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deniscollins · 5 years ago

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The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t?

If you were a medical director and had 10 ventilators with 30 people needing the, thus can only save the life of 10 out of the 30, how would you determine who gets a ventilator by: (1) age (preference to young), (2) highest likelihood of survival, (3) most in need, (4) lottery, (5) first-come, first-served, (6) combination (if so, which ones), (7) something else (if so, what)? Why? What are the ethics underlying your decision?

The medical director of the intensive care unit had to choose which patients’ lives would be supported by ventilators and other equipment. Hurricane Sandy was bearing down on Bellevue Hospital in New York City in 2012, and the main generators were about to fail. Dr. Laura Evans would be left with only six power outlets for the unit’s 50 patients.

Hospital officials asked her to decide which ones would get the lifesaving resources. “Laura,” one official said. “We need a list.” After gathering other professionals, Dr. Evans checked off the names of the lucky few.

Now, she and doctors at hospitals across the country may have to make similarly wrenching decisions about rationing on a far bigger scale. Epidemic experts predict an explosive growth in the number of critically ill patients, combined with severe shortages of equipment, supplies, staffing and hospital beds in areas of the U.S. where coronavirus infections are surging, hot spots that include New York, California and Washington State.

Health workers are urging efforts to suppress the outbreak and expand medical capacity so that rationing will be unnecessary. But if forced, they ask, how do they make the least terrible decision? How do they minimize deaths? Who even gets to decide, and how are their choices justified to the public?

Medical providers are considering these questions based on what first occurred in China, where many sick patients were initially turned away from hospitals, and now is unfolding in Italy, where overwhelmed doctors are withholding ventilators from older, sicker adults so they can go to younger, healthier patients.

Choosing between patients “goes against the way we used to think about our profession, against the way we think about our behavior with patients,” said Dr. Marco Metra, chief of cardiology at a hospital in one of Italy’s hardest-hit regions.

In the United States, some guidelines already exist for this grim task. In an effort little known even among doctors, federal grant programs helped hospitals, states and the Veterans Health Administration develop what are essentially rationing plans for a severe pandemic. Now those plans, some of which may be outdated, are being revisited for the coronavirus outbreak.

But little research has been done to see whether the strategies would save more lives or years of life compared with a random lottery to assign ventilators or critical care beds — an option some support to avoid bias against people with disabilities and others.

Some commonly recommended rationing strategies, researchers found, could paradoxically increase the number of deaths. And protocols involve value judgments as much as medical ones, and have to take into account the public’s trust.

If hospitals withhold treatment by age, where do they draw the line? If they give lower priority to those with certain underlying health conditions, they may in effect be offering black Americans less treatment than white Americans. If physicians try to redirect resources — putting a patient on a ventilator for a few days, then giving it to someone else who appears to have better prospects — more people may die because few would get adequate treatment. And if many patients have a similar chance of survival, what fair way is there to make a choice?

The federal government, so far at least, is not providing national rationing guidelines for the coronavirus outbreak. Officials from various states, medical associations and hospitals are discussing their own plans, potentially resulting in very different decisions on life-and-death matters about which there are deep disagreements, even among medical professionals.

“You have to be really clear about what you are trying to achieve,” said Christina Pagel, a British researcher who studied the problem during the 2009 H1N1 flu pandemic. “Maybe you end up saving more people but at the end you have got a society at war with itself. Some people are going to be told they don’t matter enough.”

‘The Most Good’

Just before the coronavirus outbreak, Dr. Evans, the physician at Bellevue, moved across the country to direct the intensive care unit at the University of Washington Medical Center in Seattle. The city became one of the first areas in the United States to see community spread of the virus.

The hospital is doing whatever it can to prevent the need to ration — what Dr. Evans referred to as “an ethical obligation.” Like other institutions, it is trying to increase supplies, training staff to act in roles that may be outside their usual jobs and postponing elective surgeries to free up space for coronavirus patients. Some cities are racing to construct new hospitals.

Strategies to avoid rationing during the pandemic were published by the National Academy of Medicine. But hospitals across the country vary in their adherence to such steps. At the University of Miami’s flagship hospital, surgeons were told last Monday to cancel elective surgeries, but across the street at Jackson Memorial Hospital, they were “given wide discretion over whether to cancel or proceed,” according to an update sent to physicians.

Dr. Evans is working with health leaders in Washington State to figure out how to implement triage plans. Their goal, she said, would be “doing the most good for the most people and being fair and equitable and transparent in the process.”

