Maurice A. Ramirez, DO, CNS, CMRO

London Got Lucky - The World is Still Not a Safe Place

This morning’s announcement by London Police that their “ordinance division” (bomb squad) had defused a “viable device” near Piccadilly Circus demonstrates yet again that the world is not yet a safe place.  While, no organization has claimed responsibility for this bomb, reports indicate that the device was of sufficient sophistication as to include vehicle fuel tanks, propane gas cylinders as part of the incendiary charge as well as nails for shrapnel. All this only 7 days short of the second anniversary of the bombing of the London Underground and two days after a new Prime Minster tooks office.

Multiple studies, including a June, 2006 report by the Institute of Medicine, have decried the fact that terrorism and national preparedness in general have fallen from the main public debate despite response catastrophes such as Katrina and the recent tornadoes, wildfires, and floods that have plagued various regions of the United States.

Even as the candidates line up in droves for potential presidential consideration, that the public debate centers more on the issue of keeping out individuals on whom our economy relies rather than excluding those who would seek to do us harm.

In the long history of disaster response in the United States, we have been fortunate to have enjoyed great success with a rather haphazard approach to our preparedness and security.  Individual portions of the system have worked extremely well, including planning by the Federal Emergency Management Agency (FEMA) and its sister departments at the various state and local levels. 

Rescue has been well represented by local EMS, Fire Rescue, Urban Search and Rescue, and Coast Guard Units.  Medical response for the last two decades has been the purview of the National Disaster Medical System and its various medical venture, veterinary and mortuary response teams.  These have been in the recent year been augmented by State Medical Response Teams and the all volunteer Medical Reserve Core.  These medical assets served with success and distinction in virtually every declared national disaster since their inception in 1986, providing medical care to survivors and rescuers alike. 

Response activities have been augmented by various volunteer and charitable organizations including pay based organization, the American Red Cross we have shelter, clothes and beds for those who have been displaced as well as for those who have come to serve, to assist the survivors.  Recovery has been a mutual effort involving various aspects of Federal Government, charitable organizations, local communities, corporations and even individuals. The ad hoc group has clustered around the only organized recovery system that our nation has had for the last 20 years, FEMA. Through it all rescue response and recovery had been augmented by our national guard and in our greatest of tragedies, the men and women of our armed services.

In an era of terrorism, law enforcement has played a critical role in both interdiction and at times capture of those who would attack innocent civilians. Despite the injustice of these acts our society has insisted that our judicial system mete out our just retribution.

Despite the tremendous assets brought to bear, it has only been since 2003 that there has been a National Response Plan and that plan has only had form and framework since 2004.  Both healthcare and non-healthcare corporations in this country have failed to take up their mantle of responsibility and even some communities have preferred to believe it could not happen to them… that it could not happened again. 

Today’s “near miss” in London, a car bomb left on a busy thorough fare, in front of a popular nightclub, just down the street from 10 Downing street and Buckingham Palace demonstrates how vulnerable we all are.  Today Londoners are lucky, how long will the United States rely on luck alone.   

The Unsung Heroes

On this second anniversary of Hurricane Katrina, we must not only think of those still in the recovery, those still displaced from New Orleans and Gulfport and homes and businesses all across the Gulf Coast of the United States.  Among those who were the first to provide aid and assistance to the survivors of Hurricane Katrina who were the unsung heroes of the National Disaster Medical System (NDMS).  Few in the United States have heard of the men and women of NDMS.  These healthcare professionals shied away from the public eye and publicity of any kind.  They strive to always observe the first lesson of the disaster field office: “Don’t get in front of the camera!”  Yet those who serve in the various divisions of the National Disaster Medical System are perhaps heroes in the truest sense of the world because it is these men and women who place their lives on hold often on as little as two hours notice and travel to communities not their own to help those in need, to help people whom they do not even know and will likely never see again.

The National Disaster Medical System has existed for over two decades, beginning as a single unit of field responders under the United States Public Health System.  Since its simple beginning NDMS has grown to include units dedicated to providing medical assistance to disaster survivors through Disaster Medical Assistance Teams (DMAT); domestic animals and pets through Veterinary Assistance Medical Teams (VMAT); and the respectful care of those not fortunate enough to survive a disaster through Disaster Mortuary Operational Response Teams (DMORT).

Why are NDMS teams and the people that serve on them unsung heroes?  It is because not only do they shy away from publicity, but they choose to serve rather than to self-promote.

NDMS members exist in a unique place in our federal government and our federal response to disaster.  Although they serve in uniform and operate within a command structure that closely mimics that found both in the fire service and in our esteemed military, NDMS personnel are not technically reservists.  NDMS began at the volunteer program functioning more like AmeriCorp, the Peace Corp or the American Red Cross than like a government agency.  Over time however, the need to provide these intrepid rescuers with the basic protections of workers’ compensation, liability insurance and malpractice insurance spurred the federal government to make them “intermittent part-time employees.”  At times of nationally declared disaster, NDMS personnel respond to deployment request within as little as two hours.  NDMS personnel maintain equipment that they have paid for in deployment ready condition at all times, often carrying that equipment in their automobiles and even on vacation with them.  Three months out of the year NDMS teams place themselves on call, notifying employers that in the event of a national disaster they may have to leave their workplace almost immediately. Yet unlike all other federal assets, in those times between disasters NDMS personnel receive a biweekly federal pay stub for zero dollars. They receive no benefits, no retirement, no reservist pay, none of the other benefits, discounts, or protections afforded those who serve in the United States Military, the National Guard, the Military Reserves, or as federal employees. 

