62 SECTION I Pediatric Critical Care The Discipline lifesaving interventions (1) respiratory support, (2) fluid resusci tation, (3) vasopressors, (4) antidotes and antibiotics, and (5) analgesia and s[.]
62 S E C T I O N I Pediatric Critical Care: The Discipline lifesaving interventions: (1) respiratory support, (2) fluid resuscitation, (3) vasopressors, (4) antidotes and antibiotics, and (5) analgesia and sedation In order to provide adequate essential care to a greater number of patients, some more resource-intensive interventions may need to be delayed or foregone in EMCC settings Examples include strict monitoring and frequent recording of vital signs and fluid balance, parenteral nutrition, invasive hemodynamic monitoring, intracranial pressure monitoring, renal replacement therapy, and extracorporeal life support.2,22 Similarly, lifesaving EMCC interventions can be extended to much larger than usual numbers of patients by conservation of resources, substitution, adapting personnel, supplies, and spaces, reusing selected items, and reallocation of resource-intense interventions from patients not expected to survive to patients with a higher likelihood of quick recovery and survival Patient care plans may need to be based more on physical examination findings than on ancillary studies; relying less on laboratory and imaging studies may represent a fundamental shift in patient management paradigms The degree of deviation from usual practices should be proportional to the gap between patient needs and existing resources, and EMCC should be implemented in an organized way by each hospital’s ICS with the input of public health experts How Can the Intensive Care Unit Support the Emergency Department During a Public Health Emergency? To provide continuity of patient care and maintain situational awareness, ICU teams must interact closely with the ED Rapidly accommodating patients from the ED or operating room will be essential to allow those areas to continue receiving new patients Triage of patients to match needs with available resources evolves as the PHE unfolds, according to shifting needs and available resources Initial triage categories are assigned in the ED by an experienced clinician whose sole role is to act as triage officer and should be based on existing triage algorithms In some cases, ICU staff may be temporarily reassigned to work in the ED as a triage team to speed this process and ensure appropriate patient allocation Physiologic triage identifies patients needing immediate lifesaving interventions Physiologic triage tools identify patients in five categories: (1) those needing immediate lifesaving interventions; (2) those who need significant intervention that can be delayed; (3) those needing little or no treatment; (4) those who are so severely ill or injured that survival is unlikely despite major interventions; and (5) those who have already died Care of patients triaged to group 4, often referred to as “expectant,” will deviate most significantly from usual approaches to intensive care Because of overall demands on the system, scarce resources must be allocated to other patients who are more likely to survive, and expectant patients should receive appropriate palliative care While no single triage tool is always rapid, completely accurate, appropriate for all ages and disorders, and already familiar to all providers, triage and ED staff should be familiar with the physiologic triage tools in use locally.24 The local chosen tools should be made available online and in printed form to all relevant areas so that patients are triaged and treated in a standardized manner Pediatric experts should partner with regional healthcare coalitions to provide standardized pediatric healthcare education, such as pediatric triage and other specialized pediatric topics, prior to a PHE.25 When decontamination or infection control are central to the PHE at hand, these should be incorporated into the ED and triage response Decontamination reduces toxic effects for the victim and mitigates contamination of providers, staff, and the hospital facility Antidotes are given after cleaning an area of the body for administration Consideration should be given to risks of hypothermia by using warm water preferentially for those at highest risk of thermal instability Respiratory support during decontamination may be necessary and should be planned for.26–28 For PHEs with highly virulent transmissible infections, infection control must begin outside the ED entrance and continue without interruption in the hospital while the patient is infectious.29,30 How Can All Intensive Care Units Work Together? Pediatric hospitals often have more than one ICU with at least some patient flux between the NICU, PICU, and CICU depending on census There may be flux between the PICU and adult ICUs depending on patient age, size, underlying conditions, and disease process During a PHE, usual boundaries for these areas should be evaluated and stretched to accommodate the greatest number of critically ill patients (Fig 9.4) Critical care