Maurice A. Ramirez, DO, CNS, CMRO

Limited Resources and Ethics

Please discuss the ethical challenge of dealing with limited resources in a mass disaster.
(Question posed via: Ask@MauriceARamirez.com)

The importance of dealing ethically with people in times of limited resources deals not only with mass disaster, but business continuity and even daily business operations. Whether the limited resource is food water, and medical care in a disaster or wages, shifts and benefits in a business down turn a goal oriented decision process must be employed.

In a mass casualty event, Continuous Integrated Triage should be employed to determine who receives care now and who waits for care based on degree of injury balanced against resources available.

To maximize the delivery of products and services during a time of scarcity, Business Triage must be applied, even by non-healthcare enterprises.

The need for triage is not an opinion, but the consensus of the vast majority of experts in crisis management, healthcare and business continuity. To determine the ethics of such an approach, several ethics boards were asked to address the issue.

Dr. Mark Pastin, President of Health Ethics Trust believes that the need for triage is the, “simple and obvious answer.” Dr. Pastin points out that there is the “risk of violating what would ordinarily be viewed as your professional responsibilities if you do triage.” Dr. Pastin posed the example of an existing doctor-patient relationship with one of the casualties. Dr. Pastin, a long time advocate for resource based standards of care in disaster healthcare points out that the lack of such standards leaves an array of questions should the care available fall below the usual standard of care. Dr. Pastin also points out that some have even wondered if euthanasia might be appropriate to those who are suffering but not likely to be treated.

Ethicist Dr. Ken Solis finds that the distribution of limited resources equitably or most effectively is sometimes “opposing priorities.” Dr. Solis observes that “most disaster plans, for example, allocate a limited resources to health care workers (and their families so the health care worker is willing to show up at work), safety officials (police, firemen/women), and public officials to keep critical infrastructures operating and so that more subsequent people can be treated - a utilitarian or effectiveness approach. After that, most models go by ‘first come-first serve’ or ‘lottery’ to try to be equitable.   Of course, those with the most means will still tend to come in earlier due to their greater resources and might even be able to cheat the lottery in some way, e.g. pay a poor person a lot of money for their ‘ticket’."

Dr. Pastin and Dr. Solis agree that, in a disaster situation, some of the norms that guide the typical provider-patient relationship will undoubtedly become difficult to sustain. The 2001 anthrax attacks and subsequent fear resulted in behavior by physicians and other healthcare providers that culminated in a nationwide shortage of Cipro (ciprofloxin) and doxycycline.

Dr. Solis echoes the concerns of many both in and out of healthcare when he reminds us of another challenge: the competing interests that a health care worker will have balancing their family versus their patients.  “Some healthcare providers will give priority to their family, especially if their absence could cause their family harm. Similarly, the healthcare provider may decide that their presence at the disaster (e.g. an infectious disease epidemic) could cause their family harm.  During the black plaque in Europe, many doctors fled to the country side, not an effective tactic, but acted based on their personal priority.”

The decisions involved in the triage and resource allocation process will result in dissatisfaction at many levels. While the first principle of medicine for centuries had been Primum Non Nocerum (First Do No Harm), it is increasingly obvious that in disaster healthcare the first principle should be “Do the Most Good for the Most People with What You Have Now.”

An ounce of soap is worth a pound of medication!

I think too often the public’s attention is captured by new medical discoveries while forgetting older methods that have worked well for us for years.

I have not seen any recent articles on the use of probenecid with Tamiflu, or the use of bacteriophages to treat our present MRSA epidemic.

If given my choice, I’d pick a box of masks, gloves and a bar of Dial soap over 10 caps of Tamiflu to avoid the flu.

What are your thoughts on it?

I agree that the industrialized nations of the world as a global  society and medicine as a profession have both become far too dependent on ever escalating doses of medications to solve major public health problems. The great medical philosopher Benjamin Franklin once said, “An once of prevention is worth a pound of cure.” Your masks (in 1918 a handheld cloth handkerchief), gloves and soap will do far more to treat future epidemics and pandemics (influenza, MRSA, SARS, or who knows what) than any pharmacologic agent.