While deployed NDMS personnel are protected from employer discrimination and retaliation for their service just as those in the National Guard or the Military Reserves are protected.  During times of deployment, they are full-time federal employee but they receive pay that is seldom more than 25 percent of their usual civilian wage.  For most NDMS members, each week of deployment takes 2-3 months of personal financial recovery.   Informal surveys of NDMS teams responding to the hurricanes of 2004 (Charley, Frances, Ivan, Jeanne) and 2005 (Katrina, Rita and Wilma) found that most team members were still financially recovering as of this writing in 2007. 

Because an employer is required to hold the job open but not for maintaining the employee on the work schedule, upon an NDMS team member’s return it is not unusual for that team member to spend one or even two weeks off the job waiting for the next work schedule to begin. This means that after returning from a two week deployment where they earned 25% of their usual wage, they go without pay at all until their employer can integrate them back into the schedule.  In 2004 and 2005 this meant that individuals deployed to all seven major hurricane, spent on average seven months away from work in only a 14 month period of time.  In that same time period, few made more than the equivalent of three weeks of their regular civilian pay. Despite the fact that in that 14 month period of time, every team in the nation was deployed repeatedly and most deployed for all seven events, the loss of team members across the nation was surprisingly low.

The heroes of the NDMS system are not the typical field responder that most citizens would envision.  These are ordinary doctors and nurses, respiratory therapists, supply personnel, paramedics, EMT’s, physicians’ assistants,    nurse practitioners, administrators and accounting personnel from the whole spectrum of the healthcare workforce.  They are most accustomed to working in nicely appointed offices for well-equipped hospitals.  In their civilian lives -- like most Americans, they sleep in a comfortable bed in an air-conditioned or heated home with pillows and blankets, an alarm clock and a hot shower.  However, in addition to the financial hardships that they gladly endure, they deploy into a field environment where one trip may they sleep on the floor in an airport or on the baggage conveyor belts and the next, they sleep in a tent in a sleeping bag or in the seats of vans and buses.  Although their treatment areas are air-conditioned for patient benefit, seldom if ever do they enjoy air-conditioning in their own billet or bivouac.  A once a week shower is a luxury and since resourcefulness and creativity are the hallmarks of NDMS personnel, it is not unusual to see them washing uniforms in a bucket, in the rain or even in an unmonitored dishwasher, in the first class lounge of the Louis Armstrong International Airport.

Despite the hardships and the lack of personal benefits beyond that satisfaction of having served their fellow American, an increasing number of healthcare professionals from all areas of healthcare, both clinical and nonclinical are seeking to join not just NDMS but the state equivalent medical response teams in all 50 states and US Protectorates.  Those not willing to leave their homes are joining Medical Reserve Corps Teams in order to afford themselves an opportunity to assist their own communities in the event of disaster.

But it is the members of the National Disaster Medical System, those first out the door, first in the field, first on scene, this first line of the nation’s medical and rescue response who are truly the unsung heroes and truly most deserving of our gratitude and praise on this second anniversary of Hurricane Katrina.

Healthcare Recovery for the Gulf Coast

A recent article in the USA Today stated that there was a 47% rise in deaths in the Gulf Coast states within the impact area of Hurricane Katrina as a result of the loss of healthcare professionals in those areas.  Healthcare professionals displaced by Hurricane Katrina, many laboring under the burden of student loan repayments and the daily financial needs of life assimilated themselves into their new home community as they landed in cities and towns across the United States.

Now that the cities of the Gulf Coast are rebuilding they are discovering that these healthcare professionals are not rushing home to the Gulf Coast.

Startup cost for a private medical practice vary between $100,000 and $200,000 for rent, business insurance, malpractice insurance, equipment, supplies, information systems, computers and simple office decorations.  Most of the healthcare providers in the Gulf Coast region lost well-established practices and if they were insured at all they used the funds from those insurance payments to begin again in their new communities.  Unfortunately, healthcare practices in 2007 have little resale value; particularly, when only one or two years old.  Even if these professionals were inclined to move back to the Gulf Coast region, they face significant financial hardship in accomplishing that feat.

Add to this the lack of meaningful business recovery and a decline in the number of insured patients in many of these regions.  The sad facts are that employment statistics and new business starts in the areas most affected by Hurricane Katrina are well below national averages.  Healthcare providers, now comfortable in their new homes, find little inducement to assume the responsibilities, liabilities and hardships of returning to their former practices and even when they do often find that their former patients have yet to return as well.

Physicians are not the only individuals affected in this fashion.  Hospitals that have already reopened in the Gulf Coast region are finding it more difficult to recruit nurses in a nation where there are already nursing shortages. Even when temporary staffing agencies provide nurses, known as travelers in the industry, to the Gulf Coast region to fulfill short-term contracts, most of these nurses decline the opportunity to extend their stay, take full-time positions, or return at a future date.