may be represented by a single ICU leader within the ICS in order to facilitate awareness of the global pool of ICU beds, staff, equipment, and supplies As many more infants require ICU admission compared with older children, there is a notably larger pool of NICU beds within any given region There is considerable variation in equipment and staffing between the four levels of NICUs, but all NICUs have at least one nurse with resuscitation and stabilization training in the hospital at all times (Table 9.1).31 All NICUs have devices to deliver positive-pressure ventilation; intubation supplies, including endotracheal tubes between 2.5 to 4.0; warmer beds; and a supply of medications in pediatric doses Adult hospitals experiencing a surge of pediatric patients should engage local neonatal and pediatric providers and staff to aid in triage and stabilization of infants and children until transport to regional PICUs and pediatric hospitals becomes available What Steps Can Be Taken to Maximize Intensive Care Unit Treatment in a Disaster? Patient Spaces Single-patient spaces may be converted for use by two or three patients with careful discussion of how to monitor additional patients if centralized monitoring is limited After exhausting PICU space, additional space for EMCC may also be created by Young disproportionately affected NICU CICU PICU Adult ICU Adults disproportionately affected • Fig 9.4 Intensive care unit flux and the continuum of critical care in surge events CICU, Cardiac intensive care unit; ICU, intensive care unit; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit CHAPTER 9 Public Health Emergencies and Emergency Mass Critical Care TABLE Levels of Neonatal Intensive Care Unit Treatment 9.1 and Expected Pediatric Specific Resources Respiratory Equipmenta Level Population Staffing I: Nursery Late preterm to term Pediatrician off site PPV II: Special Care Nursery Moderately preterm to term APP, pediatrician, or neonatologist on site or home call 24/7 PPV HFNC CPAP III: NICU Extremely preterm to term APP or resident in house 24/7 Neonatologist on site or home call 24/7 PPV HFNC CPAP CMV High-frequency ventilator IV: Regional NICU Infants with subspecialty needs APP or resident in house 24/7 Neonatologist usually on site 24/7 PPV HFNC CPAP CMV High-frequency ventilator ECMO a Lower-level NICUs may have a limited supply of ventilators for pretransport stabilization APP, Advanced practice provider (nurse practitioner, physician assistant); CMV, conventional mechanical ventilator; CPAP, continuous positive airway pressure; ECMO, extracorporeal membranous oxygenation; HFNC, high-flow nasal cannula; NICU, neonatal intensive care unit; PPV, positive pressure ventilation 63 hospitals use a single type of ventilator for patients of all sizes, with appropriate circuits and software algorithms In other hospitals, ventilators usually used for adults that have high compliance circuits and adult algorithms may have to be adapted for use in infants or small children When local supplies have been exhausted in a major PHE, adult-focused pediatric-adaptable ventilators and supplies may be accessed through the Strategic National Stockpile.33 Some difficulties in adapting equipment may be encountered The inspiratory flow or pressure sensor may not be sensitive to an infant’s inspiratory effort—triggering of inspiration may fail for synchronized intermittent mandatory ventilation, assist control, or pressure support Likewise, ventilator algorithms to terminate inspiration pressure support may fail in the presence of air leaks around endotracheal tubes if incorrectly sized tubes are being used owing to limited supply In a volume-controlled mode, adult ventilators may be unable to provide small tidal volumes and inspiratory flow appropriate for a small infant Extremely preterm infants often require tidal volumes of less than mL of air and are especially at risk for adverse effects from dead space Pressure-dependent losses of tidal volume in compressible spaces of adult ventilator circuits exaggerate breath-to-breath variation in delivered tidal volume if peak inspiratory pressure varies with patient effort or changing respiratory mechanics Difficulties in providing small tidal volumes and variation in ventilation due to leaks around uncuffed endotracheal tubes may necessitate using a time-cycled, pressure-limited mode of ventilation Supplemental providers need considerable assistance in caring for an infant on a ventilator, especially if nonstandard equipment and techniques are being employed Manual Ventilation adapting intermediate care units, postanesthesia care units, EDs, procedure suites, or non-ICU hospital rooms Considerations for adapting non-ICU spaces include the availability of equipment, monitoring, and staff and whether these areas are needed as part of non-ICU surge activities The hospital ICS should coordinate these decisions to ensure overall resource optimization Overflow of critically ill adolescents or young adults may be shared between PICUs and adult ICUs, while younger infants and children