Sunday, February 23, 2020

Ep. 29: Introduction to Triagism: A Philosophy of Life Based on Medical Triage (podcast script)

This is the script for my podcast episode on 21 February 2020. It may differ slightly from the final broadcast. This episode is available on major platforms, including Podbean, Apple Podcasts and YouTube. This script has not been proofread for publication and may contain typos and minor errors. See the description on the YouTube version for possible corrections. You can also comment on this episode there. (I might not see any comments left on this blog post.) The main website for this project is DemographicDoom.com


I’m Glenn Campbell. I call myself a demographic philosopher. I’m looking at life and trying to predict the future through the lens of demography, or the study of human populations.

Today, I want to talk about “triage”. In a medical sense, triage is the sorting of patients and allocating of resources to save as many lives as possible. If you go to the emergency room at a hospital, triage is the first station you encounter. Here, a nurse will make a quick assessment of your condition and decide whether you need to be taken immediately into the operating room or whether you can sit in the waiting room for a while.

Triage happens to be highly relevant at this moment in history, on February 21, 2020, because it’s an important part of the coronavirus response. Emergency rooms around the world could soon be deluged with more patients than they can handle – as has already happened in China – and somebody, somehow has to decide which of those patients are going to be served and where they’re going to go. That’s literal medical triage, and how well it is conducted has a strong correlation with the fatality rate.

But I am also interested in figurative triage. In fact, I have built a whole philosophy of life around it. I call my philosophy Triagism. That’s T R I A G I S M. Triagism. I invented this term about four years ago, in November 2015, when I made four videos about it. I had forgotten about them until now. You can find my videos by searching YouTube for Triagism as I just spelled it. The basic idea is that every choice in life is a triage decision. You’re trying to choose your own actions in such a way as to maximize certain outcomes or minimize damage.

For example, if you are visiting a new country for the first time, and you’ve only got two weeks to see it all, you have to make some triage decisions about what cities and attractions to see and which to skip, and you’ve got to make these choices in advance in spite have having never been to the country before and having limited information about it.

In this episode I’m going to focus on medical triage because it is easiest to understand and most relevant to the current moment, but I hope you will see by the end how this could turn into a whole philosophy of life.

First I want describe the current moment. I realize that you could be likely listening to this episode months or years after I recorded it, so I want to summarize my current positio in history. Today is Friday, February 21, 2020. The coronavirus has spread across all of China and seems to be on the verge of erupting in several other countries if not the entire world. The growing consensus among disease experts is that the disease will eventually become “endemic”, meaning it will become a permanent disease of humanity, much like the common flu. The difference between this virus and the flu is that it is far more transmissible and deadly. It might kill 1 or 2 percent of the people who catch it, compared to a tiny fraction of that for the common flu.

I already recorded a couple of podcast episodes on the coronavirus, so I don’t want to repeat that discussion here. The most remarkable thing I have observed since my last episode ten days ago is the high degree of denial here in the United States. Virus-related shutdowns in China are already severely disrupting supply chains around the world, yet stock markets like the Nasdaq and S&P have been making all-time highs. This is insane to me, but then again, the markets have been insane for quite some time thanks to central bank intervention. I still believe this epidemic is the Black Swan event that will bring down the economy, but the panic hasn’t yet begun. Don’t worry, it will, and as a denizen of the future, you may already know about it.

The disease experts on TV all “hope” that the virus is contained, but I think most of them know that it won’t be. The big challenge now is not stopping the virus but slowing it down, so new cases don’t overwhelm medical resources. A relatively low fatality rate depends on people with serious complications getting adequate medical care. Even though hospitals have no cure for the disease, there are things they can do to keep people alive, like giving them supplemental oxygen or antibiotics for secondary infections. If people with serious complications can’t get treated, the fatality rate goes way up. If everyone who needs treatment gets it, the fatality rate goes down. Since there are only limited medical resources in any particular country, you want to slow down the rate of infection as much as possible so hospitals aren’t overwhelmed.

When hospitals are overwhelmed, you get into the realm of triage. Triage is the sorting process that takes place when casualties enter a hospital. Someone has to decide who gets treated and who doesn’t and how patients are going to assigned within the hospital.

What happens when a hospital with only 10 intensive care beds gets slammed by 1000 sick people demanding attention? That’s the essential triage problem. How do you decide who gets into those 10 beds? The general goal of triage is to save as many lives as possible, and that means selecting the right patients for treatment.

