Maurice A. Ramirez, DO, CNS, CMRO

Pardon Me Mr. President

As our nation pauses to pay its respects to the memory of former President Gerald R. Ford, the importance of this under appreciated leader and his service to the people of the United States is finally coming tot he fore. President Ford came into office at a time when Americans had lost confidence in the government and the Office of the President.

The Vietnam War had divided the nation along philosophical line like no war since the Civil War. The Watergate scandal had embroiled all levels of the administration and had brought down a president. The economy was suffering. In short, the United States of America was a political disaster area.

President Ford had never run for his office. Appointed Vice-President after Spiro Agnew, he ascended to the Presidency after Richard Nixon resigned. He would be in every way the reluctant hero.

Why a hero? Because he was everything his nation needed. The brief presidency of Gerald R. Ford represented a period of recovery, a time when our nation rebuilt and restructured itself and its confidence in its leadership. The pardon of Richard Nixon for which President Ford is best known and most criticized was but the first step in a necessary process of recovery our nation desperately needed. In the process of that recovery, we gained both confidence and pride.

Disaster recovery takes years, often decades, yet under the watchful eye and gentle guidance of President Gerald Ford, the nation found itself ready to advance in little over 2 years. Gerald Ford was our good shepherd.

By the end of the Ford presidency, the United States was ready to resume its place a world leader in diplomacy and humanitarianism. We chose a president consistent with this purpose, James Carter. President Carter would be followed by a president who would lead us as to international prominence, Ronald Reagan. Finally, our recovery would be completed by a president who would reconnect the presidency to the people, William Clinton.

But none of this recovery would have been possible without the foundation laid quietly and humble by a President and a man perfectly suited for his time, Gerald R. Ford. Pardon me Mr. President for not saying "Thank You" sooner.

Setting The Record Straight on Pandemic Preparedness

The November/December 2006 issue of the AARP magazine carried an interesting story on pandemic flu.  The expert virologist who authored the article painted a grim picture of the future of the coming pandemic and gave one view of how to prepare.

Let's set the record straight.

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. What makes avian flu more likely to be a pandemic?

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. In short it is something that the human immune system has never seen before.

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 half would become seriously ill.  Half of those would develop severe lung disease and half of those with the severe lung disease would ultimately die. 

The picture changes significantly, however when you look at the infection by age group.  H1:N1 caused virtually no more deaths in those over age 65 than the average flu.  In fact in 1918 you were no more likely to die of the pandemic if you were over age 65 than you had been in 1915 or than you would be in 1920.

So what does that mean for the coming Avian flu (H5:N1)?  Pandemics are very consistent.  They act virtually the same every time they occur as long as they are a novel avian virus.  H5:N1 has not been different to date.  It is expected to cause no greater number of deaths in those greater than age 65 than the flu did last year in 2005 or the year before in 2004. 

Yes, there will be an increase in the number of people who become ill across the age spectrum from birth to those over 100.

Yes, there will be a total increase in the number of people who die.  Unfortunately the vast majority of those will be between the ages and 15 and 40.  This was the age group that showed the greatest increase in death rate in 1918, in 1958 and 1969.

AARP magazine is to be tremendously complimented in their January/February edition they published an exquisite interview with Anthony Fause, a noted expert in infectious disease and pandemic preparedness.  That interview asked insightful questions and gave good, logical answers.  Unfortunately the same cannot be said of the recommendations made in the November/December edition.

The article in the November/December edition recommended stockpiling food and other supplies in anticipation of infrastructure collapse and supply chain failure.  This advice ignores the lessons learned from history. In 1918, as with all other pandemics, 100 percent of the population was exposed despite social isolation efforts. In 1918, one third of the working population was out of work and yet food was still delivered.  Farms still produced.  Society did not collapse. There is no reason for panic.