should be shared with local NICUs CICUs provide an additional pool of critical care services Nonhospital facilities should be used for EMCC only if hospitals become unusable Personnel Supplemental providers may include healthcare workers who have skills in non-ICU pediatrics or nonpediatric critical care Rapid credentialing procedures, just-in-time education, and local or distant supervision by experienced pediatric and neonatal ICU clinicians can help extend the provider pool Hospitals should expect and plan for a need for significant psychosocial support for patients and providers during and after a PHE, especially for those who were asked to work beyond their usual scope of care.32 Mechanical Ventilation Most hospitals have only a small number of extra ventilators and support devices It may be necessary to consider temporary use of transport and anesthesia ventilators, bilevel positive-pressure breathing devices, and noninvasive support devices Some pediatric Few hospitals stockpile enough mechanical ventilators to support three times the usual number of ICU patients The temporary use of manual ventilation with a self-inflatable bag may need to be considered Manual ventilation has been used successfully via tracheostomy tubes for days in a polio epidemic, and for hours in a power failure and during weather emergencies.34–38 It provides similar gas exchange compared with mechanical ventilation when provided via an ETT.39–41 However, manual ventilation is labor intensive, may expose staff to infection risks as a result of close and prolonged bedside contact, and may prove to be insufficient respiratory support to meet patient needs In extreme circumstances, family members or nonclinical staff could be tasked with providing manual ventilation with just-in-time training to free up clinical staff Equipment and Supplies Mass critical care can be provided only if essential equipment and supplies are available on-site, as resupply and rental deliveries may be limited during a PHE Thus, hospitals must balance the benefits of an adequate stockpile against the costs of maintaining items on-site that may expire or become defunct before being needed The Task Force on Mass Critical Care has recommended that a hospital should first target a mass critical care capacity of three times the usual maximum ICU capacity for 10 days, but decisions regarding equipment stockpiles should be made by individual hospitals.2 Each hospital should also maintain information on how to contact neighboring hospitals and clinical spaces to evaluate capacity for sharing supplies and equipment locally 64 S E C T I O N I Pediatric Critical Care: The Discipline Nonpediatric hospitals must also consider stocking critical pediatric equipment to care for children until transport and pediatric hospital bed spaces become available Although it may be possible to carry out many interventions by adapting nearly equivalent equipment and supplies, some adult equipment cannot be adapted to infants and small children It is essential to stock adequate numbers of resuscitation masks, endotracheal tubes, suction catheters, chest tubes, intravenous catheters, and gastric tubes in pediatric sizes If cuffed endotracheal tubes are used, it may be possible to cover the majority of pediatric needs with 3.0-, 4.0-, 5.0-, and 6.0-mm cuffed tubes without stocking intermediate sizes.2,42 Medications In order to extend medication stockpiles in mass critical care, rules should be formulated prior to PHEs regarding appropriate substitutions, dose and frequency reductions, reasonable parenteral to enteral conversions, restrictive indications, and shelf-life extension.2 Experience in recent PHEs indicates that large quantities of analgesics and sedatives will be needed.21,43 Weight-based dosing may be simplified to improve efficiency by specifying a limited number of weight range categories When time constraints make it difficult to weigh patients, length-based estimates of weight may suffice.44 How Will the Intensive Care Unit Evacuate if Needed? ICU providers must be aware of processes to ensure a safe and timely evacuation in the event that this is ordered by the ICS or government authorities Hurricane Sandy demonstrated a lack of ICU evacuation knowledge, processes, and tools.45 Pediatric patients are especially vulnerable during ICU evacuation, as few hospitals can serve as recipient hospitals and few transport agencies are familiar with pediatric and neonatal critical care Thus PICU, NICU, and CICU evacuation is critically dependent on regional coordination of resources.46 ICU evacuation best practices are available from the Mass Critical Care Taskforce, which include tools such as ICU evacuation checklists and job action sheets that should be used for preparedness and just-in-time training.47 How Will Limited Services Be Ethically Rationed? If a PHE overwhelms resources despite EMCC approaches, rationing of resources may be needed Rationing might occur on a first-come, first-served basis or by selecting patients most likely to survive as a result of brief lifesaving