The default form of triage is what I call “First Come First Served”. The first ten patients who show up at the hospital’s door get admitted, then the doors are barricaded and no one else gets in. The trouble with this method is that not all the 10 people you let in are seriously ill. They might have survived anyway, but now they are occupying a bed that could have been used to save someone in greater need. You might also be admitting someone who is already too far gone. No matter what you do, they are going to die, so your efforts are wasted. The bottom line with the First In First Out method is that it doesn’t save as many patients as it could. It’s an inefficient use of medical resources that might end up saving only two patients when it could have saved, say, eight.

Another form a triage might be bribery. Only the richest people get treated. If you can slip some cash to the guard at the door, maybe you can get one of those precious 10 beds, but the problem here is the same as the First In First Out method: You aren’t maximizing the number of people saved. This method is effective only if you believe rich people are inherently worth more to society than others, so they deserve special treatment.

A third method a triage might be to admit only your own family members and allies. You try to save your clan or the people who you identify with. Everyone else gets locked outside. I can’t say that this is morally wrong. People do it all the time: They prioritize their own kin over others. All you can say is that it’s not saving the maximum number of patients, because some of those family members might not be seriously ill.

The most effective form of triage is something called “yield management”. Someone takes a broad survey of all the 1000 people outside the hospital’s doors and selects the 10 patients who they think will benefit most from treatment. You’re going to ignore the people who are only mildly sick, because they are probably going to survive anyway. And you’re also going to ignore the people who are so seriously ill that they’re probably going to die anyway. Why waste your resources on them? Finally, you might make a judgement about who is going to most benefit others if they survive. For example, if you save the life of a doctor, that doctor might go on to save 100 other lives, so in an epidemic, it is appropriate to prioritize medical personnel.

And there you have triage in a nutshell. It is simply the judicious allocation of resources to maximize final gains. The basic concept isn’t hard to understand. Triage is difficult only in its real-world implementation. For one thing, you usually have to reject more people than you select. If you choose 10 people for treatment from the 1000 outside your door, the other 990 people aren’t going to be happy about it. They might rush the hospital, ram down the doors and lynch all the doctors, in which case no one gets saved.

I’ve been thinking about triage since around 2009, when I first wrote a one-page essay about it. You can find it by Googling for “Triage Kilroy CafĂ©” That’s Kilroy K I L R O Y space C A F E. The essay is called “Triage: Doing What You Can With What You Have.” Although I hadn’t invented the word “Triagism” then, I pretty much captured the essence of it. Every decision is a relative one based on the goals you are seeking and resources actually available. There will always be more needs than resources, so you have to judiciously apply those resources to maximize outcomes.

I’ve always thought of triage in abstract philosophical terms. Everything we do is an exercise in triage. But the coronavirus pandemic means that triage is now being practiced in pragmatic medical terms. Triagism isn’t just academics discussing things. People are living and dying based on this philosophy.

Prior to the outbreak, if you went to a hospital emergency room in North America or Europe, you knew you were going to be treated. You would still see a triage nurse upon entering the E.R. but this only determines how long you wait. In wealthy countries not yet in crisis, there are usually enough medical resources to go around. The people who are shot up with bullet holes get wheeled into the operating room right away, while others may have to wait for a while, but ultimately everyone gets served and an optimal number of lives are saved. In more of a battlefield situation, like a pandemic, Triage decisions have a huge effect on who lives and dies. In this case, the triage nurse may actually have more power than the doctors in determining how many live and die, because they are determining who gets treated.

In a modern emergency room not in crisis, every patient is evaluated in isolation. The nurse takes them into an exam room, assesses their symptoms and decide what the best practices are for this kind of situation. There are all sorts of rule books and procedures for this, and a triage nurse can take pride in making the optimal decision for every patient. In a battlefield situation, you don’t have the luxury of looking at each patient in isolation. You have to have a broad overview of all the patients who are vying for medical attention. The decisions you make when the ICU has plenty of beds are different than those you make when beds are at a premium and only a limited number of patients can be served. In this case, you have to look at all of the patients and select the few who are going to benefit the most from treatment.

Medicine in wealthy countries usually has the luxury of treating every patient equally, at least in the emergency room. It doesn’t matter who you are or whether you deserve treatment; when a doctor sees you, they are going to make the best decision for your particular case. This is true even in the United States, with a notoriously screwed up insurance system. If you turn up at an emergency room full of bullet holes, a doctor is going to treat you, and they are not going to discriminate against based on your ability to pay or whether you’re a gang-banger who deserved to be shot full of bullet holes.
Doctors, in fact, face great legal liability if they discriminate against a patient for any reason. If someone comes into the hospital with cancer and they’re 90 years old, the doctor is obligated to offer them the same costly treatment they would give a 25-year-old – assuming, of course, that they both have health insurance. The doctor can’t say, “I’m not going to treat you because you’re too old and are probably going to die anyway.” That would be a breach of his Hippocratic Oath and could get him in trouble.

