usually like using the R word in the context of their health care system was required. And yet what some of the thoughts might be about who gets to be first in line, although there's all sorts of reasons that one needs to think about. Obviously there are the frank and foremost surgical priorities of this, the medical consequences of this, people social situations. But this has been a place where in fact in most all jurisdictions, ethicists have not been involved. So not used a crowdsourcing software to determine the preferences of 722 people obtained through this regarding their preferences about surgical rescheduling after re-opening. So they were asked some questions about what they were thinking in terms of their own postponed surgeries. And 61% worried about contracting COVID-19 in the period around the surgical procedure, mostly during the intake process in waiting room, although a certain amount were also worried about contact with staff. Interestingly, 57% of people preferred hospitals over free-standing surgical centers to make up their surgery, feeling that in fact a hospital was ultimately a safer place to be because of protocols. So I think we need to take that into account when we think about planning if that's in general the public's impression. And then 25% only would choose the first month of re-opening. So I think that this is something that we see often as a human principle. We think it's a good idea to go ahead but we'll let somebody else be first if we think that there's a risk associated with this and see how it works out for them. This therefore means that people are postponing procedures that we might think of as maybe best not postponed. There was a higher likelihood of overall viewing, moving ahead with the postponed surgery favorably in independently by people who were native English speakers, people who were men, and people interested in the who had veterans department insurance. That meant therefore that persons who were non-native English speakers, women, and other groups were more reluctant to move ahead and reschedule the surgery that they had postponed in order to have some maintain sense of safety is what the authors assume. And I think that that's probably a reasonable assumption. So how do we use these data to avoid the acceleration of health inequities and issues of unequal access when considering elective surgeries after the re-opening? That is if we say that many people in various medically underserved communities have poor or access pre-pandemic to many of the things we're talking about here, elective surgeries being this particular case in point. How do we not use the COVID-19 re-opening where there's a huge pressure on the system to get the backlog that's been acquired and not have that accelerating what already existed before in terms of elective surgeries? And again, we can come back perhaps during the question and answer period. If some systems that have been proposed such as weighted lotteries might be brought into play in order to try and make this a more just system. So obviously children were explicitly excluded from being considered under crisis standards of care. The hospital drafted a response that reiterated to our communities that we would not use disability or chronic illness as it determined into who received critical care. Even if the age of the person was greater than 18 or 21, which was a somewhat shifting standard over the early periods here. But this basically said that once a patient here, always a patient here and that we wouldn't consider them under the adult ages if they were our patient and were older than this age. And we also know that there was a certain surplus of ventilators that were able to be lent to nearby adult hospitals in the earliest phases of the first surge, making that a more fungible resource. We certainly saw a multi-system inflammatory syndrome in children as well as more typical COVID-19. But this did not overwhelm our system. And after the initial drawdown where anybody who is around can remember that parts of the hospital felt a bit like a ghost town or a derelict vessel. Most services then saw a significant increase in what they always did before as other regional pediatric resources were repurposed. And although this was uniformly true across the hospital, we certainly have evidence to suggest that all of us saw a lot more of what it is we usually do in some instances from quite a lot further away or from patients who were traditionally taken care of in other systems that had repurposed parts of their ICU or their pediatric, there's more pediatric ones for adult purpose. So reopening, therefore, poses challenges similar to those that we see in adult institutions for different reasons, but nonetheless with the same consequences. And therefore with the same set of questions, which is who goes first and then how do we prioritize? I'm going to take the last part of this to the impact on the public sense of the system's trustworthiness. So social scientists and some nice work that was done by CREPS and Criner in late last year demonstrated doing a meta-analysis of five fairly large studies of public opinions about the pandemic is that public trust in science over the spirit of time. Really rested on four pillars, transparency, understanding of probability, who the Q giver was and what Q was given. So transparency. So if we think about the vaccine rollout in the Commonwealth of Massachusetts, there's a nice poll in the Boston Globe this morning that shows all of the aspects of his governorship. And leadership over the course of the pandemic, although in general, Governor Baker gets very high marks. The lowest were for the vaccine rollout. The thing about which people were most suspicious were actually only about half of the Commonwealth poll at least found his performance, thought of his performance in a favorable light, whereas the numbers are up in the 70s and 80% overall. So what's going on? So the Commonwealth through its Department of Public Health has spent about $20 million over the last 10 years to develop a vaccination rollout in the local BCP offices. And this was in response to several threats of pandemics in the past, thinking about both Ebola and H1N1. PCP offices are singularly well poised to give vaccines. They do it all the time. Even if the Pfizer vaccine and the Moderna vaccine required refrigeration that was above and beyond the can of PCP offices, nonetheless the operation of a PCP office to get out vaccines is something that they do and they do well. Public Health departments or local health departments have variable