interventions.2,48 Proposed eligibility criteria to receive intervention include absence of severe chronic conditions, predicted mortality risk below a threshold chosen by the ICS or public health officials, and improving clinical status on periodic reevaluations Suggested algorithms exist for both children and adults.49 In pediatrics, however, there is little consensus about, or data to support, which mortality risk score to use, especially in light of typical PICU mortality of less than 5% and NICU mortality rate of less than 1%.19,50 Rationing should only occur using a formal hospital system or regional triage policy or protocol and should be performed by triage officers with critical care training under the direction of the ICS At present, neither evidence nor consensus of opinion supports a particular rationing strategy Thus, local ICSs need to evaluate needs and resources in real time in order to guide the triage team.51,52 Medical ethicists and community members are key partners in planning for crisis standards of care and potential rationing Difficult questions surrounding the ethics of triaging patients as expectant, removing life support, and which patient factors should be considered when deciding who will (and who will not) be offered life support all benefit from careful consideration with trained bioethicists as well as community leaders Ideally, these discussions happen as part of the PHE planning phase to allow thorough discussion and input from members of the medical community and the public Public input can be accomplished with focus groups representative of local population demographics and structured discussions of relevant issues The Institute of Medicine specifically recommends community consultation during development of CSC to ensure that the final recommendations “reflect the ethical values and priorities of the community.” This form of planning ensures transparency and provides reassurance to both affected patients and staff members during a PHE that issues have been sufficiently thought through beforehand A carefully considered plan created with public input creates a legal basis and liability protections.53 How Should Pediatric Patients Be Tracked? What Are the Mental Health Considerations Relevant to Emergency Mass Critical Care? Hospital care of children is more efficient, more effective, and less stressful when children are accompanied by a familiar caregiver Unaccompanied children must be properly identified, tracked, and reunited with their families Proper identification of adult caregivers is necessary before releasing children Examples of child identification and tracking documents are available online.12 A tracking and communication center should be activated by a designee within the ICS in order to centralize patient tracking and field calls from caregivers Every pediatric patient should have a patient-specific tracking identification number assigned upon arrival to the ED, and the tracking center should be provided any potentially identifying information to aid in reunification (such as physical features, clothing, location where the patient was initially found, information provided directly by verbal children, and a photo whenever possible) Situations requiring EMCC cause stress and trauma to patients, families, and staff Requiring care for a significant disaster-related illness or injury is a risk factor for severe mental health deterioration Use of a mental health triage system such as psySTART can aid in allocation of psychiatric, behavioral, and psychosocial resources.54 For children at risk for significant mental health effects, attention to this should start as soon as possible Tracking children with the goal of identification and reunification, recording of individual exposures with known mental health effects, and protecting children from additive harm are key early steps For alert and interactive victims, ICU staff should follow basic support, including establishing safety and security, orienting to the situation in developmentally appropriate ways, and facilitating communication with familiar caregivers and trained support staff Simple messaging that the child is in a safe place and that the family will join the child as soon as possible is appropriate for all pediatric patients CHAPTER 9 Public Health Emergencies and Emergency Mass Critical Care 65 Staff of all disciplines may also have significant mental health effects during PHEs.55 Anxiety regarding risks to themselves, their family, and their coworkers can combine with fatigue and trauma from caring for multiple dead and dying patients in a short period of time and lead to emotional and physical exhaustion To mitigate these effects, clear protocols and procedures for varying levels of PHE should be created in the planning phase and shared with front-line staff Job aids and just-in-time tools are important methods to support staff Rest breaks and basic self-care—such as access to bathrooms, food, and water—are necessary for any sustained response In longer events, hospitals may consider shortening shifts