The problems with any pharmacologic solution are side effects, resistance, compliance and prescribing practice. Our current MRSA problem is the direct result of the overuse of antibiotics, especially for “prophylaxis” after low risk lacerations and “treatment” of upper respiratory infections most of which are viral. Add to this the fact that many patients save “left over” antibiotics from prior prescriptions only to use them at a later date thus creating two incomplete treatment periods and bacterial resistance rapidly develops leading to MRSA (and other resistance problems).

Bacteriophages may one day hold the promise of disease targeted treatment, but chaos theory as it relates to mutation and genetics dictates that resistance will eventually develop even to these targeted therapies. The best solution is the oldest, a correct diagnosis linked to a specific and conservative treatment with full compliance to the treatment on the part of the patient.

The use of probenecid to raise the serum levels and area under the curve for Tamiflu (or Relenza) is an interesting theoretical solution to the need for double dose antivirals to treat H5:N1. Unfortunately, the degree of serum level elevation and area under the curve change that would result from probenecid in a given patient is unpredictable. Further, increase serum drug levels, whether from increased dosing or probenecid, will increase side effects including psychosis, depression, suicidality, toxic epidermal necrolysis and Stevens Johnson reactions. Like any pharmacological solution, risk and benefits must be weighed and Ben Franklin’s lesson must be updated for the new millennia...

An ounce of soap is worth a pound of medication!

Question submitted through Ask@MauriceARamirez.com

Identify, Notify, How?

During a recent planning session for a Catastrophic Health Incident Response Plan work shop the problem of victim identification / family notification was identified. What is your solution?

Your question touches on the key issue of priorities during a disaster response, most significantly in the initial hours after an event (when resources and information are most limited). Given the limited resource environment, any solution must conform to a resource allocation (business triage) model.

Most in disaster and emergency management would agree that the most important goal during the response to an event is the preservation of life. Close behind in importance is the prevention of further loss (preservation of property and resources); then the dissemination of information. Somewhere after these three (and perhaps a dozen more priorities) is the identification of the dead and the notification of families. The problem is that the notification of the families of survivors and the notification of the families of patients is too often lumped into the same priority category with the notification of the deceased. This means that families remain separated from survivors and patients increasing the psychological impact and pain caused by the disaster. Counterbalancing this need to reunite is the fact that the most limited resource in the early hours and days of a disaster response is people. Given the relative priorities of preserving life and mitigating loss, diverting resources to reunification is difficult to justify operationally while it is simultaneously difficult to delay morally.

The most obvious solution is to utilize resources not already dedicated to other early response activities. Unfortunately, untrained volunteers are of little assistance in the notification process and may inadvertently create hardship and confusion with a mistaken notification. Automation of the notification process using systems such as EMSystems, EMTrack, IRIS, or KatrinaSafe.org is less resource (personnel) intensive and in the case of KatrinaSafe.org, requires minimal orientation (great for those volunteers above). The problem with automated systems is that the system must know where to send the information so that the families can find it. EMSystems, EMTrack and IRIS collect information as part of other functions (effectively resource neutral) and send information to the Joint Information Office or the Emergency Operations Center. The JIO and/or EOC then must deal with notification and the resources required for that process. KatrinaSafe.org requires resource utilization to enter the survivor information, but notification is via a computer matching system in which the family enrolls on the internet (effectively resource neutral). The ideal would be some merger of these existing systems such that the already collected information were filtered to KatrinaSafe.org or another similar national system and then matched to the searching families without further resource utilization.

Question Submitted via Ask@MauriceARamirez.com

Antiviral Stockpiles and Prophylaxis

"An organizational decision to stockpile antiviral medication and then acquiring anti-virals is the simplest part of a plan.  The protocol associated with securing, transporting, screening and eventually dispensing the antivirals is another matter altogether. Please comment on some of the antiviral initiatives that you are seeing and give your personal opinion on the use of antivirals as prophylaxis."

There are several issues to consider when dealing with antivirals and pandemic flu. The first deals with the dose, regimen and efficacy of antiviral treatments for pandemic flu. Experience with antiviral regimens against H5:N1 influenza in South East Asia has shown that even with the best healthcare professionals in attendance and the greatest minds guiding care, the usual dose of antiviral medication must be doubled and that the length of time required for treatment is twice as long. Further, the past several months has demonstrated a disturbing trend towards the need for the use of both drugs at this four fold increased regimen. This set of facts alone means that a company planning to stockpile must now plan on four times as much of each drug for each person to be treated.