Much of the problem is that as healthcare has moved from the individual private doctor and the small community hospital to large corporate enterprise, it severed its relationships with its healthcare professionals seeing them more as expendable drones and less as a necessary and valued part of the healthcare delivery system.

Healthcare professionals regularly find themselves mandated to choose between maximizing patient flow and maximizing patient safety.  They are often forced to forego important family events under threat of suspension, retaliation or termination.  When the healthcare professional finds a home where they can achieve a level of work/life balance, it is difficult if not impossible to dislodge them again.  It took a hurricane to dislodge these professionals from the Gulf Coast and nothing short of another force of nature, perhaps this one favorable, will move them back.

A Homeland Security Role for Vitamin B12

Research into transmucosal absorption of intranasal Vitamin B12 gel supports a significant absorptive capacity for Vitamin B12 by this route.  Given that the mucosal thickness of the intranasal mucosa compared to the sublingual mucosa is approximately the same in that mucosal vascularity is also approximately the same such dispirit results between the two routes would not be expected based on a pharmacokinetic difference alone.  Given that both areas are supplied by branches of the carotid artery and therefore have the same flow rates, vascular profusion also fails to explain the disparity of results that is in fact seen when these routes are compared.  The most logical and obvious explanation is that the intranasal administration allowed for a retention time greater that found sublingual administration of Vitamin B12 gel.  This “holding time” allowed for a greater absorption of the Vitamin B12 gel.

Although this has interesting implications for the treatment of Vitamin B12 deficiency in a number of patient types including those with Dumping Syndrome and Pernicious Anemia, all other patient populations with Vitamin B12 deficiency have been shown to be adequately supplemented by high dose oral Vitamin B12.  The intranasal use of Vitamin B12 gel does represent an opportunity to treat those patients for whom oral Vitamin B12 is either unacceptable as an administration route or ineffective due to decreased intestinal transit time or the lack of intrinsic factor.

Of far greater potential if the application of this research to the treatment to cyanide poisoning.  The incidence of cyanide poisoning as an industrial exposure continues to this day to be a significant occupational risk worldwide.  Although that risk is significantly lower in industrial countries due to the shift to a more technological economy third world countries continue to use large volumes of cyanide and its conjurers in the manufacturer of precious metals and the processing of gemstones and other products.  The most famous of these accidents occurred in Bhopal, India in 1984 when 40 million tons of methyl-isocyanate was inadvertently released by a union carbide plant worker.  The number of casualties quickly outstripped the medical capabilities of the local community and the casualty rate both in disabled and dead was astronomical.

The loss of the amyl nitrate based cyanide treatment kit has created a void in the continuum of care for cyanide exposed patients.  The amyl nitrate based cyanide treatment kit allowed for a bystander with no medical training to read simple picture based instructions and administered the first, life sustaining step in cyanide treatment.  In many cases individuals exposed to cyanide can self treat in using this first amyl nitrate based step since it required only that the amyl nitrate ampoules be open and poured on gauze or another cloth which could then be held to the face and the medicine breathed in.

The new Vitamin B12 based cyanide treatment kit, while safer, requires the reconstitution of powdered Vitamin B12 and administration by use of an intravenous infusion.  While this is relative simply procedure for an experienced health care professional it is beyond the reach of most bystanders and prohibitly difficult if not impossible to be performed by cyanide exposed individuals upon themselves.

Transmucosal administration suggests a potential solution that will fill the void between immediate field care between cyanide toxic related toxicity and dissentative intravenous care using Vitamin B12 base cyanide treatment kit. The volume of Vitamin B12 gel required would exceed that reasonable for intranasal use, but an intrarectal route would provide both adequate volume capacity and holding time.

Currently there are several intra-rectal treatments utilized in toxicology and emergency medicine.  Intra-rectal diazepam is utilized for the treatment of seizures by school nurses, parents and in a limited number of situations by patients during their pre-seizure aura.  Kayexalate is utilized extensively for hyperkalemia whether a result of renal failure or muscular injury from glass or crushed trauma intra-rectal kayexalate.

In both of these treatments volumes of medication between ten and 120 milliliters are instilled and retained in the rectum allowing for the absorption of medication across the rectal mucosa.  Like the intranasal mucosa the rectum mucosa is relatively thin and of approximately the same vascularity and profusion rate.

The scientific literature suggest that a Vitamin B12 gel at a concentration similar to that described in multiple British research projects (15 to 20 milligrams per milliliter) would result in a dose comparable to half of the total Vitamin B12 based cyanide treatment kit.  This dose of 1.8 to 2.4 grams could be repeated in four hours allowing for the administration of the entire recommended 5 gram Vitamin B12 dose for moderate to severe cyanide toxicity within the recommended six hours via the rectal retention method alone.

Although further, more specific research on the utilization of high dose Vitamin B12 intra-rectal gel in the treatment of cyanide toxicity would be required before a definitive recommendation could be made for this route of administration; the potential of this route is clearly supported by the literature. Transmucosal Vitamin B12 may represent the missing link in the care of cyanide related toxicity both in the industrial and the tourism related exposures.

