"Pittsburgh is in pretty good shape" in terms of preparing for and handling the reemergence of the H1N1 influenza, a University of Pittsburgh School of Medicine bioethicist said yesterday.

The same is not necessarily the case across the United States, said Dr. Douglas B. White, a trained pulmonologist who is in the medical school's department of critical care medicine. Earlier in the week, the Journal of the American Medical Association published his editorial "Preparing for the Sickest Patients with 2009 Influenza A (H1N1)." Co-author was Dr. Derek Angus, chairman of critical care medicine for Pitt.

"[Pittsburgh] is health-care heavy, as you know," Dr. White said. "There are a lot of hospitals and a lot of ICU beds, so, relatively speaking, Pittsburgh is in as good a shape as most major cities in the United States."

But when asked if he thinks the United States is prepared to care for its sickest patients, he vacillated.

"Well, the good news is that the vast majority of patients who get infected will do just fine. However, there will likely be a small percentage become very sick, very quickly," he said. "The U.S. has a very sophisticated health care system and we're lucky because we have a huge number of ICU beds, the most in the world.

"... Those who get very sick may still ... be enough to stress and fill up ICUs. Most agree there's a concern that demand for ICU beds may exceed the supply.

"Most of the ICU beds are filled on any given day. Most of the regular beds are filled on any given day and that in the day-to-day workings of a hospital is a good thing because it keeps cost down," he said.

"But when disasters or pandemics come down it can lead to a situation where ... essentially the benefit of a lean health system can become a liability."

In their JAMA editorial, Dr. White and Dr. Angus suggest three ways hospitals within a given region might respond to the needs of the sickest patients:

• Centralize them in a few hospital centers;

• Develop a system of telemedicine consultation for clinicians at outlying hospitals; or

• Have each hospital make temporary staffing changes to ensure the continuous presence of clinicians with the training these cases require.

Citing the controversy that surrounded triage decisions during Hurricane Katrina, Dr. White and Dr. Angus called on hospitals to develop "explicit policies to equitably determine who will and will not receive life support should absolute scarcity occur."

Dr. White was asked yesterday what would be a fair and explicit policy.

"This is very ethically complex," he said. "The standard approach is first-come, first-served. That has a lot of ethical limitations. The wealthy and well-connected tend to get to hospitals more quickly than the poor and marginalized. So first-come, first-served seems fair but isn't.

It is not enough for a hospital just to have a fairness policy. Rather, Dr. White said, it also must make sure the policy is known to its potential patients.

"It should be written down, disclosed to the public and followed consistently in the hospital," he said. "I think the public trust may be different in a very scary emergency like an influenza pandemic and that's all the more reason for a health care system to be very transparent in how they make life and death decisions."

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