But guidance endorsed and distributed by the Washington State Health Department last week suggested that triage teams under crisis conditions should consider transferring patients out of the hospital or to palliative care if their baseline functioning was marked by “loss of reserves in energy, physical ability, cognition and general health.”

The concept of triage stems from Napoleon’s battlefields. The French military leader’s chief surgeon, Baron Dominique Jean Larrey, concluded that medics should attend to the most dangerously wounded first, without regard to rank or distinction. Later, doctors added other criteria to mass casualty triage, including how likely someone was to survive treatment or how long it would take to care for them.

Protocols for rationing critical care and ventilators in a pandemic had their beginning during the anthrax mailings after the Sept. 11 attacks, but have not previously been implemented.

Dr. Frederick M. Burkle Jr., a former Vietnam War physician, laid out ideas for how to handle the victims of a large-scale bioterrorist event. After the SARS outbreak stressed Toronto hospitals in 2003, some of his ideas were proposed by Canadian doctors, and they made their way into many American plans after the H1N1 pandemic in 2009. “I have said to my wife, ‘I think I developed a monster here,’” Dr. Burkle said in an interview.

What worried him was that the protocols often had rigid exclusion criteria for ventilators or even hospital admission. Some used age as a cutoff or pre-existing conditions like advanced cancer, kidney failure or severe neurological impairment. Dr. Burkle, though, had emphasized the importance of reassessing the level of resources sometimes on a daily or hourly basis in an effort to minimize the need to deny care.

Also, the plans might not achieve their goals of maximizing survival. For example, most called for reassigning a ventilator after several days if a patient was not improving, allowing it to be allocated to a different patient.

But rapidly cycling ventilators might not give anyone enough chance to improve. When the coronavirus causes severe pneumonia, doctors are finding that patients require treatment for weeks.

In Canada, a study of H1N1 patients found that 70 percent of those who would have been withdrawn from ventilators after a five-day time trial if a rationing plan had been implemented actually survived with continued care.

Researchers at a British hospital had similar findings, concluding that “a new model of triage needs to be developed.”

A Score Card and a Lottery

Many of the original plans in the U.S. were developed exclusively by medical personnel. But in Seattle, public health officials gathered community input on a possible plan more than a decade ago.

Some citizens feared that using predicted survival to determine access to resources — a common strategy — might be inherently discriminatory, according to a report on the exercise. Citing “institutional racism in the health care system,” they were concerned that the metrics for some groups, like African-Americans and immigrants, would be skewed because they had not received the same quality of care.

There were similar findings in Maryland, where researchers at Johns Hopkins engaged residents across the state in deliberations over several years.

The researchers presented them with several options. Hospitals could assign ventilators on a first-come, first-served basis. Some thought that could disadvantage people who lived far from hospitals. A lottery struck other participants as more fair.

Others argued for a more outcome-oriented approach. One goal could be saving the highest number of lives, regardless of factors like age. A different goal could be saving the most years of life, a strategy favoring younger, healthier patients. Participants also considered whether those playing a valuable role in a pandemic, like medical workers who risked their lives, should be made a priority.

After the project ended, the Hopkins researchers designed a framework that assigns scores to patients based on estimated probability of short- and long-term survival. The latter was defined by whether the person had a pre-existing life expectancy of at least a year. Ventilators would be provided, as available, according to their ranking. The framework recommends a lottery for lifesaving resources when patients have identical scores. Stage of life may also be used as a “tiebreaker.” Decisions should be made by designated triage officers, not individual doctors caring for patients, and there should be a limited appeals process in cases of resource withdrawal, the protocol said.

The public input led the Hopkins researchers not to incorporate most exclusion criteria.

Dr. Lee Daugherty Biddison, one of the effort’s leaders, said that was because most participants were uncomfortable excluding patients with underlying health issues. Preconditions don’t always predict survival from respiratory viruses, and having chronic diseases like diabetes, kidney failure and high blood pressure often tracks with access to medical care. Rationing based on these conditions would be “essentially punishing people for their station in life,” Dr. Biddison said.

The Hopkins group published a description of the framework last year, and doctors from other Maryland hospitals are teleconferencing twice a day to prepare to implement the plan if conditions grow extreme. Dr. Biddison has also been sharing the recommendations with doctors across the country.

In Pennsylvania, Dr. Douglas B. White, chairman of ethics in critical care medicine at the University of Pittsburgh School of Medicine, is using the Hopkins protocol to help prepare hospitals in his state.