Three Simple Rules for Media Relations

In the disaster field office there are three simple yet absolute rules to managing media relations. Businesses, celebrities, and even hospitals have created for themselves foibles and catastrophes due to a basic lack in the ability to manage media relations and the press.  These problems stem from the fact that most failed to understand that the press serves the same people that they serve.  Whether you are a corporation, a small business, a healthcare facility, or a movie star the press speaks at one time en masse to your public.  If you remember this simple fact it is then no great intellectual stretch to understand that by partnering with the press and the media you can communicate vital information to your entire market simultaneously.

Rule Number One: Don’t get in front of the camera!

This may be obvious but if it is not your job to speak to the press do not get in front of the camera. Moreover ensure that your employees and staff do not get in front of the camera unless it is their job to interface with the media.  Most media mishaps occur because the press is presented with multiple messages and good, honest reporters attempt to make some logical sense of these conflicting stories. 

Unfortunately no matter how good the reporter and how well meaning your staff when conflicting stories enter the press simultaneously nothing but bad can come of it for your organization.

Rule Number Two: Do not lie!

Now this is probably good advice in life in general, but if you lie to the press they will catch you and then they will make it their mission in life to destroy your career because you have just done irreparable damage to theirs, you have damaged their credibility.  The media succeeds because people trust them.  If they violate that trust no matter how unintended or innocent the violation they lose the public trust.  With this loss of credibility comes the loss of the ability to do their job.  Therefore everything that you say must be absolutely true and absolutely consistent with what the reporter observes.

Rule Number Three: Remember how the press keeps score!

The media does not keep score the same way that you do. 

• They do not count dollars.
• They do not count lives saved.
• They do not count how many movies they appear in. 

The press keeps score either in terms of minutes of face time on camera or inches of newsprint.  In order for the press to score they must capture 1.5 seconds of you, approximately 15 words in print, and surround it with several minutes of themselves, at least 2 inches of newsprint. 

If you know what message you wish to communicate to your market, their audience, and you must:

• Condense your message into a 1.5 second sound bite (fifty words for print).
• Ensure that message is absolutely true and consistent with what the reporter sees.
• Deliver that same message regardless of the question asked.

Do these three things and you will leave the reporter with only one choice, use your message or to not score today.  Under those circumstances the media will use your message every time because they keep score based on minutes of face time or inches of newsprint and to score they must surround your message with their voice or their prose. 

Remember these lessons from the disaster field office and your next media encounter will serve to bolster your relationship with the media and your position both with the press and the community. 

The Choice to Love

We hear the word love throughout modern society.  We are told to love our customers and that as customers we are loved.  We are told to love our neighbor as ourselves.  We are told that there is no greater gift than love.  We even have a special holiday, Valentine’s Day, dedicated to the notion of love.

Love has been described a basic building block of resilience, the foundation of the family, and in the goal of marriage.  But does love have a place in business?

Father Dan Schulte, a Catholic Priest and Philosopher, has defined love as “Love is the unifying thoughts between two people who have cared for and have said ‘yes’ to each other total being.  It implies mutual respect, freedom and trust, and seeks the happiness of fulfillment of each other as a common goal.”

Father Robert Mitchell has stated that love is an act of choice while “life” is an uncontrollable emotional response to our experience of another individual.  Father Mitchell states that while respect is a pre-requisite of love, life is not.  Father Mitchell does posit that respect is the ideal foundation for a love relationship and that from this respect “life” would ideally spring forth to form the framework of the love choice however, life is not the pre-requisite to the act of choice to love.

In the business world the admonishment to “love our customers” has been criticized as minimizing the meaning and importance of love.  As this admonishment is a pride in most businesses that criticism is quite true.  Father Schulte in his definition points out that love is a unifying response, it binds those in the relationship together trading a new individual, the love relationship itself.  In his definition those in the love relationship choose to “care for and face ‘yes’ to each other’s total being.”  Here Father Schulte and Father Mitchell agree completely, love does not require that you “like” the other individual only that you choose to love.  How many of our customers do we have the immediate emotional response of dislike?  Father Mitchell and Father Schulte prove here that we can embrace that “dislike” and still choose to love that customer.

But how can I love somebody whom I dislike?  Father Schulte’s definition answers this question as well by including that love implies mutual respect.  Just as Father Mitchell stated that respect is the foundation for love, Father Schule states it is an absolute pre-requisite.  Even if we dislike our customers we can still find in ourselves respect for them and perhaps even acceptance of them as they are and through these make the choice to love them. 

Finally Father Schulte points out that a love relationship requires that we seek the “happiness and fulfillment of each other as a common goal.”  Is this not the goal of every business?  Few of us work to be unhappy despite the fact that for many this is the end result.  Instead we speak to gain fulfillment and happiness through the work we do.  Father Schulte points out that it is not the work that creates the fulfillment and happiness but the relationships that we garner from that work.  Interestingly, when the relationships from our work provide fulfillment and happiness we need the last pre-requisite to love our customers.

