Background: The COVID-19 pandemic significantly disrupted emergency medicine residents' education. Early in the pandemic, many facilities lacked adequate personal protective equipment (PPE), and intubation was considered particularly high risk for transmission to physicians, leading hospitals to limit the number of individuals present during the procedure. This posed difficulties for residents and academic faculty, as opportunities to perform endotracheal intubation during residency are limited, but patients with COVID-19 requiring intubation are unstable and have difficult airways. Case Scenario: When PPE is being rationed, who should be the one to perform an intubation on a patient with respiratory failure from severe COVID-19?
Discussion: We examined this case scenario using the ethical frameworks of bioethical principles and virtue ethics. Bioethical principles include justice, beneficence, nonmalfeasance, and autonomy, and virtue ethics emphasizes the provision of moral exemplars and opportunities to exercise practical wisdom. Arguments for an attending-only strategy include the role of the attending as a truly autonomous decision maker and the importance of providing residents with a moral exemplar. A resident-only strategy benefits a resident's future patients and provides opportunities for residents to exercise character. Strategies preserving the dyad of attending and resident maintain these advantages and mitigate some drawbacks, while intubation teams may provide the most parsimonious use of PPE, but may elide resident involvement.
Conclusions: There exist compelling motivations for involving senior residents and attendings in high-risk intubations during the COVID-19 pandemic. A just strategy will preserve residents' role whenever possible, while maximizing supervision and providing alternative routes for intubation practice.
Keywords: COVID-19; bioethics; emergency medicine; intubation; personal protective equipment; virtue ethics.
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