success with this, but again have a pretty good tab on the community that they serve and therefore a great on the ground knowledge. However, when the time came, instead of flipping the switch on this system, a no bid contract system empowered three private concerns to run the large vaccination sites across the state and actually non-had had any non-had had any previous experience running vaccination campaigns. Two of them were relatively new companies. One had been involved in medical testing before this and pivoted in the course of what was viewed as an opportunity. And then as we all know, the Commonwealth's policies regarding dispensing through hospitals and then not through hospitals had a huge messaging problem in terms of what vaccination supplies would or wouldn't be available and when they would or wouldn't be available. I think that it's perfectly both rational as well as advocate, defensible that staff was immunized first so that the institution could keep rolling. It didn't look great, however, when we wanted to pivot to patients, especially those in high risk conditions and then had no supply to offer them. So probability. I think this is difficult for most people under the best of circumstances and a pandemic is not the best in circumstances. And when you ask, you know, even reasonably intelligent late people, what in fact does 90% efficacy of a given vaccine actually mean? Their answers get a bit befuddled and therefore we tend not to be able to rely in the public venue on probabilistic thinking in the same way that we can in terms of thinking within the hospital. And then how do people interpret at an on the ground level the varying rates of total protection from a vaccine versus protection against the more serious forms of the illness and how much are people willing to embrace in the difference in the differences there where most vaccines are more effective for serious forms of the illness. That is if somebody gets the illness that it may mitigate it will likely mitigate it, but not always providing complete protection. So, caregivers, that is, who's delivering the message makes a huge degree of difference. And so we can think about some of the messages that this man delivered rather consistently over the course of the pandemic versus those that this man delivered over the course of the pandemic. And again, the information that's being given will tend to influence people hugely. One of the interesting things that people that rather the study demonstrated is that with the exception of people who are true believers at either end of the spectrum, self-characterized, self-characterized. Most people listened to this man and thought what he was saying was probably pretty much true. And most people listened to this man and didn't think anything he was saying was particularly true or useful. This becomes a huge problem, he identified, when high levels of leadership are viewed as untrustworthy caregivers. And then how about the cue given? So I think one of the things that we've seen over the course of the last four years and probably longer is the weaponization of facts. And what's interesting is the demonstration that the study had, that the weaponization by social media, press, text, etc. that was generally identified as left leaning or democratic, was viewed as more problematic if it was proved wrong than things that came out of the right leaning press. And that was true actually across the political spectrum. So that if something that was said, for example, on Fox or places like that, proved to be untrue, it was less distressing to people than if something like this, which appeared in the Atlantic monthly, proved to be untrue. So Georgia opted to open this economy relatively early and the DPH there essentially acquiesced in the Atlantic monthly titled its article Georgia's experiment in human sacrifice. And basically the article predicted that people would basically just be dropping by the sides of the road as Georgia prematurely opened up its economy. Although there were spikes in cases, obviously Georgia didn't turn into the walking dead. And the DPH's agreement figured heavily on this story, which then led most people to view this organ of opinion, which has been useful as less available and less reliable. So we know that medically underserved communities were the hardest hit by the pandemic and they certainly felt more disenfranchised by version one of the crisis standards of care. And in many instances they didn't have ready access to some of the large vaccination sites given the location of those sites and public transportation issues getting to those sites. They also, by and large, had poorer access to workarounds. For example, you know, many of our departments quite quickly pivoted to telehealth visits. My own home department in neurology still runs about 95% of the health visits under the 5% live visits in most given weeks, which is terrific except for the fact that many medically underserved communities have relatively poor access to broadband. Have relatively poor access to some of the technologies that are necessary for this and often have difficulties interfacing with our systems, which are linguistically driven and may not be in a language that is one of comfort, especially for technical instruction for them. Interestingly, the highest rates of pre-COVID-19 vaccinations in medically underserved communities were in those with functioning community health centers. For example, the South End Community Health Center consistently ran rates in excess of 96% adherence to AAP pediatric immunization guidelines. These were exactly the health care facilities that were left out of the COVID-19 vaccination rollout. So I think we can look at this in terms of lessons learned as a missed opportunity. This is a community health center that serves a medically underserved population that in general has been highly suspicious of the vaccine rollout. But has huge trust in its local providers and therefore would have been a likely way to get at least one medically underserved community effectively vaccinated early on. If we multiply that across all of the reasonably well functioning community health centers in the commonwealth, this was a missed opportunity for distribution and effectively driving up our vaccination rate and therefore getting us closer to the grail of herd immunity. So if the system is not proven itself inherently trustworthy in the eyes of its constituents, why should we be surprised if it's not trusted? And so I think we'll finish just with a couple of images. You know, for all of its