From an ethical perspective, the essential case is simple: if you, as a professional or an employee, have been entrusted with someone’s care, and you have accepted such responsibility, you should reasonably provide such care according to professional standards, and you should accordingly and to your best reasonable ability, avoid harming that person and protect that person from harm, as long as you are not harming yourself or placing yourself or others in danger to do so. You are not obligated to sacrifice your life for them. The essential ethical case is clearly and convincingly made in a brief New York Times Magazine article.1
A 2018 New Taipei City, Taiwan hospital fire that resulted in 14 tragic deaths also resulted in the arrests or criminal prosecutions of five people, including four hospital staff.2,3 We cannot comment on the justice or injustice of this outcome specifically, and we refrain absolutely from doing so here. However, it does remind us of another tragic hospital fi re ten years ago, which also resulted in deaths, and also in prosecutions of hospital staff.
That fire was in our hospital. We retell the story from our perspectives here.
The evening of December 17, 2008, began as a routine one in the OR department at National Taiwan University Hospital, a world-class teaching hospital in Taipei. Four scheduled procedures were underway: an open ankle fracture, a rigid bronchoscopy, a coronary artery bypass graft, and an esophageal reconstruction.
All normalcy in the OR was shattered when a nurse in the room housing the esophageal reconstruction opened a door into a hallway to investigate a smell of smoke. Heavy black smoke rushed in, and the room was blasted with heat. An electrical fire had ignited in a hallway surrounding the block of ORs, and erupted into an inferno. The surgeon worked frantically to stabilize and evacuate the patient.
The other surgical teams also hurried to stabilize their patients for evacuation. The patients undergoing the orthopedic and bronchoscopic procedures, being further from the fi re and with their procedures nearly completed, were safely evacuated. The cardiovascular surgery, however, was situated almost as near the fi re as the esophageal procedure, and was at an early and delicate stage. Medical personnel from the ORs were dispatched to obtain a portable oxygen tank and additional help, but a power failure and rapidly worsening smoke conditions rendered their returns impossible.
Closest to the fire, the surgical team on the esophageal reconstruction tried to close before moving their patient. However, the smoke and heat quickly became unbearable, and they were forced to abandon the patient and crawl to safety in order to survive. Smoke was also beginning to debilitate the cardiac surgical team, and they too were ultimately forced to abandon their patient and flee for their lives.
One of us (Sun, an anesthesiologist in the department) arrived on the scene to witness one of the surgical staff emerge from the OR suite and collapse to the floor unconscious.
Arriving fire fighters refused to allow us to lead them to the two patients remaining in the OR, and required detailed instructions on their locations in the somewhat labyrinthine area. They were finally able to go in with respirators and protective gear, and retrieved first the cardiac patient. He remained adequately oxygenated throughout the ordeal, and his surgery was later successfully completed. The esophageal reconstruction patient was last to be removed, from the room directly adjacent to the heart of the fire. On arrival to a safe area, he was found cyanotic, asystole, and burnt. Resuscitation efforts failed, and he was pronounced dead.
The medical teams from the two ORs all suffered respiratory injuries, some requiring treatment in the ICU. Before they could—literally—catch their breaths, sound bites were broadcast, and they were vilified in the public eye for supposedly abandoning their patients. Moreover, the esophageal patient’s entire surgical team was charged with manslaughter— charges later dropped by a judge, but which cling to our colleagues to this day.
We watched with great pain as the press sensationalized and oversimplified the story, and as prosecutors, to the best of our ability to discern, acted primarily to appease public outrage, to point a finger of blame driven by emotional, irrational, factors, by base instincts, not by the highest and best of what make us human. These actions added significant and unjust injury to a tragic situation which had already claimed a life. It is transparent to us, from all available evidence, including our (Sun’s) personal observations of event at the tragedy, that all members of the surgical teams involved struggled their best under life-threatening conditions to save the patients. The only thing they did not do was essentially commit suicide for the sake of clearly lost causes.
We hope our public retelling of this event and its aftermath, while necessarily incomplete, can remind health care providers and hospital staff to ask ourselves if we are sufficiently prepared to make the best possible decisions under circumstances of disaster— under physically and psychologically overwhelming conditions. As has been exemplified in this column, too often hospital staff are not even aware of the existence of emergency or disaster plans.4 We also urge the widest possible implementation of more effective preparedness training, which should not comprise standard drills calmly executed under routine conditions, but should contemplate the intense physical and emotional stressors present in actual crises.
We hope that journalists, legal authorities, the public in general, and perhaps even our fellow physicians and allied health care professionals, can refrain from making hasty judgments in such situations. We tend to blindly and automatically assume that health care professionals in disasters are always empowered to make choices, while only patients can be helpless victims. This cannot withstand scrutiny in the cool light of reason. Professional ethics oblige us to care for our patients to a high standard, as they should, but not to automatically jeopardize our lives in all situations for the mere possibility of saving those of our patients—especially given that such sacrifices may actually result in a greater number of casualties among patients, staff, or both. Again: We grieve for the patient who lost his life as would any compassionate person touched by this event. This grief has been expressed with tears, the shock and sadness communally shared among a small and closely-connected national population, and all of this validated in somber public occasion.
We are also much pained and saddened by the public blame and condemnation that was reflexively perpetrated on the other victims of this terrible event: our colleagues who endured not only the psychological trauma and physical injuries they sustained in the fire, but the shame and the harm blindly inflicted on their personal and professional reputations—permanent injuries caused not by a fire, but by a collective rush to judgment.
We write now to address one matter that remains to us outstanding. To our colleagues: We are sorry for your suffering as well, and we write publicly in the hope that in similar situations to come, we may take pause before criticizing professionals who may or may not have breached their moral or professional obligations and duties, professionals who may well have performed at or beyond a level anyone could ask of them. People who may be victims as well.
From Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan (P.Y.S. and Wei-Zen Sun) and Center for Emergency Medical Service, College of Medicine, National Taiwan University Hospital (Wei-Zen Sun).
Must the captain always go down with the ship?
The New York Times Magazine. Published May 23, 2014. https://www.nytimes.com/2014/05/25/magazine/must-the-captain-always-go-down-with-the-ship.html. Archived: http://www.webcitation.org/75UM7phNB
行政院衛生福利部臺北醫院火災事故 (Executive Hospital Health and Welfare Department Taipei Hospital Fire Accident).
https://reurl.cc/Wxz1e. Accessed January 17, 2019. Archived: http://www.webcitation.org/75UNQ1VVK [Mandarin]
台北醫院大火釀 14 死 代理護理長等 5 人轉列被告 .
Liberty Times Net. Published November 2, 2018. http://news.ltn.com.tw/news/society/breakingnews/2599500. Archived: http://www.webcitation.org/75UU4La6L [Mandarin]
Code red in the OR—implementing an OR fire drill.
AORN J 2004;79:797–805.