Which Patient Gets the ICU Bed?

The phone rang just after I’d turned off the light and snuggled into bed for a long winter’s nap. “Dr. Krentz, this is Dr. Smith (not her real name), the senior resident on duty in the ER.” (The attending emergency physician had gone off-duty hours earlier, leaving this second-year resident to fly solo for the rest of her 24-hour shift supervising an intern and two medical students. By end of shift they would evaluate some one-hundred patients seeking care in our busy public hospital ER.)

This rare late-night call got my attention. “What do you need?”

“We have two patients who require admission,” she said in a stress-tinged voice. “One is a fifty-four-year-old man who suffered a myocardial infarction (heart attack) four hours before he came in. His condition is stable.” She paused. “The other is an eighty-year-old woman who arrived in respiratory failure. She’s intubated and on the ventilator but remains unresponsive.” The doctor paused to catch her breath. “CCU (coronary care unit) is full, and ICU (intensive care) has only one open bed.”

This young physician wanted me to help her choose which patient would get the best shot at survival. The man with the stable heart attack would probably live, whereas the elderly woman would require more care but likely never recover to any semblance of useful life. Both patients had families who loved them, lives already lived, and unknown future years to go. Who were we to decide either one’s destiny? I should not make the decision for the young doctor. I should support and teach her how to handle a conundrum the likes of which she would face again in her career.

“Doctor Smith,” I said, “you have both patients in front of you and I don’t. You should make the best decision you can under the circumstances. Admit one and manage the other in the ER until another ICU bed opens up. I have confidence in your ability to care for either patient, and I trust your judgment. Don’t think of it as a right-or-wrong decision, but as a necessary choice between two rights. Trust your clinical intuition. I will support whatever you decide.”

She didn’t seem happy with my response. Over the years I’ve chided myself for not crawling out of bed and going into the ER to help her. The decision and final outcome may have been the same, but what would she have learned?

When I arrived in the ER the next morning, I found the elderly woman still there, still on a vent, looking very much alive. I learned that the fifty-four-year-old man was doing well and would soon be moved to an open CCU bed to make room in the ICU for the elderly woman. In the end, both patients survived and went home.

I’ve lost track of Dr. Smith, but I still remember our conversation that night involving the Parkland Hospital ER in Dallas, Texas, in late winter of 1990—thirty years before anyone heard of COVID-19. Perhaps she’s now a seasoned emergency physician guiding the early careers of other young emergency physicians. Maybe she’s facing the terrible decision of which COVID-19 patient gets the last ventilator, the last ICU bed, the last best shot at surviving and going home to rejoin their family.

An unfathomable dilemma for any physician. Whatever Dr. Smith and the others like her decide, they have my full empathy and support. Fight on, BAFERDs.