The second issue deals with obtaining sufficient quantities of both drugs to provide effective treatment. Based on standard doses, experts and governments agree there are insufficient supplies of antivirals available to treat just those in healthcare critical infrastructure and national critical infrastructure roles. The four-fold increase in dose and the need for duel drug therapy effectively reduces supplied eight-fold.

The third issue deals with the ineffectiveness of prophylaxis and the risk of creating resistance to the few drugs we have now. While drug prophylaxis has a certain theoretical appeal, it has not been shown to be effective for influenza. Worse, constant exposure of the disease to low doses of the antivirals increases the likelihood of mutation resulting in resistance to the antiviral drugs. Finally, any drug used for prophylaxis is taken out of the total supply, thus reducing the amount of drug available for treatment. Given that at worst, only one in three people exposed to the disease actually falls ill, giving prophylaxis to everyone means using three times more drug than needed, or running out of drug three times sooner.

The fourth issue deals with the ethics of superseding national needs regarding critical healthcare infrastructure support and national critical infrastructure support. Given a limited worldwide supply of antivirals, such redirection of drug means that some segment of critical infrastructure will be denied treatment.

In short, the decision to stockpile medications is ill-conceived, impractical and quite possibly unethical. Prophylaxis is perhaps the only decision that would be worse.

Question submitted through Ask@MauriceARamirez.com

How do the kids who rely on two meals a day from the schools get fed when the school is shutdown?

Non-pharmacological response plans for pandemic include no only social distancing, but often some combination of school closures, cancelation of mass gatherings and travel restrictions. These last three hold significant financial implications for the communities and society in general. Imagine if you can all shopping malls, concerts, theme parks, conferences and movie theaters being closed down in your area for months at a time. Not only would the economic impact of lost sales be overwhelming to local economies, but the loss of small and even medium sized businesses would lead to the loss of jobs and worse, the loss of employers.

However, not only will there be severe economic impact, but even more dire psychosocial impact. One example is the impact on childhood nutrition. 30.1 million American children depend upon school nutrition programs for one or two meals each day. Unfortunately, many of these children receive no other meaningful nutrition each week. The loss of these 5 to 10 meals per day places all these children at risk. The families who rely on school nutrition programs often lack the financial means and/or know how to provide meals for these children. Current plans at a national, regional, or state level do not account for this and similar issues. The first rule of disaster planning is that all disasters are local, therefore it is up to local emergency managers, local disaster planners and individual families to prepared to feed these children in the event of school closures.

Question submitted through Ask@MauriceARamirez.com

What support can the private sector expect from the U.S. Government during a pandemic?

Question submitted through Ask@MauriceARamirez.com

During a typical disaster related emergency, needs exceed resources in a limited region of the United States. Even disasters on the scale of Katrina are limited in their region of impact. A pandemic by definition will effect the entire nation (and the entire world) simultaneously for a period of 12 to 24 months. The extended time over which the disaster event will exist combined with the fact that there will be no geographical limit to the impact area means that the typical governmental response of shifting resources from unaffected areas to the impact region will not work.

When asked about resource allocation for pandemic, Secretary of Health and Human Services Levitt said, “from where to where?” All pandemic response plans are geared towards supporting critical healthcare and defense infrastructure, followed by critical national infrastructure. With the realization that there is no drug or vaccine regimen that significantly changes the course of disease, the emphasis on a “pharmacological response plan” is being a downgraded in favor of a “non-pharmacological response plan.”

This non-pharmacological response plan depends on concepts of social distancing, personal hygiene, cough hygiene and sneeze hygiene supplementing regional plans for school closures, cancelation of mass gatherings and travel restrictions. Unfortunately, these last three have never been shown to work for large scale zoonotic pandemics. Further, closure, cancelation and restriction plans will negatively impact the private and public sectors economically, but that is tomorrow’s question.

How to Become a Critical Service Provider

The following question was submitted through Ask@MauriceARamirez.com

How do we get assurance from state/local emergency preparedness agency that, in the event of a local disaster get placed on a priority list with the utilities companies (power, water, waste management) and critical service providers (cellular, bottled water, critical supplies)?

