For example, more than 70% of those who would have been triaged to expectant after a 5-day ICU time trial and would have been designated for terminal extubation or ICU discharge actually survived with continued treatment. Paradoxically, under the triage algorithm their sellekchem ventilators could have been reassigned to newly admitted, intermediate treatment priority patients whose rate of survival was lower (62.5%).Many of the days of ventilation made available through the use of the protocol were thus made available by denying or removing them from patients who would have benefited. The study fails to account for these patients’ deaths explicitly in its discussion of the protocol’s ability to increase resource availability.

For example, the authors use ‘rates from the first wave of H1N1 in Canada’ to contend that the protocol could have saved 50 lives ‘based upon the 568 days of ventilation made available … assuming an average of 10 days of ventilation and an 89% survival rate’ [1].The data do not, however, support this prediction. The calculation does not subtract for H1N1 survivors who would have probably died after being either excluded from ICU care – comorbidities described in these patients suggest many would have been [3] – or withdrawn from treatment under the Ontario protocol guidelines. The fact that most of the critically ill H1N1 patients had acute respiratory distress syndrome and a long ICU course suggests that, in many of them, Sequential Organ Failure Assessment scores would not have improved after 48 or 120 hours.

Many patients would therefore probably have fallen into the protocol’s blue category (for example, Sequential Organ Failure Assessment score <8 and no change at 120 hours) and would have been terminally extubated.This raises the specter of wave after wave of acute respiratory distress syndrome patients being put on ventilators for 2 to 5 days only to be extubated before they improve. One could envision a greater loss of life using the triage tool, which the study's triage officers were instructed to consider as the standard of care, compared with using another approach that did not involve extubation. Many draft pandemic triage plans in the US include reassessment tools that are similar to those of Ontario.Further, the calculation of lives saved does not subtract for the deaths of 30 patients who would have been excluded or withdrawn from needed treatment under the protocol, but who actually survived in the real world.

Also, the days of ventilation made available by excluding these patients would not necessarily be contiguous for each new H1N1 patient or available in the ideal way assumed by the calculation. Further, first-wave H1N1 Brefeldin_A survivors in Canada required a median of 12 days (not 10 days) of ventilation, and overall survival in the critically ill was 83% (not 89%) [3].