difficulties and foibles, the National Health Service is viewed by most Britons as with a huge degree of affection and was hugely trusted during the pandemic. During the vaccine rollout, which in Britain was based on both NHS sites as well as primary care doctors, obviously linked into the National Health Service. And as we know for a variety of reasons, Britain has leading the globe in terms of rates of vaccination across their population. I don't think that people have the same warm and fuzzy feeling when they see this logo, despite all of the great efforts that it's made. It hasn't had the same impact on the population and also hasn't gained the same level of trust that the National Health Service has. And therefore, we've had more of a struggle here in the commonwealth. So thanks for your kind attention. And at this point, I'll stop sharing the screen and we can open it up for questions or Rick Bats or. David is Jeff Burns. First of all, you know, thank you for everything you did during the pandemic, your leadership at the state level on our behalf and your leadership in the hospital as co chair of the ethics committee. My question for you, I have two questions for you. The first one is, what is children still not prepared for that we should be prepared for? And secondly, if you could comment briefly on our own pandemic, which is the behavioral health pandemic. And what more could have or should have been done for that as well. So actually, I think I'll answer both of those questions with one because the place that has obviously been the huge Achilles heel or beyond this of the system has been has been behavioral health. This was a system that was not working before the pandemic and then basically sank in the context of the pandemic. You know, I think most days I wake up and think that Americans profess to be a society that loves children. And then I spend all day trying to find evidence to support that contention. Usually I'm unsuccessful. And I think that this is a huge example of that. You know, this is a process like most disasters that began a long time ago. Although I think there was a noble thought about de institutionalization, right, and closing down some of the huge warehouse like facilities. The babies were thrown out with a bath water. The Gabler Center, for example, which took care of the 45 psychiatrically most disturbed children in the Commonwealth who's shuddered none of its resources were returned to community health centers and those children were put out into the world. That's a that's a calamity that then expands and expands and rolls. The Gabler was actually an institution that we could all have been proud of as citizens of the Commonwealth because it provided excellent care for the children that were there. So I think that we began with a long system of neglect for this. If we then add on top of that, that a system that was barely keeping its head above water and most days was actually going under for the second time. Then gets stressed beyond all belief because the pandemic not surprisingly makes most people who are anxious, more anxious, most people who have significant behavioral health concerns more so. And we had utterly no place to turn for them. You know, facilities had been shuttered, nurses with expertise, physicians with expertise have gone elsewhere, had had other employment. And so we ended up with this as an ongoing, huge both crisis and moral stain on the Commonwealth. I don't think it's I think that this institution, like most, is doing the best it possibly can in an utterly impossible situation. So if we don't crawl out from the rubble of the pandemic and try and have some systematic solution to that problem, that will be our bad and people will wonder what were we thinking. That's probably the biggest crisis for us to solve. I think the other one that's sort of grumbling along is something I think we all see when we are at work and talking with people. This is getting to be a grinder. I think in the early days, there was lots of like most conflicts. This one was with an organism as opposed to another nation. But there's always huge optimism. Everybody's going to be home by Christmas. Everybody rolled off into pick your conflict in world history. And it was going to be over in two or three months. We'd be rolling into fill in the blank. Berlin, Paris, wherever. And then things turn into a grinder. And I think that keeping up morale over multiple generations of house officers, where this is now the new normal. I mean, lots of us can remember what it used to be like, right? Because we're older. But we now will have two years of host, who have been totally immersed in this group of medical students emerging from their training for whom this is normal. What will that look like and what will that do to our senses of professionalism and the way we care for people? So those are the two things that I think mostly keep me up nights. I see that Dr. Trude has a special for you. Hi, David. That I got to say that was the best high level overview that I have seen or heard of what we've been through in the last year in terms of crisis standards of care and allocating resources. You know, as a part of the mass task force that developed the initial guidelines, Sally Vitaly also from Children's Hospital. It was a bit of a PTSD experience here and you describe it because it was all true. The point I wanted to make is that for, if you regard to, as you correctly put, we were obsessed with how to allocate ventilators at the beginning. And you know, dozens of articles were written mathematical models were formulated, we were rebuising them constantly in terms of thinking about how to account for race and disability and socioeconomic status. And yet, as I sit here today, I do not believe there was a single case that I can get up that I know of where those allocation models were actually used to distribute ventilators. That in the heat of the moment when somebody comes into your emergency room or into your ICU, if they need a ventilator, nobody actually calculated a score and said, you know, your priority is a little bit low. We're going to put you over there in the corner for a while. We we reacted as you described with our limbic systems and or in ethical terms, what we call the rule of rescue. And all of that went out the window, you know, when when Los Angeles was in the midst of its crisis, I recall to the ambulances were aligned up, you know, for blocks outside of hospitals. Nobody was going from ambulance to ambulance and calculating a priority score. It really devolved the first come first