The only way to receive priority services is to be a recognized as a provider of critical community response or recovery services. In most cases, these providers are already known to emergency management, but any business capable of contributing to their community’s response or recovery should contact their local office of emergency management to become part of the local response plan and to be added to the local response resource list.

Local companies that provide much needed services, even those not usually considered critical service providers, can be designated such by the local office of emergency management. Once a company is determined to be a critical service provider, that company will be asked to provide the office of emergency management a list of resources needed to continue services and that need triaged against other demands for a given resource.

Getting "Buy-In" for Preparedness

The following question was submitted through: Ask@MauriceARamirez.com

As a Business Continuity / Disaster Recovery consultant, my biggest challenge is getting my customers (and their senior management) to seriously consider the hazards posed by a pandemic / major health issue. They’ve heard the statistics, but find it difficult to accept that a pandemic-like incident could threaten their future. What would you suggest?

In the early days of business computing, it was difficult to convince management to invest in backup tape drives. After the first high impact data losses, computer professionals found it easy to sell backup tape drives, but few businesses made provisions for offsite storage of the backups. Again, high profile losses convinced management that such storage was vital. As business continuity planning entered the common vernacular before Y2K, off site redundancy was the “hard sell” for consultants. Now 9/11 has made offsite redundancy an industry standard.

Unfortunately it is human nature to believe in an inherent personal invulnerability. Those in charge of a business often transfer that feeling of invulnerability to the business.

It is “blind spot” that predisposes businesses to all manner of mishap from the mundane to the spectacular. This “blind spot” is also the reason that hazard planning is not taken seriously despite overwhelming evidence.

To overcome the comfortable belief of invulnerability requires either inducing sufficient fear to overwhelm complacency or creating doubt regarding personal invulnerability. When a loss occurs in an industry, everyone in that industry experiences doubt about their invulnerability. The problem is that creating fear seldom helps the people creating the fear because with the discomfort of fear comes resentment for those that created the discomfort. Similarly, it is both difficult and unethical to create a “near miss” event in an industry.

The alternative to creating fear or doubt is to use incentive, mandate, regulation or legislation to generate “buy-in.”

1918 is four generations of business leaders in the past. No one in management today has personal experience with a level 6 pandemic event. No one in management today knows anyone with such pandemic experience.

What little pandemic planning currently seen is a response either directly or indirectly to incentive, mandate, regulation or legislation. The issues that most spur pandemic planning deal with workforce and staffing regulations or the ability to deliver of products and services to customers. The key to increasing management “buy-in” for planning is to tie preparedness to compliance with existing incentives, mandates, regulations, or legislation.

For an example of tying preparedness to compliance, email ask@mauricearamirez.com and request a copy of the Homeland Security Presidential Directive white paper for healthcare.

Should We Plan for Pandemic at All?

Question submitted via ask@mauricearamirez.com

Why should we plan for pandemic if we aren't even sure its going to happen? Is there really a potential for this to be a pandemic?

Let' set the record straight, pandemic will occur.

Almost all of our predictive models for pandemic flu are based on 1917/1918 Spanish flu (which actually originated in Kansas); the 1957/1958 pandemic and the 1968/1969 pandemic.  The 1918 Spanish flu is known in virology circles as H1:N1.  Genetic reconstruction has allowed us to isolate this virus from pathologic specimens collected in 1917 and 1918 and stored by the U.S. military and other organizations.  This means that we can now study the actual virus H1:N1 aka the Spanish flu and compare it to the current pandemic risk H5:N1 aka Avian flu.

As we all know now from the media, influenza virus mutates over time.  Small mutations are known as antigenic drift while large mutations are known and antigenic shift.  These drifts and shifts slowly change the virus from something that the human immune system can recognize and therefore protect against to something that is novel or new to the human population – a pandemic. Antigenic drift occurs every seven years while antigenic shift occurs every 13 years. When antigenic drift and antigenic shift overlap (every 7 time 13 years plus or minus 3 years), a new and novel influenza virus is created. In short, approximately every 91 years there is a virus that the human immune system has never seen before This means that every 91 years there WILL BE a pandemic. Pandemics are very consistent and we can rely on seeing this one between 2006 and 2012.  H5:N1 will act virtually the same H1:N1 did in 1917. 