In Colorado, Dr. Matthew Wynia, a bioethicist and infectious disease doctor, is working on a plan that would also assign a score. In his rubric, the first considerations are odds of survival and expected length of treatment. He said there was wide agreement among planners “not to make decisions on perceived social worth, race, ethnic background and long-term disability status,” which some fear could happen if doctors had to make seat-of-the-pants judgments without guidelines.

He is also trying to ensure that patients on admission to Colorado hospitals are asked whether they would forgo a ventilator if there were not enough for everyone. “One thing everyone agrees on is that the most morally defensible way to decide would be to ask the patients,” Dr. Wynia said.

He supports the idea of reassigning ventilators in certain cases. “If things are clearly getting worse, it’s really hard to justify a stance of once you’re on a vent, you own it, no matter how many people have to die in the meantime,” Dr. Wynia said.

Unlike in Italy, where age has been used in rationing treatment, some people developing protocols elsewhere have de-emphasized it. “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” Dr. Pagel, the British researcher, said, including that young people should be a higher priority because they have more life ahead of them.

“Where is your threshold? Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?”

A Right to Know

As Hurricane Sandy intensified outside Bellevue in 2012, Dr. Evans referred to New York State guidelines, since updated — which some hospital leaders have said they will follow if overwhelmed by the coronavirus — on how to allocate ventilators in a pandemic using a scoring system that tries to estimate someone’s chance of survival. She pulled together an ad hoc committee of doctors, ethicists and nurses. “Having a system and procedures gave us a sense we had some control of the situation,” she recalled.

For those about to lose electricity, she and her colleagues stationed two staff members at the bedside of all patients who relied on ventilators, preparing to manually squeeze oxygen into their lungs with flexible Ambu bags.

Looking back, Dr. Evans feels the patients and their families had the right to know that their machines would lose power, but in the crisis they hadn’t been told. The doctors also did not think to ask whether any patients or their families might volunteer to give up a power outlet so that it could be provided to someone else. “It wasn’t even on my radar,” Dr. Evans said.

In the end, it was improvisation that prevented tragic rationing at Bellevue. The generator fuel pumps failed, but a chain of volunteers hand-carried diesel up 13 flights of stairs. Dr. Evans’s patients were all maintained on backup power until they were transferred to other hospitals.

“I remember it really vividly,” she said of the experience. “It’s going to stay with me my entire professional career.”

#Hospitals #Doctors #Rationing

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anycontentposter · 5 years ago

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How to Get Better at Street Photography

It goes without saying that if you want to get better at something you have to practice. Simple, right? The thing is, that unlike more structured pursuits such as sports or music, the idea of practicing street photography seems a bit hard to wrap one’s head around.

But before we get into that, we should establish the best methodology for practice in in general.

A shot I’ve taken before many times (not in this spot, but the same idea) before getting this awesome opportunity. Regular Practice vs Deliberate Practice

Regular practice happens any time you do almost anything. If you think about it, that’s how we learn most things in life: from using a fork, to talking to tying our shoes. If you just do it, you’ll gradually get better at it. It applies to more specific skills as well. If you sit down to jam on guitar for 30 minutes, you just practiced a bit. Shoots hoops after school? Practice. The same goes for street photography—shoot for an hour: that’s practice.

You can certainly have revelations and make improvements with regular practice. And it’s a lot of fun! But there is a more refined approach, commonly called “Deliberate Practice.”

Deliberate practice is when you make a conscious effort to practice very specific skills in a targeted manner. It also includes feedback and consistent rules or a set of constraints. Let’s break all that down.

To use analogies in sports and music again, it would be like running drills of very specific actions or movements, and in particular targeting ones where you think you have a weakness. In basketball it might be shooting from the free throw line, or perhaps it might be playing a particular part of a song again and again on guitar until that one part is perfect.

Deliberate practice is about breaking skills down and targeting weaknesses. But how can we apply that to photography?

Orange stripes on a 28mm lens (Ricoh GR II)… …and the same place a few weeks later on a 40mm lens (Nikon D4). Constraints are the Key: Prime Lenses

In photography, especially street photography, it’s hard to break down skills into sub-skills and drill them. What are you going to do, run around with the camera like a soldier in boot camp? It sounds silly. When practicing photography, it’s most useful to focus on the last part of deliberate practice: constraints.