to allow recovery between intense exposures PHE responses, care should be taken to ensure that they can safely participate to the benefit of the patients and their own education What Is the Role of Medical Learners in Public Health Emergencies? Key References Medical learners are a vital component of the healthcare team at many pediatric centers Whenever a significant PHE occurs, the needs of the patients and learners must be balanced Residents and fellows provide extensive patient care in ICUs They are routinely trained to care for patients with contagious infections and high-risk conditions; with supervision, they can provide care to a large number of critically ill patients at a time Their value as patient care providers must be weighed against potential risks to their learning, their own health, and their families’ health Severe PHEs—in which supplies of personal protective equipment are inadequate, training insufficient, or supervision limited—place learners at risk In this scenario, their role as junior team members may discourage speaking up about these risks Very junior learners, such as observers and students, are especially vulnerable to these issues—the decision to include them in PHE responses should be carefully considered by their program, especially in settings with limited PPE When learners of any stage are used in Conclusion It is essential that critical care providers are knowledgeable about and active in hospital and regional disaster planning, EMCC triage protocols, and surge strategies to be prepared for future events and maximize the survival of pediatric patients Preparedness efforts should include education on the local ICS, surge protocols, methods to extend care capacity, and triage techniques American Academy of Pediatrics American College of Critical Care Medicine Consensus report for regionalization of services for critically ill or injured children Pediatrics 2000;105:152-155 EMSC National Resource Center Checklist of Essential Pediatric Domains and Considerations for Every Hospital’s Disaster Preparedness Policies Washington, DC: EMSC National Resource Center; 2014 Kanter RK, Andrake JS, Boeing NM, et al A method for developing consensus on appropriate standards of disaster care Disaster Med Public Health Prep 2009;3:27-32 Kanter RK Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs Crit Care Med 2007;35:2837-2842 Phillips SJ, Knebel A Mass Medical Care with Scarce Resources: A Community Planning Guide Rockville, MD: Agency for Healthcare Research and Quality (AHRQ Publication No 07–0001); 2007 Schreiber M The psySTART Rapid Mental Health Triage and Incident Management System Center for Disaster Medical Sciences, University of California; 2010 The full reference list for this chapter is available at ExpertConsult.com e1 References US Census Bureau Age and Sex, Table S0101, American Community Survey Washington, DC: US Census Bureau; 2006 Christian MD, Devereaux AV, Dichter JR, et al Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement Chest 2014; 146(suppl 4):8S-34S Tilford JM, Simpson PM, Green JW, et al Volume outcome relationships in pediatric intensive care units Pediatrics 2000;106: 289-294 Pollack MM, Alexander SR, Clarke N, et al Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities Crit Care Med 1991;19: 150-159 Osler TM, Vane DW, Tepas JJ, et al Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry J Trauma 2001;50: 96-101 Densmore JC, Lim HJ, Oldham KT, et al Outcomes and delivery of care in pediatric injury J Pediatr Surg 2006;41:92-98 Randolph AG, Gonzales CA, Cortellini L, et al Growth of pediatric ICUs in the US from 1995 to 2001 J Pediatr 2004;144:792-798 Goodman DC, Little GA, Harrison WN, et al, eds The Dartmouth Atlas of Neonatal Intensive Care Lebanon, NH: The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth; 2019 Kanter RK Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs Crit Care Med 2007;35:2837-2842 10 American Academy of Pediatrics American College of Critical Care Medicine Consensus report for regionalization of services for critically ill or injured children Pediatrics 2000;105:152-155 11 EMSC National Resource Center Checklist of Essential Pediatric Domains and Considerations for Every Hospital’s Disaster Preparedness Policies Washington, DC: EMSC National Resource Center; 2014 12 Auf der Heide E The importance of evidence-based disaster planning Ann Emerg Med 2006;47:34-49 13 Deleted in review 14 King MA, Koelemay K, Zimmerman J, et al Geographical maldistribution of pediatric medical resources in Seattle-King County Prehosp Disaster Med 2010;25(4):326-332 15 Hazards Vulnerability Analysis Emergency Preparedness California Hospital Association; 2017 https://www.calhospitalprepare.org/hazardvulnerability-analysis 16 US Department of Homeland Security National response framework 4th ed Washington, DC: Department of Homeland Security; 2019 https://www.fema.gov/media-librar y/assets/documents/ 117791 17 Phillips SJ, Knebel A Mass Medical Care with Scarce Resources: A Community Planning Guide Rockville, MD: Agency for Healthcare