But what if our customer refuses to enter into this love relationship?  What if our customer does not care for us, is not accepting of us and does not respect us, does not trust us or does not seek our happiness or fulfillment as their goal?  Increasingly in American society we find an almost schizophrenic response to the concept of customers and businesses and business people entering into a love relationship. 

When we fill the role of customer we are often impatient, untrusting, unaccepting, unloving.  Yet when we are in our own business and work environment we strive to respect, accept and even love those whom we serve.  Father Mitchell points out that because love is choice we can choose to offer love even when the requirements of a true love relationship are not there.  For Father Mitchell this is a form of self reliance and self respect.  Father Mitchell states that it is the ultimate form of self love to not allow another person to denigrate decisions and the ideal that we have set for ourselves.  This means that even though we may not like our customers, even though our customer may disrespect us we can choose to offer them love.  This is not to say that we should allow ourselves to be abused.  Nor should we allow ourselves to be exploited.  There is a vast difference between offering love and becoming a victim of our own love choice.  In offering love we are respecting our own choice to enter in to a love relationship however, that relationship becomes exploitive when it is not a unified response, when we are not cared for nor accepted.  We may offer love despite apparent disrespect but if disrespect, distrust and a failure to value our happiness and fulfillment by what we receive in return for our love choice then it is not love but masochist to remain in the relationship.

For many years it was the professional responsibility of physicians to constantly evaluate their relationship with their patient.  The doctor/patient relationship was seen as the ultimate love relationship.  In that relationship the physician along with the patient sought health and happiness, however when evaluating that relationship if the physician found that the relationship itself was not healthy either for the doctor or the patient that physician was both morally and ethically bound to end that doctor/patient relationship and assist the patient in finding a new physician. 

Unfortunately as healthcare became more a business and less a relationship physicians began to abandon this professional responsibility remaining in relationships where they were neither respected nor trusted and where they failed to respect or trust their patient.  Over time the professional decisions to find the patient a more supportive relationship became replaced with the legal decision to “severe the doctor/patient relationship”.  It is interesting to note that about the same time the number of malpractice lawsuits in the United States began an exponential rise.

In any choice to enter into a love relationship there must be the inherent choice to end that relationship if it fails to meet the basic requirements of love.  This is a prospect that is frightening too many businesses however, if a business is to be financially resilient, if it is to be able to extend the same love relationship to its employees as it frequently extends to its customers than it must obey the moral imperative to love its customers enough to seek for them the best business relationship possible even if it is with another business.  How often had a business garnered our undying loyalty by referring us elsewhere for service that they can not truly meet?

The choice to love is the basic building block not only of friendships, marriages and resilience, it is the basic building block of business.

How to Think Like Einstein

You’ve likely met some people who are the epitome of the classic absent-minded professor. You know the ones…They can’t remember facts or formulas, much less people’s names, and they need to continually reference information that others believe should be second nature. However, once these so-called absent-minded people look up the information they need, they have the uncanny ability to encapsulate very complex concepts into simple-to-understand formulas or words. They’re the conceptual thinkers—the people who create new knowledge, products, or innovations. They are the Einstein thinkers of the world.

When asked why he had trouble memorizing formulas and why he earned poor grades in school, Einstein replied, “I do not clutter my brain with facts I can look up in any standard reference within two minutes.” Instead of wasting energy with memorization, Einstein took those easily-accessed facts and created something new with them—he saw the connections among the facts and the patterns underneath the processes. As such, Einstein, who failed math, gave us the power to harness the atom and ultimately create nuclear power.

Today’s most innovative executives are a lot like Einstein. While they may have difficulty knowing precisely, step-by-step, what they do or replicating it on paper, when asked to just do it, they have tremendous success. They have the ability to find the patterns that underlie successful processes and can apply those patterns in new and different industries, thus achieving amazing results wherever they go.

5 Types of Leaders
Very few people are true Einstein thinkers. Rather, people tend to fall into one of four categories.

• The logical thinkers: These people learn from data. They must analyze data in order to move to the next decision. If they don’t have hard data, they can’t move forward. And without that data, they can’t communicate to others how to advance through the needed steps.
• The verbal thinkers: These people learn by hearing. They are more conceptual. They can process information they learn and can write it out. But while they understand the processes that others do, replicating that process in a different location is difficult for them. 
• The pictorial thinkers: These people learn by seeing. If you graphically show them how to do something, they can do it. But if they have to read instructions without pictures, even instructions that are very well written, they’re lost. They can build pretty molecule models, but they can’t do the calculations to tell you what the reaction will be.
• The kinesthetic thinkers: These people learn by doing. You can put them under the hood of a car, show them how to fix a car, and let them dig in and get greasy. Then you can line up a hundred cars and they can fix them all. But if you hand them a manual for fixing a car, and you never show them how to do it hands-on, you’d better find another mechanic to fix what they just broke. These people have to learn by doing, and they have trouble communicating what they learned.

Think of the previous four thinking styles as overlapping circles. In the center of the overlap point are the Einstein thinkers.

• The Einstein thinkers: These people have a little bit of all four thinking styles, yet not enough of one to make them extremely effective in any one realm. However, they have the ability to take a process, no matter how it’s presented—whether verbally, in writing, in pictures, or hands-on—and duplicate the process in different scenarios. Yes, they need to review the process or  calculation or formula each time, but once they review the initial process, they move forward and create new things. They read the roadmap and follow it.