We can put constraints on many aspects of our photography, the most obvious being focal length. I believe this is why prime lenses are traditionally so highly praised by street photographers. The common wisdom is that prime lenses spur creativity, but I believe that underlying this commonly held notion is the fact that by constraining the field of view, the photographer must learn how to compose the frame by moving their body (the cliché of “zoom with your feet”) which, over time, results in a better spatial awareness and understanding of the effects of that particular focal length.

However, as mentioned above in regard to deliberate practice, it’s good to tailor this advice by focusing on weak points. If you’ve been shooting with a 35mm prime lens for years, perhaps trying a 28mm or a 50mm for a few weeks will help you improve your skill with those focal lengths as well.

Eventually, using a zoom lens will become a more mindful and deliberate shooting experience where your own positioning (and therefore, your perspective) become less influenced by the lens. You will more easily be able to choose either a perspective and then match the focal length, or a focal length (effectively, a field of view) and then adjust your perspective to make it work.

I had my 28mm on the camera, but felt this would have been better with my trusty 40mm (this shot is cropped a bit). Nonetheless, I feel that having a prime lens helped me make an interesting composition in the heat of the moment. The constraint stimulated my creativity.

Of course, you could learn all of this with a zoom lens, but it’s more efficient to apply the deliberate practice method by giving yourself this focal length constraint. And if you don’t have many (or any) prime lenses, that’s okay! Just tape your lens to a particular focal length and go out and shoot that way for a day or two. Bam! Instant prime lens!

After this kind of practice, I now think of a zoom lens more as a series of prime lenses than a single continuously zoomable lens. That’s not to say that I look at the markings on the lens and set it to exactly 35mm or 50mm or whatever before I take each photo. It’s just that in my mind, I think to myself “I need about 35mm for this shot,” or “around 50mm would suit my idea for this composition.” And I got to that point by shooting on primes for a few years almost exclusively.

I somehow instinctively knew that the simplicity of primes would force me think in a different way with them. It wasn’t until years later that I learned about deliberate practice (mostly when I read the book The Talent Code by Daniel Coyle) that it clicked for me: prime lenses create constraints, and that’s why they are a great tool to help us build an understanding of the relationship between focal length and field of view while developing spatial awareness.

Shot in Aperture Priority, this shot required a 3-stop underexposure, something I expected from having practiced with both Aperture mode and Manual mode for quite some time. Constraints in Exposure: Manual Mode

By using prime lenses, we can apply a constraint to our field of view. Another way to constrain the way we shoot is to use Manual Mode. Generally, I don’t think Manual Mode is a must for street photography. I feel it can be a hindrance in some cases, although in others it does allow for more precise, accurate and, most importantly, consistent exposure.

For the most part, I use Aperture Priority when walking about town and shooting street photos; however, in the context of this article, I feel that Manual Mode is a must for training one’s understanding of exposure. It applies a constraint in the sense that it forces the photographer to think about the three main settings that are available in almost every camera–shutter speed, aperture and ISO–and understand how they relate.

It’s also possible to take it a step further and “lock” one or two settings for a day. That is, you can choose a particular combination of settings for two of the three, and then only adjust the third one to maintain a correct exposure. For instance, on a sunny day, you can select f/8 for the aperture, and 1/500 shutter speed, and the only adjust the ISO as needed in order to get the correct exposure. Similarly, say at night, you can choose f/2.8, 1600 ISO, and then adjust the shutter speed as needed. The point is to get an inherent understanding of how these settings work together and individually. Once you have this intuition, it becomes much more obvious what’s happening when shooting in semi-auto modes like Aperture Priority with Auto ISO enabled.

The ultimate goal of all this is to move beyond the phase where the camera’s operations are some sort of “black magic” and move into a mindful awareness of what the camera is up to at all times. This will allow for more consistent exposure when you’re out doing street photography, which is very beneficial in a photographic genre where speed is important and there are few second chances.

A shot inspired by the work of Siegfried Hansen… …while I shot this one with Saul Leiter in mind. Constraints in Theme: Emulate the Masters

So, we’ve talked about ways to constrain your framing and exposure. The third constraint that can be applied for the sake of deliberate practice is a constraint of style or theme.

An easy and fun way to do this is to “emulate the masters.” What that means is that you can find a photographer whose work you admire, or even simply has certain aspects or qualities that you wish to include in your own work. Once you find such a body of work, identify the consistent themes and choices that the “master” has made in his or her work, then go out and keep these themes in mind: constantly asking yourself “what would _____ do in this case?”