served. And I think that's a powerful lesson to me about the limitations of rationality or as you kind of put it there, the ethicist role is a magpie, you know, attracted to theory and how we how we ought to be doing things that just seem to fall apart in the moment of crisis. And anyway, that was that's been one of the takeaways for me and I wondered if you had any thoughts about that. Yeah, well, that's why I love the Eisenhower quote, right? You know, in the fog of war, all of our plans go out the window and therefore we have to planning to think about what what to do. I think that one of the things that we need to take from this is in what you know, what you say is true. I think that the rule of rescue is an incredibly powerful incentive for physicians. So one thing I'll go on record is there have been a couple of proposals that I see floating out in the ethics vlogosphere, acknowledging the fact that that's what happened saying that in fact that's not what should happen. And therefore we should hand this job over to artificial intelligence. I'll cast a vote against that and I'm not sure that I want, you know, a little, you know, like drone driving from ambulance to ambulance outside those hospitals in Los Angeles and calculating surface course. So I'll just go against that. But I think we can learn from this and say so so when this happens again because you know in the world that we live in it will there'll be some other virus that manages to mutate and do this. How can we do it better next time in terms of better planning. So one of the things I think we need to come out with is is a more at the very least regionalized system and less, you know, sort of vulcanized system of actual care delivery when we go into crisis standards of care or start getting close to that. I think that that's likely to be helpful. I think we should also acknowledge the fact that this system that we developed didn't work at all. And Bob, since we have a couple of minutes, I was wondering and it didn't see anybody else's hand up. If you would talk about some of the work you've been doing with folks at MIT on weighted lottery. I'll give everybody just to see just because lottery just like rationing makes most people feel uncomfortable. I see we just have a minute. Thank you for bringing it up. Yeah. So right after the pandemic began, I got an email from an economist at MIT saying I got a great idea. And I was almost going to press delete, but I thought, well, he's an economist from MIT. I ought to look at it. And it was this 25 page paper, 22 pages of which were, we're equations that I didn't understand, but I read the introduction and I thought he's maybe really on to something here. And without going into the details, it's a version of a weighted lottery where you decide what are some of the values that we care about, things like people who have been disadvantaged in the past and, you know, those who's of race disability, all of those sorts of things. And how do you build that into an allocation system? Now, initially, we tried to apply that to the ventilator strategy. And for the reasons I said, it fell apart. I mean, it just wasn't going to work. But I think it really has gotten traction with vaccine allocation. And we're starting to see it being used now with various jurisdictions that are absolutely prioritizing disadvantaged communities within their state. And I think that as we go into the next pandemic, which is you said is unfortunately, probably an inevitability, I think that this way of thinking about how to level the playing field within our society has really gotten a toe hole. And I hope it's going to make a difference the next time we face this. David, it's the efficient. I want to, we only have one there. I want to thank you for an incredible talk. As Bob said, we're always learn from those of you who think about this at a higher level. I hope that we learned from these principles, some that succeeded, some that failed. What will something for the next crisis? Like, as you say, crises come and crises come. We live through them. And, you know, I remember growing up as a medical student and a surgical trainee in the year of AIDS, where the way we made a diagnosis of AIDS was by doing a lift note by a city. It wasn't even proven it was a virus yet. There was no test. HIV hadn't been described. And back then, we didn't use gloves for anything gloves are only used in operating room for sterile procedures. The concept of protecting oneself as opposed to the patient totally turned around work to the advantage in some ways. You look at what we were prepared for here and not how many people here knew what N95 was let alone in public society. How many of us complained about having to do a fit test with saccharine every year. And boy, did we want to get those N95s available to us when rationing came out? I do think that our institution can be proud of the way we handle things internally. Of course, we were so much less stressed than the adult institutions, but we did some of us on this screen had to spend hours a day prioritizing deciding who would get resources. We shut down from 25 ORs to basically six ORs. And then we had that backlog. We had 5,000 kids and families who had been canceled or delayed and had to figure out how to prevent them. We had to prioritize how with social distancing and protecting ourselves and our families, we could serve those children and who go first. There are still some people waiting, although it's pretty much dealt with. So I hope that we do have taught us. We'll give us perspective next time the waters up to our clavicles because although maybe for us it was only up to our armpits as opposed to our adult colleagues, we will face this again. It is people like yourself and Bob and Jeff who bring rational thought to us in very difficult times. We watched people in this institution who some people never heard of. How many people know who Gen 1's be was or Tom Sandora. And these people were empowered to make incredibly rapid decisions and we respectfully got aligned behind them because that's what you do in a war. You get behind the general who are set to lead. I do think that for the most part our institution can be incredibly proud of what we did for our staff, our faculty, our entire teams, our families and what we did to help the community around when we realize we actually want to have ice useful children on Valerars. So thanks so much for your leadership and for helping us. I think through this at a very high level. I'm so sorry about time. We're going to go on forever. Thanks. Thank you. Take care.