Stockpiling medication is also a formula for disaster and disappointment.  The current strain of H5:N1 is already showing resistance to Tamaflu, requiring far higher than usual and longer than usual doses to be effective.  Tamaflu's shelf life is also far shorter than the window of likely infection from the pandemic (as late as 2012). This means that you may purchase Tamaflu and have it expire before the disease attacks. 

Finally, previous pandemics have come in multiple waves over an 18 month period. In most cases the disease appears first as a low level infection in the population, followed by a large flood of influenza and then an aftershock of disease.  You simply cannot stock enough Tamaflu for all three events.  You cannot prevent yourself from being exposed during those three events.  And you cannot stock 18 months of food and water to safeguard yourself and your family during that event.

So what can you do? 

Bring pressure to bear on the healthcare community to better prepare for surge capacity. 

There are fewer than 1,000,000 hospital beds in the United States and in an average cold and flu season fewer than 40,000 hospital beds are empty.  The federal government recommends between 150,000 and 190,000 available hospital beds even during the peak of an average cold and flu season. The United States is woefully short of hopsital beds and it falls to private hospital corporations to provide that surge capacity.

The New England Journal of Medicine in 2004 an article by Dr. Michael Osterholm they found there are 105,000 ventilators in the United States.  Eighteen percent of those are either broken, in repair or in cleaning at any given moment.  Sixty-seven of those are in chronic use for ventilator dependent patients outside of the hospital.  This leaves 16,000 ventilators available nationwide.

If we break down the expected number of illnesses just in those over age 65, those 16,000 ventilators will all be in use.  What happens to those between age 15 and 40, the children and grandchildren of those who read the AARP magazine?

The healthcare community must step up to the plate rather than pedaling panic in the pages of the AARP magazine.  The juxtaposition of the Avian flu article in the November/December issue and the far more insightful and useful interview in the January/February issue show the division within the house of medicine.  The AARP magazine has the largest circulation and readership in the English-speaking world.  Which side of that division will its members come down upon - Panic or preparedness?

It was once said of the generation that now reads the AARP magazine that they are the "Great Generation".

The Great Generation earned this title because of their self-sacrifice during World War II.  They guided a great nation through an industrial revolution and a technological revolution that became an economic revolution that swept the planet.  Many have tried to discount the Great Generation because they are now the "Geriatric Generation."  I believe the Great Generation will lead us again not into panic but into a new era of preparedness.

Tamiflu Psychosis

Just when AARP magazine, and so many other well respected and widely read publications, are carrying articles about pandemic flu planning for personal homes, more bad news.  This news is not for the publications, nor is it for their readers, but for the authors who have tied their name to poorly researched advice.  November14, 2006 the U.S. Food and Drug Administration (FDA) and Roche Laboratories, Inc., the manufacture of Tamiflu, announced that new labeling would be provided for this highly publicized pandemic flu drug.  It turns out that Tamiflu is just one more drug to be added to the long list of medication recently implicated in self-injury (suicide) and other psychiatric side effects.

While the data is not completely clear as to how much of the hallucination and confusion associated with Tamiflu administration in the Far East is related to influenza and how much is directly related to the drug, several things are clear.

1. Those who received Tamiflu are far more likely to display abnormal behavior and self-injury than those who have not received the drug.

2. The likelihood of having these side effects increases as the dose increases and as the length of time the drug is taken increases.

Tamiflu is one of two drugs available for the treatment of pandemic influenza. Unfortunately, the pandemic strain currently being studied in Asia (H5:N1) is already showing resistance to normal doses of Tamiflu.  In fact, in recent cases the dose of Tamiflu has had to be doubled and the length of treatment also doubled.  Further complicating this fact is the need in these cases to add the second pandemic flu drug, also at double dose and double length of treatment.

What does this mean for psychiatric side effects?  It means that these side effects will increase if not arithmetically then logarithmically.  In other words, the side effects may not just double, but quadruple or more.