Things change when you’re in a pandemic situation and you’ve got all ages and conditions scrambling for medical attention. The triage nurse might have no choice but to discriminate. It’s not a discrimination based on skin color but a discrimination based on the probability of survival. If you have two patients with the same life-threatening condition, one is thirty years old and the other is eighty, the triage nurse might select the thirty year old for treatment, because they have a better chance of survival.

I want to emphasize how hospitals and medical personnel in the United States and elsewhere aren’t set up for this kind of triage. Triage in America means directing a patient’s treatment. Triage in a crisis might mean denying treatment altogether. Every medical professional has been trained to pursue the best practices of each individual patient. They haven’t been trained to balance the needs and prognosis of one patient against those of another. They haven’t been trained to look at 1000 people and pull out the 10 who can most benefit from treatment. They haven’t been trained to ignore some patients and let them die. This is the sort of triage decisions that a battlefield medic had to make in World War One, but I don’t think modern medical staff are prepared for it. They have been trained to give optimal care to everyone who comes through the door. They haven’t been trained to balance the needs of the entire community to maximize overall survival.

Consequently, I don’t think modern healthcare systems in democratic countries are going to handle a pandemic well. I think the kind of triage they will use, at least initially, will be the First Come First Served method. All the hospital beds will fill up with the first patients who come in the door, then police will be called; the doors will be bolted, and no one else will be let in.

That’s not to say that non-democratic countries will do any better. Right now, in February 2020, no one outside of China has a big-picture view of how well the epidemic is being handled there, but I would wager it’s being handled poorly. China famously built a hospital in about 10 days, but that doesn’t mean they have competent staff to man it or that they’re using the facility effectively to save the maximum number of people. At every hospital, there is an entry point where choices have to be made about what happens to each prospective patient. Will this patient be admitted to the hospital, and if so, where will they go? Do they go to the Intensive Care Unit? Do they go to an isolation ward? I doubt China is making these decisions well, because they weren’t prepared. No one is.

Even in the United States, the health care system is finely tuned for the mix of patients we have now. A hospital might have its cardiac ward and its cancer ward, and most of those beds are already filled with routine patients. It might have only ten ICU beds available for emergencies, because that’s the number of emergencies they normally have. If they get slammed by a thousand virus patients demanding to be seen, they’re going to fill up those 10 beds on a First Come First Served basis, and they won’t know how to deal with the rest.

When and if the virus invades the U.S. Authorities might have to do what they did in China: set up temporary hospitals to deal with the influx. Gymnasiums can be turned into makeshift hospitals, but then how do you staff them? All the doctors and nurses are already occupied at their own hospitals, so who is going to man the new makeshift hospitals? What is prevent these makeshift hospitals from turning into pandemonium? Everyone is crying “I’m dying, please help me!” but there’s no one to help and no system in place for effectively distributing resources.

Our only real hope lies in slowing down the spread of the disease to give us more time to prepare. This means educating people on how to avoid infection. People WILL pay attention if they know their lives depends on it. If you can limit the number of new infections each day, then you give your country more time to develop new systems to handle them. Unlike the medical systems we are used to, these systems are going to seem imperfect and brutal. You can no longer say, “We’re going to save every patient.” When the system is overburdened, you have to say, “We’re going to save as many people as we can with the limited resources we have.” This is a brutal philosophy because it means many people are going to be denied care, and those people won’t be happy.

This is the essence of triage, and it extends to all aspects of life. In everything you do and every decision you make, you are engaged in triage. You’re not going to be able to go everywhere and do everything, just like you can’t save everyone during an epidemic. You have to parcel out your limited resources to the options that offer the most gain, which means denying your resources to many noble causes.

I hope you can begin to see how the concept of medical triage can morph into a whole philosophy of life. This is what I tried to do when I invented Triagism back in 2015. Maybe it’s time for me to reactivate that project. Triagism. How do you get the most you can from the limited resources you have? I’m sure there will be plenty of opportunity to think about triage in the coming weeks. Everyone will be thinking, “If I catch the disease, what is going to happen to me?” What happens to people when they go to the hospital and there aren’t enough beds. In country after country, we’re going to start putting this question to the test.

I didn’t start this epidemic, and I can’t control its spread, but if its going to happen, at least I can use it for something. It can help me refine this philosophy that I had forgotten about. Assuming you and I survive, we might come out of it with some new tools for dealing with life.

The main lesson of Triagism is that there are no perfect solutions. There are only solutions that are relatively better than others. It all depends on your resources and how you choose to divvy them out.

[Note: Episodes prior to this one (#1-29) and earlier videos were recorded without scripts.]