I try to avoid pushing my specific preoccupations when giving “study” advice for photographers, but I think it’s useful to illustrate this idea with a few example masters from whom I’ve drawn influence. The first is Alex Webb, whose work emphasizes multiple layers and subjects, all coming together to a single whole. Basically, he’s a master of having many individual subjects in one frame.

Something I learned from Saul Leiter, but made my own—obscuring subjects with bold splashes of color in the foreground.

The next is Saul Leiter, in whose work we can see an abstract approach to color and form. He sometimes avoids giving a direct portrayal of his human subjects instead opting for compositions that are more abstract, emphasizing splashes of colors, often blurred in the foreground. To the same end, he regularly employs reflections and glass in his images. Shooting in ‘bad’ weather is also common in his work.

Finally, I enjoy the work of Siegfried Hansen, who is a master of geometry and in particular utilizing lines and shapes in his work. Much of his work does not involve people, which is a bit unusual for most street photographers, yet he makes it work. All three of these photographers employ color to greatest degree, having little to no work in monochrome.

Of course, the work of each of these photographers can be analyzed in much more depth, but these visual elements and ideas are what I took from them and keep in mind when I am out shooting and practicing. Find the masters that inspire you and do the same!

I’m certainly a fan of Saul Leiter’s work… Self-Feedback and Mentors

The last piece of this “deliberate practice” puzzle is feedback. This is arguably the most important part, and in general it is not unique to the deliberate practice model. Everyone can agree that critiques and feedback are crucial for artistic growth. The problem arises when we can’t find a mentor to give us feedback… so… how can we get around this?

What I’ve learned is that being your own mentor is possible by channeling the masters. Just as I mentioned above, when you’re out shooting you can think to yourself “how would ‘so and so’ compose this scene?” Or even more concretely, you can focus on specific aspects of your composition: “what would ‘so and so’ say about this framing, or this element in the shot, or my timing?”

From this idea you can create for yourself a mental checklist of dos and don’ts. For example, here are some that I often keep in mind:

What (if anything) can I remove from this frame to make the story stronger? What (if anything) is in the immediate vicinity that I can add to the frame to make the story stronger? Can I improve any leading lines in the scene, by moving them into the corners, etc. Is my timing as good as it can be? Did I catch the action in the perfect moment? Can I imagine a better subject here, that is, a more suitable passerby that would enhance my composition?

And so on… The mental checklist can be anything that you think you need to work on. You can, and should, think of specific weaknesses or aspects you would like to improve, and then keep those in mind. It’s totally fine to write these things down to help you remember them.

An example of more reps: I had plenty of time to shoot here, so I took quite a few frame of this scene. Notice the general idea is not much changed, but the composition changes quite a bit from shot to shot…. …with the door handles… …and without… …and finally with a tilt—this is the shot I chose as the final. Focusing (Your Mind) and Doing More ‘Reps’

As a final note, I want to mention a few concrete and specific things that I do when I’m out shooting street photography.

The first is to make sure I give myself every opportunity to focus. This means I put my phone on airplane mode, or put in my bag. Another thing is that I typically bring only one camera and one lens. This can be a drawback at times, but it also makes for less indecisiveness. I don’t stand there wondering if I should switch lenses. I just focus on the gear I have and make do. This goes right back to the idea of constraints to spur creativity. To further enhance my focus, I tend do as much shooting as I can on an empty stomach. I find that having lunch first is the death of creativity, but when I’m hungry my senses seem heightened and my awareness and perception are increased. Also, getting some nice food after a few hours of shooting is a great reward!

Finally, in the words of Muhammad Ali, “I don’t count my sit-ups; I only start counting when it starts hurting because they’re the only ones that count.” In photography, when you are presented with a scene worth shooting, the first few shots “don’t count” when it comes to practicing and stretching your “perception muscles.” Even if you’re satisfied with that first shot, take more anyway. Give yourself a specific goal, like “shoot each subject from 10 different perspectives” (or any number you like). This is commonly boiled down into the phrase “work the scene.” In any case, the point is to force yourself to think harder about how to frame the shot. Do it until it hurts!

As always, I hope I’ve inspired some new ways of thinking about your own photography. And if you have anything specific you want to practice, please let me know in the comments and I’ll be happy to give any advice I can to help you come up with a training regimen.

About the author: Lukasz Palka is a freelancing Tokyo photographer who is the co-founder of EYExplore photography workshops. You can find more of his work on his website or by following him on Instagram, YouTube and Facebook. This article was also published here.