Most executives are in one of the first four areas of learning and thought. Those who truly excel no matter where they lead or work are the Einstein thinkers. They have figured out the process of being a CEO or any other c-suite position, and they can apply the process in any environment.

The Process of Einstein Thinking
While thinking like Einstein is not innate for most people, you can learn how to analyze the process underneath everything you do, thus enabling you to venture into the realm of Einstein thinking. Think of it as a process for creating a roadmap, so to speak, and once you own that roadmap, you can apply it to other industries and replicate success. The following guidelines will help.

• Ask “Why?”
  Become fanatical about asking yourself “why” at every turn. This enables you to identify the main decision points in any process. Realize that there are actually very few things at a management level that are unique to an industry or company. Yes, there are facts and circumstances that are unique, but no matter what industry you’re in, you have to build relationships inside and outside; you have to comply with certain regulations; and you have to deal with a certain level of customer service. Therefore, identify how you function in each process and ask why you’re doing something, not what you’re doing.
• Know Your Decision Options
  When you come to a decision point, ask yourself three key questions:

1. Why do I make this decision at this point?
2. What influences my decision?
3. What are my choices?

Your choices are always the same at any decision point. You can either act or not act, or you can act in a series of choices. So it’s always a yes/no decision or a multiple choice decision. At this point, step away from the tendency to focus on what the question is, and instead focus on the reasoning behind the question.

Create a flow chart that details what you’re asking yourself at this point. Is it a yes/no question or is it a multiple choice question at this decision point? Then follow that up by asking, “Why do I make this decision?” If you know at a certain point that you are making a multiple choice decision, then you can reference what the choices are and what question led you to the choices. At another point in the business cycle you may be faced with a yes/no question. Follow up yes/no questions with, “What happens if I say yes? What happens if I say no? What are the questions I’m answering at this point?”

One of the basic concepts of physics is the unified field theory. The theory states that no matter what the special circumstances are, there are a set of equations or rules under which the entire universe functions. The same exists in business. There are certain things that are always absolutely true in business. When you know the truths and the processes that underlie the truths, then you are thinking like Einstein and can move from point to point in any circumstance.

• Get the Right People on Your Side
  Whether or not Einstein thinking comes naturally to you, you need to surround yourself with people who don’t think along the same process that you do. Very few people are truly like Einstein where they can write down their process so others can follow in their footsteps. However, the executives who surround themselves with those who can do the communication for them will have the upper hand. Therefore, get people on your team to interview you and get you talking about your goals and how you got from point A to point B to point C. Your team can then capture your process, encapsulate it, and put it on paper so you can read it and validate it. Doing so enables you and your company to more rapidly achieve goals.

Think Like Einstein Today
Training yourself to think like Einstein—to see the patterns and processes behind everything you do—will enable you to reach your full potential and bring new and innovative ideas to market. Remember that those with the greatest potential are those who are the most adaptable to any circumstance. They innately understand the process that underlies any other person’s success and can replicate it with ease. So create your own roadmap of what you do and follow it in every situation. And if you can’t write your own roadmap, then at least learn how to read the map that others have already created. With some analysis and perseverance, you can be the next Einstein thinker.

Disaster Medicine: Beyond the ER

In the year since 9/11 disaster medicine has come into its own.  Now a recognized specialty the practice of disaster preparedness, disaster planning, disaster response and disaster recovery as it relates to the practice of medicine and the function of healthcare and healthcare institutions has moved from the realm of the emergency manager and hospital safety officer and into the realm of the healthcare professional.  As with any burgeoning specialty, disaster medicine drew from its strengths and grew from its roots.  Disaster medicine had its beginnings in the disaster field office.  Field response units formulated much of the early information regarding the practice of this newest medical specialty. 

Just as patients flow from the field to the hospital decontamination a triage in decontamination arena the science of disaster medicine grew next in the areas of triage and hospital-based decontamination.  Soon nonemergency room staff were being drawn from their primary duties on the hospital floor to actually step outside the hospital to provide triage and initial treatment in the event of a mass casualty incident.  From the triage and decontamination tents disaster medicine moved quickly into the emergency department bringing with it new concepts in toxicology and mass casualty patient care.  Lessons drawn from military medical experience and from civilian emergency room experience melded in textbooks as well as discussion groups that inside disaster medicine and within the hallowed halls of the emergency medicine professional organizations.

But in this expanding universe of knowledge the hospital floor and the Intensive Care Unit were all but forgotten.  Michael Osterholm and others have discussed the impact of mass casualty events and pandemic influenza on the ability of hospital Intensive Care Units and other high acuity departments to meet the needs of a disaster response.  Unfortunately while models created by Schultz and Ramirez had demonstrated that with a small application of behavioral health savvy surge capacities can be increased not only by the required 20 percent under the US Department of Health and Human Services guidelines but by as much as 400 percent, this vast expansion of surge capacity rely in small part on the ability of the inpatient services to accommodate additional admissions.  A simple review of historically corrected pandemic predictions compared to hospital capability surveys demonstrates the dangers of not expanding hospital inpatient capacity as aptly as intake capacity has expanded.