Common sense and good science are stakes in the heart for those alarmists encouraging the general public to stockpile Tamiflu or any other medication. Stockpiling just in case medications is always a bad idea. Most simple infections are now resistant to basic antibiotics because patients have stockpiled "left over" antibiotics from prior infections and taken them on their own. For too many decades, physicians have sent patients home with "just in case" antibiotics for the next time they get sick.  This technique is lazy and it is the medical profession that is responsible for the problems we now see as a result of this lazy approach to healthcare.

What is surprising is that the American public stands for it.  If you took your car to your favorite mechanic for an oil change and he sent you home with an extra case of oil "just in case," you would change mechanics. If you went to your favorite hairdresser and she sent you home with an extra pair of scissors "just in case," you would quickly change stylists or at least think her crazy. This style of medical practice was born of the same medical hubris that allowed doctors to think themselves gods and should have died with that mindset.

The most recent announcements by the U.S. Food and Drug Administration on the risks of psychiatric side effects in Tamiflu only point out the dangers of good medication taken the wrong way or for the wrong indication. Prescribing any medication is a balance of risks and benefits, and when balancing risk and benefits we can all use good advice, both physicians and patients, alike.

Physician Wake Thy Self!

Kathleen Fackelmann’s article on the front page of the December 12, 2006 USA Today entitled “Sleep:  Long Hospital Shifts, Sleep Depravation Can Kill” details on yet another study linking long shifts, lack of sleep, over work, and fatigue to medical errors and patient’s deaths.  This is no new news.

The medical literature abounds with research done in medical students, residents, physicians, nurses, and other healthcare professionals on the increase in error rate beginning after as little as 12 hours of “on duty” time. The main problem is that most shifts for medical professionals are 12 hours long at a minimum.

As early as 1986, New York State imposed limits on resident work hours after several highly publicized deaths due to “resident error.” In 1999 the Institute of Medicine and the National Academy of Sciences published the To Err Is Human report.  In addition to numerous other issues, fatigue was cited as one of the correctable causes of medical error. Two decades later, little has changed. Medical residents still work excessive hours even though I am “on the books” there work periods are restricted.  The average physician still works over 60 hours.  Although nurses now generally will work less than 60 hours per week, most still work 12 hour shifts and it is not unusual to see a nurse still on duty after 13 or even 14 hours. 

A safe nurse to patient ratio in a non-critical care arena are considered to be between four and six patients per nurse yet the national averages vary between 8 and 12 patients per nurse depending on the time of year.  In the Intensive Care Unit and Emergency Room, the safe ratio is between one and two patients per nurse, yet in most emergency rooms the ratios are six to one and at peak times, more.

Efforts to limit physician work hours, place mandatory restriction on residency training times, decrease nurse to patient ratios, decrease nursing shift hours have all been met with not only resistance but in some cases even outright intimidation, job termination, and all manner of resistance. In short, the people with the ability and duty to make the changes have chosen to ignore the data.

Innumerable economic excuses are offered and it has even been stated by some administrators and supervisors that those who are fatigued themselves don’t want the change, but our patients deserve it.

Kathleen Fackelmann again trumpets the fact that fatigue kills.  The question is:  Is everyone in the house of medicine deaf!?

“A Date That Will Last in Infamy”

On this 65th anniversary of the surprise attack on Pearl Harbor it is becoming all too easy to forget the lessons learned on that horrific Sunday morning. As with any historical lesson we must start with an appreciation of the sentiments of the times.  The Far East and Europe were embroiled in the early months of World War II.  The world had watched in silence as Nazi Germany had blitzkrieged its way across Western Europe.  The Japanese has slaughtered tens of thousands of Chinese during the invasion of Manchuria, but America felt safe.  America was insulated by not one, but two great oceans.  It was generally believed that it was impossible to breach the safety this buffer afforded.

Somehow American had failed to learn the lessons of World War I or perhaps they had just forgotten them.  In World War I we had thought that simple isolationism would protect us from a worldwide war.  By 1917, history had proven us wrong.  We were embroiled in a “war to end all wars”.  It was not the war that ended all wars but a virus, the Spanish flu.  While military historians argue the point, medical historians can draw a clean and clear line between the onset of the Spanish strain of avian flu and a loss of fighting forces worldwide.  World War I did not end with a bang but with a sniffle.