Research and Quality (AHRQ Publication No 07–0001); 2007 18 Kanter RK, Cooper A Mass critical care: pediatric considerations in extending and rationing care in public health emergencies Disaster Med Public Health Prep 2009;3:S166-S171 19 Kissoon N, Task Force for Pediatric Emergency Mass Critical Care Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: executive summary Pediatr Crit Care Med 2011;12(suppl 6):S103-S108 20 Gostin LO, Sapsin JW, Teret SP, et al The Model State Emergency Health Powers Act JAMA 2002;288:622-628 21 Mahoney EJ, Harrington DT, Biffl WL, et al Lessons learned from a nightclub fire: institutional disaster preparedness J Trauma 2005; 58:487-491 22 Eriksson CO, Uyeki TM, Christian MD, et al Care of the child with Ebola virus disease Pediatr Crit Care Med 2015;16:97-103 23 Kanter RK, Moran JR Pediatric hospital and intensive care unit capacity in regional disasters Pediatrics 2007;119:94-100 24 Chevalier MS, Chung W, Smith J, et al Ebola virus disease cluster in the United States–Dallas County, Texas, 2014 MMWR Morb Mortal Wkly Rep 2014 https://www.cdc.gov/mmwr/preview/ mmwrhtml/mm63e1114a5.htm 25 Lerner EB, Schwartz RB, Coule PL, et al Mass casualty triage: an evaluation of the data and development of a proposed national guidance Disaster Med Public Health Prep 2008;2:S25-S34 26 Kenningham K, Koelemay K, King MA Pediatric disaster triage education and skills assessment: a coalition approach J Emerg Manag 2014;12:141-151 27 Fertel BS, Kohlhoff SA, Roblin PM Lessons from the “Clean Baby 2007” pediatric decontamination drill Am J Disaster Med 2009;4: 77-85 28 Freyberg CW, Arquilla B, Fertel BS, et al Disaster preparedness: hospital decontamination and the pediatric patient—guidelines for hospitals and emergency planners Prehosp Disaster Med 2008;23: 166-173 29 US Department of Homeland Security Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities 2014 https://www.dhs.gov/sites/default/files/ publications/Patient%20Decon%20National%20Planning%20 Guidance_Final_December%202014.pdf 30 Siegel JD, Rhinehart E, Jackson M, et al Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007; https://www.cdc.gov/infectioncontrol/guidelines/ isolation/index.html/Isolation2007.pdf 31 American Academy of Pediatrics Committee on Fetus and Newborn Levels of neonatal care Pediatrics 2012;130(3):587-597 32 Kanter RK, Andrake JS, Boeing NM, et al A method for developing consensus on appropriate standards of disaster care Disaster Med Public Health Prep 2009;3:27-32 33 Strategic National Stockpile Public Health Emergency US Department of Health & Human Services; 2020 https://www.phe.gov/ about/sns/Pages/default.aspx 34 Rubinson L, Vaughn F, Nelson S, et al Mechanical ventilators in US acute care hospitals Disaster Med Public Health Prep 2010;4(3):199-206 35 West JB The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology J Appl Physiol 2005;99:424-432 36 O’Hara JF, Higgins TL Total electrical power failure in a cardiothoracic intensive care unit Crit Care Med 1992;20:840-845 37 Norcross ED, Elliott BM, Adams DB, et al Impact of a major hurricane on surgical services in a university hospital Am Surg 1993;59:28-33 38 Nates JL Combined external and internal hospital disaster: impact and response in a Houston trauma center intensive care unit Crit Care Med 2004;32:686-690 39 Barkmeyer BM Practicing neonatology in a blackout: the University Hospital NICU in the midst of Hurricane Katrina: caring for children without power or water Pediatrics 2006;117:S369-S374 40 Gervais HW, Eberle B, Konietzky D, et al Comparison of blood gases of ventilated patients during transport Crit Care Med 1987;15:761-763 41 Hurst JM, Davis K, Branson RD, et al Comparison of blood gases during transport using two methods of ventilatory support J Trauma 1989;29:1637-1640 42 Johannigman JA, Branson RD, Johnson DJ, et al Out-of-hospital ventilation: bag valve device vs transport ventilator Acad Emerg Med 1995;2:719-724 43 Branson RD, Johannigman JA, Daugherty EL, et al Surge capacity mechanical ventilation Respir Care 2008;53:78-90 44 Kumar A, Zarychanski R, Pinto R, et al Critically ill patients with 2009 Influenza A (H1N1) infection in Canada JAMA 2009;302: 1872-1879 45 Luten R, Zaritsky A The sophistication of simplicity: optimizing emergency dosing Acad Emerg Med 2008;15:461-465 46 Espiritu M, Patil U, Cruz H, et al Evacuation of a neonatal intensive care unit in a disaster: lessons from Hurricane Sandy Pediatrics 2014;134(6):e1662-e1669 ... team.51,52 Medical ethicists and community members are key partners in planning for crisis standards of care and potential rationing Difficult questions surrounding the ethics of triaging patients... development of CSC to ensure that the final recommendations “reflect the ethical values and priorities of the community.” This form of planning ensures transparency and provides reassurance to both... that should be used for preparedness and just-in-time training.47 How Will Limited Services Be Ethically Rationed? If a PHE overwhelms resources despite EMCC approaches, rationing of resources