When the lessons of the disaster field office are applied to businesses these businesses learn first to determine what is the goal of their organization.  In the intensive care unit and other high acuity areas of the hospital the goal is the same as it is in a field disaster hospital, the preservation of life.  In the environment of the intensive unit triage has already taken place for you.  These patients are already determined to be critical and further triage can only serve to determine which individual's care will utilize so many resources as to endanger the care of two or more other individuals.  In this circumstance it is the absolute moral and ethical obligation of those providing the care to make a resource-based decision.  When the continued care of one patient will utilize sufficient resources to endanger the care or life or two or more others then the care of that one patient, then that one patient must be reassigned to the expectant (black tag) treatment area.  This is not a do not resuscitate order (DNR).  This is simply a statement of available resources.  Patients are constantly re-triaged based on available resources and current medical conditions.  A critical patient upon the loss of vital resources may temporarily be moved to an expectant category until resources or conditions are such that the patient may be re-triaged back to a critical or possibly has improved sufficiently to be "downgraded" to triage category yellow (urgent).

On the other hand, if treatment of an ICU or a high acuity patient does not utilize sufficient resources to endanger the care of two or more other individuals then that high acuity care should and in fact must continue as an ethical and moral imperative.

The key to making these decisions is to identify the critical processes that are required for the provision of essential high acuity medical care.  Once these processes are identified specific, measurable parameters must be established to determine if additional resources are needed to bolster that process.  This ensures that valuable limited resources are not squandered on processes that are not in danger of collapse as a result of surge.  More importantly, as the number of patients under treatment expand it ensures that resources are wisely allocated to maximize the surge capacity.

Resources will always be limited in a disaster because of the very nature by which resources are now obtained.  Our "just in time economy" has eliminated most stockpiles from healthcare institutions.  Few hospitals have more than two or three days worth of medication, disposable supplies or food on hand at any given moment.  They rely on regular re-supply from vendors, who themselves maintain only limited warehouse storage.  In the event of a large scale disaster needs quickly exceed resources (the very definition of a disaster) and supply chains break down.  With resources even further limited essential processes fail and a disaster becomes a catastrophe as the ability to respond is lost.

The frugal application of resources to essential processes in the provision of healthcare combined with a continuous re-triage of patients ensures that precious resources are utilized in a fashion which maximizes their impact and benefit.

This lesson has already been implemented in virtually every hospital in the United States, but it has not been implemented in a patient care area.  Information technology departments utilize the constant monitoring of key operational processes with clear and well-defined parameters to determine how best to dynamically shift available resources.  Your information technology professionals speak in terms of "bandwidth" rather than "bed space" and "memory allocation" rather than "ventilator availability."  However, with well over a quarter century experience in process analysis and resource allocation, your information technology professional is an invaluable resource in the method of evaluating your essential processes and resource allocation.

Virtually every supplier of data management equipment and software, from imaging to electronic medical records to registration and accounting software are utilizing this process to ensure continuity of their part of the operation.  Patient care component is the only portion of hospital operation that has not learned to triage itself.

A careful evaluation of the healthcare process utilizing these information technology techniques will quickly show that in addition to those items already on our resource list including medication, food, bandages and other disposable supplies the most valuable and most limited resource is the healthcare professional themselves.  It has been said that it takes at least seven years to grow a doctor, at least two years to grow a nurse or a respiratory therapist and many more years to ensure the experience necessary to operate in these professions and every other patient care profession with any degree of expertise.

The loss of a healthcare professional through injury, illness, or stress has a significant negative impact upon both operational capacity during a disaster as well as the short and long-term recovery following the disaster.  Lose just one of these professionals and you impact the care of thousands or even tens of thousands of patients into the future.

Ensuring the resilience of healthcare professionals within the high acuity arenas of the hospital is the single most effective and most efficient means of expanding surge capacity beyond the emergency department.

There are six areas of human functioning:

• Physical
• Emotional
• Intellectual
• Social
• Behavioral
• Spiritual

Each of these areas of human functioning have a corresponding form of resilience, a canteen which is filled in the time between disasters and drawn from during the response to a disaster.  These six canteens of resilience are:

• Physical
• Emotional
• Intellectual
• Relationship (social)
• Functional (behavioral)
• Spiritual

Physical resilience is exactly as the name would imply.  It is the physical capacity to continue working in light of physical and even emotional stress.  Physical resilience is enhanced through the maintenance of good health and a healthy lifestyle.  Eating a balanced diet both at home and at work, including during the disaster; regular exercise; and adequate rest, even during the disaster, are essential to "filling" your canteen of physical resilience and maintaining that resilience while responding to a disaster.

Emotional resilience deals directly with what we feel and how we respond to it.  The old saying "attitude counts" was never more true than when filling your canteen of emotional resilience.  Loving and being loved, including loving yourself; enjoying the everyday joys of life and ensuring that you have the opportunity for boundless joy and genuine happiness fill your canteen with the sweet emotions that counterbalance the many unpleasant and at times even horrific scenes that we all encounter when responding to disaster.  On the other hand, if you have filled your emotional canteen with despair; selfloathing; angst and animus then you will have nothing but bitter drags from which to drink when in the midst of a disaster response.