In 1941 the United States was negotiating to remain neutral although neutrality was far from our actual policy.  We were supplying arms as well as intelligence to Allied forces throughout Europe.  Nazi Germany had already negotiated a pact with the other Axis nations and using the old schoolyard logic of “if you aren’t with us you’re against us” that put America solidly against the Axis nations.

In the waning months of 1941 the United States was actively negotiating with the Japanese.  Up until the last days prior to the attack the Japanese sat ardently at the negotiating table.  America had lulled itself into a false sense of security.

It was a beautiful Hawaii Sunday morning, crisp December air and a blue sky when planes dotted the horizon.  Within minutes bombs were falling.  People were screaming.  Smoke and fire rose into the air.  America, the slumbering giant, had been caught sleeping.  It was not the first time nor would it be the last. Franklin Delano Roosevelt would address the nation beginning with the words, “December 7, 1941, a date that will last in infamy . . .”

55 years later, Commander Peter Margalla, USN (Ret) would write a report December 7, 1996, the second attack on Pearl Harbor.  In that report only recently declassified he would describe not a bombing attack on Pearl Harbor but an anthrax attack.  Clearly in 2001 his version of a sneak attack on America came to pass not just with aircrafts on 9/11 but with anthrax only days later.

In 2001 President George W. Bush addressed the nation.  He did not begin with a bold statement as Franklin Delano Roosevelt did but he invoked Roosevelt when he said, “A slumbering giant has been awakened.”

Now 65 years after Pearl Harbor and five years after 9/11 the question is has the slumbering giant been awakened or is America lulling itself back to sleep?

The United States is now part of a global community and the threats to a global community are threats to America.  We can never again allow ourselves to believe that distance or time, technology or ideology can protect us or our children.  As Franklin Delano Roosevelt said 65 years ago today,

“Will our whole nation remember the character of the onslaught against us?”

The Industrialized World Isn't Safe From Pandemic

The recent cover stories in the Life section of USA Today by Anita Manning and Elizabeth Weise, beautifully depict the potential spectrum of disease and the implications of human vulnerability to pandemic flu and specifically the H5N1 avian flu strain.

But the real threat lies not in the obscure genetics of a common virus or in the family lineages of its victims.  The true impact of this disease lies in the numbers.  In 1918 100 percent of the entire world was exposed to what would later be called the Spanish Flu.  This new strain of avian flu had never been encountered before by a human population, and as a result, there was no immunity to this particular strain.  Of that world population, one third would ultimately fall ill, in fact, 50 to 80 percent of the youngest, healthiest, and strongest would fall ill when future generations would divide out the victims.

Of those that fell ill, half ultimately required some assisted care.  They were placed in infirmaries or makeshift hospitals in warehouses, wharfs, and military barracks.  In today's world, they would qualify for hospital care or home health nursing.

Of those hospitals and infirmaries, half suffer extreme respiratory difficulties as their lungs filled with fluid and blood, the result of their own bodies' counterattack on the viral invasion.  Coughing and frothing at the mouth, occasionally spitting up blood, these individuals would have a disease that today’s medical professionals call ARDS, Acute Respiratory Distress Syndrome.  In the modern medical age, these patients would have a plastic tube placed into their lungs to assist their breathing and a ventilator would force air in and out of their lungs.  Half of the ARDS patients 1918 died.

But it's not percentages, but real numbers that portend the severity of this disease.  There are over 300 million people in the United States and over 6 billion worldwide. 

One third of those will fall ill.  One hundred million here at home and two billion across the planet. 

Half of those individuals will qualify for hospitalization.  Unfortunately, in a survey performed by the American Hospital Association in 2005, there are only 955,768 hospital beds in the United States, far short of the 50 million that would be needed.  To make this situation work, at the peak of cold and flu season in 2005, only four percent of these hospital beds were available and unoccupied.  That means that there will be fewer than 40,000 hospital beds available for this onslaught of 50 million patients.

