If a severe pandemic strikes North Carolina, doctors and nurses across the state will be forced to decide who lives and who dies on a scale and at a frequency few have ever experienced.

At worst, they will be overwhelmed by hundreds of thousands of gravely ill North Carolinians, many too sick to breathe on their own.

And there won't be enough ventilators, antiviral drugs and antibiotics to treat them all.

"You're going to have to turn people away and not give them care," said Betsy Sullivan, 35, a flight nurse who is also a special operations manager at WakeMed's Emergency Services Institute. "It's a horrible feeling. It's one of those gut-wrenching thoughts to have to look someone in the eye and say, 'We can't treat your loved one.' "

The expected flood of flu-stricken patients has doctors and nurses dusting off a term of art that the French coined for battlefield medicine -- triage.

In combat, that means picking which of the wounded to treat based on their likelihood of survival. In a pandemic, triage will mean doctors and nurses will pick and choose patients based on the clinical odds of survival rather than the severity of the case -- all with an eye on rapidly dwindling supplies and scarce equipment.

In both cases, the goal is to save the highest number of patients with the resources on hand. In practical terms, triage might mean a flu-stricken 25-year-old father of three in otherwise good health gets placed on a ventilator while a 65-year-old grandmother with chronic health problems does not, even though the plight of both is equally dire.

"That's the purpose of triage -- to try and pick those who you can save," said Dr. Wes Wallace, associate professor of emergency medicine at the University of North Carolina at Chapel Hill and an emergency physician at UNC Hospitals. "Most of us have not been in this situation -- virtually none of us, I'd venture to say."

Medical battlefields

Sullivan sounds like a combat veteran when she talks about her tour of duty last year caring for Hurricane Katrina survivors in Waveland, Miss. They streamed through a field hospital in the parking lot of an abandoned Kmart.

This was medicine in the raw, delivered outside the resource-rich walls of a big hospital -- served without frills and in the middle of chaos. And it sharpened the disaster skills of Sullivan and Wallace, two of about 700 North Carolina emergency medical veterans who rotated tours during the seven weeks that the state-sponsored field hospital was in that storm-ravaged parking lot.

But when she eyes the potential carnage a flu pandemic could cause, Sullivan knows her hurricane-seasoned skills won't be enough.

"I think we will all be overwhelmed, whether you're a veteran or a new nurse," said Sullivan, a take-charge emergency nurse accustomed to gauging whether someone mangled in a car wreck is too far gone to save. "We're going to have hundreds and hundreds of people coming in, and we're going to have to lock the doors and choose who is going to get treated."

All of this goes against the grain of the prevailing culture of American medicine, where the gravely ill get priority treatment -- not just those with the best shot at survival. Triage also goes against the expectations of most Americans, who are accustomed to treatment even in the face of long odds and who won't understand why there aren't enough antiviral drugs and ventilators on hand.

"You cannot do business as usual in a pandemic," said Dr. John Meredith, medical director for disaster management at Pitt County Memorial Hospital in Greenville. "We can't treat the sickest people as they come in. We need to do the best we can for the most people with the best chance of survival."

Difficult choices

State public health officials, worried about the torturous choices a pandemic will force doctors and nurses to make, have formed an ethics task force run by the N.C. Institute of Medicine to draw up triage guidelines in a report to be issued early next year. But Meredith has drawn up his own blueprint for the triage decisions he'll make in a pandemic, based on both his personal and professional life.

"My priority is going to be children and young adults. They have the best chance of survival, and they are owed a chance of living life and living life fully and contributing to society," Meredith said. "That's different from what we do now. We focus most of our resources on the elderly and people at the end stages of life."

Sullivan said she hates to think about the agonizing choices she'll be forced to make during a flu pandemic. But if one strikes, she'll bury her emotions, trust her hardened clinical instincts and practice the grim art of triage.

"Your sickest patients, the ones nearest death, are the ones you leave," she said. "As harsh as that sounds, that's the mind-set you have to have."