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Pediatric ventilation in a disaster: Clinical and ethical decision making*

Introduction: Medical resources may be overwhelmed in a mass disaster situation. Intensive care resources may be limited even further. When the demand for a certain resource, like ventilators, exceeds its availability, caregivers are faced with the task of deciding how to distribute this resource. Ethical dilemmas arise when a practical decision necessitates ranking the importance of several ethical principles. In a disaster area, the greatest good for the greatest number principle and the goal of equal distribution of resources may take priority over the needs of the individual. Nonetheless, regardless of the interventions available, it is a prime goal to keep the patients' comfort and dignity as much as possible. Background: In the mass disaster of the Haiti earthquake of January 2010, The Israeli Defense Forces Medical Corps field hospital was one of the first to respond to the call for help of the Haitian people with surgical and intensive care capabilities. It was the only facility able to ventilate children and neonates in the first week after the earthquake, although this ability was relatively limited. Special Article: Five case scenarios that we confronted at the pediatric ward of the field hospital are presented: two children with respiratory compromise due to pulmonary infection, one premature baby with respiratory distress syndrome, an asphyxiated neonate, and a baby with severe sepsis of a probable abdominal origin. In normal circumstances all of them would have been ventilated but with limited resources we raised in each case the question of ventilating or not. To help in the evaluation of each case we used a decision-support tool that was previously developed for ventilator allocation during an influenza pandemic. This tool takes into account several factors, including the illness severity, prognosis, and the expected duration of ventilation. Conclusions: Applying ethical priorities to analyze the decision-making problems leads to the understanding that an individualized approach with an ongoing assessment of the patient condition and the availability of resources, rather than a strict predefined decision rule, will give patients a better chance of survival, and will assist in allocating scarce resources.