In 1918 the H1:N1 strain was seen.  Like all of pandemics before, it struck with a predictable infection rate (attack rate); approximately 1 in 3.  Of these 1 in 3 on average in the population that became ill, half would need to be cared for by family or infirmaries. Of those needing assisted care, half would become seriously ill.  Half of the seriously ill would develop severe lung disease and half of those with the severe lung disease would ultimately die. 

Applying Business Triage to Make More of Less

The following question was submitted via: ask@mauricearamirez.com

Our facility now finds itself with only a small meeting room left functional after a recent disaster event. It will be several months to a year before our main meeting and banquet facilities are available for bookings. How can we maximize our business potential during this recovery?

Applying Business Triage, Customer Triage and Marketing Triage principles, you can identify and concentrate on those who most need your services and space.

As you recall the first step in each of these triage techniques is to identify and categorize your desired outcomes based:

- Critical/Essential Outcomes – Those that must occur to meet the overall financial or service mission

- Urgent/Important Outcomes – Those that facilitate the overall financial or service mission, but are not essential to that mission.

- Supportive/Optional Outcomes – Those that facilitate the overall financial or service mission, but are ancillary and thus not necessary to the mission.

Once the outcomes are classified into these categories, you must identify the processes that result in the desired outcomes.

Once the processes are identified, they too must be categorized:

- Critical/Essential Processes – Those that must be supported to meet the desired outcome

- Urgent/Important Processes – Those that facilitate the desired outcome, but are not essential to meeting the desired outcome.

- Supportive/Optional Processes – Those that facilitate the desired outcome, but are ancillary and thus not necessary to meeting the desired mission.

Next the resources needed for each process are identified and categorized:

- Critical/Essential Resources – Those essential to the process and without which the process will fail

- Urgent/Important Resources – Those that facilitate the process, but are not essential to the process.

- Supportive/Optional Resources – Those that facilitate the process, but are ancillary to the process and the absence of the resource will not affect the efficiency of the process.

Graphically:

Critical/Essential Outcomes
Critical/Essential Processes	Urgent/Important Processes	Supportive/Optional Processes
Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources

Urgent/Important Outcomes
Critical/Essential Processes	Urgent/Important Processes	Supportive/Optional Processes
Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources

Supportive/Optional Outcomes
Critical/Essential Processes	Urgent/Important Processes	Supportive/Optional Processes
Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources

Essential/Critical Outcomes are fully supported first with all available resources, then Urgent/Important and finally Supportive/Optional.

When applied to customer triage and marketing, the objective is to identify and categorize the market based on the best fit to the outcomes/services you triaged above. In other words:

First identify and categorize your ideal customers, those who can most benefit from your services:

- Critical/Essential Customers – Those that benefit most from your service mission and capacity and are thus most likely to be repeat customers.

- Urgent/Important Customers – Those that benefit from your service mission and capacity, but can obtain similar services from your competitors and they know it.

- Supportive/Optional Customers – Those that benefit minimally at best from your service mission, but are better served by your competitors.

Once the markets are classified into these categories, you must identify the best means of reaching the desired markets.

After the means of reaching the market are identified, they too must be categorized:

- Critical/Essential Means – Those that must be used to reach the market.

- Urgent/Important Means – Those that facilitate reaching the market, but are not essential reaching the market.

- Supportive/Optional Means – Those that might reach the market, but are not as effective as required.

Next the resources needed for each means of reaching the market are identified and categorized:

- Critical/Essential Resources – Those essential to reaching the market and without which the message will fail

- Urgent/Important Resources – Those that facilitate reaching the market, but are not essential to delivering the message.

- Supportive/Optional Resources – Those that facilitate reaching the market, but are ancillary to delivering the message and the absence of the resource will not affect the message.

Graphically:

Critical/Essential Customers
Critical/Essential Means	Urgent/Important Means	Supportive/Optional Means
Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources

Urgent/Important Customers
Critical/Essential Means	Urgent/Important Means	Supportive/Optional Means
Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources

Supportive/Optional Customers
Critical/Essential Means	Urgent/Important Means	Supportive/Optional Means
Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources	Critical/Essential Resources Urgent/Important Resources Supportive/Optional Resources