Of the 50 million patients who qualify for hospitalization, half or more will need ventilators.  Dr. Michael Olsterholm in a New England Journal of Medicine article in 2004 found that there were only 105,000 ventilators in the United States.  Of these, a high percentage were either already in use for chronic ventilator-dependent patients such as small children and spinal cord patients, or were out of service for cleaning and repair, leaving just over 16,000 ventilators available nationwide to help 25 million flu related ARDS victims breathe.

Of the 25 million with ADRS, with or without ventilator care, half would be expected to die.  This 12.5 million people will pass away in waves as pandemic influenza spread over a span of only 12 to 18 months. 

Now, admittedly, these are the most dire numbers.  The pandemic flu could prove to be far less deadly, far less contagious.  On the other hand, H5N1 has already proven to be a formidable foe with death rates initially greater than 70 percent and now still hovering around 50 percent. 

The Centers for Disease Control (CDC) have given optimistic sounding percentages but as the old adage goes, the "devil is in the details". Let's look at the percentages and the details. 

* One third of 100% is 33%
          - This is the “attack rate”.
 
* Half of 33% is 16.5% 
          - This is the number of people who qualify for hospitalization, but the CDC knows that in the event of a pandemic, only the most sick will actually be placed in the hospital. 
            Clearly the most sick will be those with ARDS. 

* Half of 16.5% is 8.25%
          - These are the sickest of the sick, those with ARDS. Rounded off, this is 8 percent, the number that the CDC says to expect for hospitalization. 

* Half of 8% is 4%
          - This is the expected death rate predicted by the CDC. 

The “devil in the details” is that these percentages are based on "the total population."  Physicians, medical planners, and other pundits usually discuss percentages based on "those with the flu". We are not talking about “those with the flu” we are talking about a number three times that size.

Anita Manning and Elizabeth Weise showed us how two third world countries are struggling and in some cases failing to deal with the crushing weight of a comparatively small outbreak of avian flu (H5N1).  In Indonesia, the efforts are crippled at best.  In Vietnam, the efforts are being met with greater success, but the disease rages on.  The industrialized world relies on the fact that its health care is unmatched.  The United States likes to believe that US health care exceeds all other.  The numbers show that when this disease strikes the whole world is at peril.

What are the answers?  As with any impending disaster, the answers lie in preparation, planning, and practice;  Repeated, Relentless, and Rigorous practice.  It is the responsibility not just of government but of private health care institutions, hospitals, health care professionals, businesses, corporations, and yes, even individuals, to prepare now for the worst while hoping for a reprieve.  We can no longer afford to prepare for the best and then stand awestruck when the worst occurs.

Another Anniversary of 9/11

As we observe this 5th anniversary of 9/11 many are asking:

“Are we any safer now than we were then?” 

As one who runs towards the disaster, it is with a heavy heart that I answer,

“No.”

The National Academies of Science recently concluded that hospitals fail to plan, fail to train and fail to integrate themselves into the community response plan.  Terrorism can be mitigated, sometimes; but what happens when there is an unstoppable disaster?  What happens when Mother Nature is the cause?  We cannot yet mitigate an earthquake or a hurricane, a tornado or a volcano.  We cannot immunize our planet against the next great pandemic or the next plague.  When these disasters cause our needs to exceed our resources, the only chance to avoid absolute catastrophe is to plan and practice. 

I am among that group of disaster response experts who lost colleagues and family when the towers fell. It is infuriating to argue with corporations or healthcare institutions before they will consider training to take responsibility for their part in our nation’s safety, security, and preparedness.  Those who teach these most critical skills remind students that the goal is not to pass a test or gain career advancement. The goal is to go home alive at the end of the day. 