Intellectual resilience is bolstered by the very act of learning and practicing the skills which you have learned.  It is as we gain experience and knowledge we slowly imprint new patterns which we may later use to compare and ultimately recognize as familiar situations and events that unfold during an event.  The more of these patterns that we have in our intellectual canteen the more quickly we can recognize and adapt to the ever changing disaster environment.  Just as we learn the patterns of a heartbeat or the patterns of respiration we can learn the many patterns that exist within medicine, patterns which occur more frequently and more rapidly but are no different when they occur during a disaster event.  When we can recognize these patterns quickly we can respond quickly thus bolstering our intellectual resilience.

Relationship resilience bolsters our social functioning.  It is through our relationships with those that we hold dear, spouses and significant others; children and grandchildren; parents; relatives; friends; coworkers that we fill our canteen of relationship resilience with memories and comforting mental images that carry us through our times of separation.  It is also these relationships that safeguard our lives and our emotions.  Disaster response is a high-risk sport not unlike scuba diving and for that reason requires that you have a buddy to check on you and ensure that you are not becoming overwhelmed, ensure that none of your canteens of resilience are running dry.  It is through these relationships that we not only fill our canteens but keep them full and keep watch on each other.

Functional resilience bolsters our behavioral function.  The skills that we have practiced in our day-to-day lives as we have moved through our careers are that with which we fill our canteen of functional resilience.  Like the patterns in our canteen of intellectual resilience the skills of our functional resilience are no different at times of disaster response than they are at times between disasters.  We need only be able to access those skills more quickly and perform them more calmly.

Spiritual resilience is somewhat different because the canteen of spiritual resilience is not filled by what we believe, but rather by the fact that we believe.  Research in the area of resilience has shown that the very act of believing enforces an even intelligence beyond ourselves, a higher purpose for higher power, bolsters our resilience, improves our function and our likelihood to master adversity.

It is through the maintenance and enhancement of resilience both for each individual healthcare professional as well as for the processes by which we provide high acuity healthcare in the intensive care unit and other areas of the hospital that we maximize the surge capacity of these most critical areas as well as ensuring that those that staff them do not become the collateral casualties of our disaster response.

One Best Step to Maximize Your Disaster Planning

There are as many ways to write an after action report as there are hospitals that are now required to perform disaster drills and write after action reports analyzing the performance of the institution following a disaster or a disaster exercise. Since there are 5,756 licensed hospitals in the United States, there are 5,756 different ways that are currently employed to write the after action review. At most institutions, after action reviews are written by a committee between 12 and 18 individuals, managers and supervisors who in addition to their regular duties, have been charged with analyzing the performance of their departments during an adverse event or disaster exercise.

When these individuals meet, they review the disaster plan and the performance of each division of the organization seeking to identify those areas where they enjoyed success. This list of successes will represent what the committee will keep as part of all future plans.

The committee will then review performance to determine where the plan failed. From this list of failures, they will perform a “root cause analysis” seeking to determine why the failure occurred at each of these critical locations. This list of failures, along with the list of root causes, will become the list of those items to be changed in the next plan.

In the last year, however, a new recommendation for a more effective after action review process has come to light. The recommendation does involve spending a small amount of money. The one best technique for maximizing your disaster plan is to buy index cards.

During a disaster or a disaster exercise, every individual involved in the operation of the hospital, regardless of their role or job, receives an index card. On the front of the index card, these employees will write the one thing that they saw that went extremely well during the disaster or disaster drill. On the back of the card, these employees will write the one key failure that they saw during the course of the disaster operation or disaster exercise.

Following the disaster or disaster drill, when it is time to perform the after action review the index cards will be collected and taken to the review committee. The hospital now has thousands of eyes that have critiqued hospital operations.

When the committee meets, they will perform their usual analysis of those things that went well and those areas of failure. They will still perform their usual root cause analysis attempting to identify the reasons for all failures. Then they will turn to the index cards. If the committee is very, very lucky, on the front of the index cards, they will find that the employees saw the same successes as the committee identified. The committee now knows, with certainty, what items to keep as part of the disaster plan.

When the committee turns the cards over to review those areas where the employees saw the plan fail. If they are lucky, they will find that the committee’s list of critical failures matches the observations of those who worked during the disaster or disaster drill. The committee now knows that their analysis is valid. They identified the same failures as the employees.

However, if the committee is very, very, very lucky, there will be one index card that identifies the early critical failure that started the domino-like cascade that ultimately led to the failure of the hospital’s disaster plan. When the committee fixes this early failure, the hospital’s disaster plan will be that much closer to a perfect plan. Unfortunately, there are no absolutely perfect disaster plans, but a “near perfect” plan can be achieved.

The “near perfect” is that disaster plan that continues to function until one second after the last emergency room patient resulting from the disaster is moved from the emergency room gurney into a regular hospital bed. Because, if a plan can last until one second after the last emergency room patient resulting from that disaster leaves the emergency room, then the plan has lasted until recovery has begun. Take this one best step and maximize your disaster planning.