On those occasions when hospitals and healthcare institutions do train, when they realize they do not have the necessary skills and bring in “the experts,” it is discouraging to see the room more than half empty.  In an industry that prides itself on patient safety and customer care, to see so few people interested in preserving the most necessary of community resources, healthcare, is demoralizing beyond words. 

Equally disturbing is the recent trend towards territorialism among medical specialties.  Since 9/11, every specialty has sought to proclaim itself the “Masters of Disaster”.  They fail to realize that most of the healthcare delivered after a disaster is simply the daily practice of medicine in more austere of conditions.  They also fail to understand that the majority of disaster medicine is practiced before disaster ever strikes.  Disaster Medicine specialists are essential to the integration of healthcare into the community disaster response, and the elimination of profession-specific silos of authority and knowledge.  What these other specialties fail to see is that in the planning, preparation, response and recovery from disaster, the healthcare community must be a seamless team, not a collection of egocentric individuals.  Rather than embracing the concept of board certification in the new specialty of Disaster Medicine, these territorial and fractious groups seek to stake their claim in this most critical part of our brave new world.  In short, they have learned nothing over the last five years. 

There is encouraging news. Disaster Life support (DLS) has become the de facto national standard for disaster preparedness of individuals, families, businesses and healthcare professionals and Healthcare First Responder training (HFR) has become the ruler by which hospitals and other healthcare institutions are measured.  It is immensely rewarding when participants “catch the bug” and understand how important it is to be prepared to protect themselves, their families, their communities, and their patients.  Much like the early days of CPR, it will take time for the nation to understand the importance of every man, woman and child knowing what to do when the wind blows, the buildings falls or the whole planet sneezes at once.  Until then, those who teach these most precious skills will continue to strive to ensure that everyone goes home at the end of the day.

Katrina: Have We Really Learned Anything?

On this anniversary of the disaster now known by a single word: “Katrina” all of us in disaster response look around and shake our heads.  One year ago we saw misstep after misstep, failure after failure. As we look back over a landscape that is still scarred by the aftermath of flooding and looting to see both despair and rebirth we ask ourselves:

“Are we any better prepared today?”

Two recent reports by the National Academies of Science clearly stated that America’s hospitals and emergency rooms are no more prepared now than one or even five years ago.  Worse, hospitals have failed to integrate emergency medical services (EMS) into their planning and response operations.  This first link in the chain is not broken it is simply unhitched. 

What happens the next time Mother Nature roars?  We cannot yet mitigate an earthquake or a hurricane, a tornado or a volcano.  We have yet to learn how to immunize our planet against the next great pandemic or the next plague. 

Why is it after we see one of the great cities of America laid low and sunk beneath the waters of its own shores that we have yet to do any meaningful planning? This is not our government’s fault.  Money is available and spent every day for training. Why we must fight to get any hospital to train to avoid the next catastrophic failure in the wake of unavoidable disaster?

On those occasions when healthcare does choose to train, it is discouraging to see a room more than half empty.  In a profession that loudly proclaims a dedication to patient safety and customer care, to see so few people interested in preserving the most necessary of community resources, healthcare, is demoralizing beyond words. Disasters can seldom be avoided. On the other hand, catastrophe can almost always be averted with conscientious planning and practice.  The difference between a disaster and a catastrophe is that while disaster is when needs exceed resources, catastrophe is when needs exceed all ability to respond. 

Equally disturbing is the territorialism among the specialties, each one laying claim to disaster medicine.  Most healthcare delivered after a disaster is a simple the daily practice medicine under the worst conditions.  These groups fail to realize that Disaster Medicine is primarily practiced before the disaster ever strikes.  Disaster Medicine Specialists are part and parcel of planning for the community disaster response and the elimination of profession-specific silos of authority and knowledge.  Rather than embracing the concept of board certification in the new specialty of Disaster Medicine, these territorial and fractious groups seek to stake their claim.  They have learned nothing. 

The good news, Disaster Life Support (DLS) has become the national standard for preparedness of individuals, families, businesses and healthcare professionals, Healthcare First Responder training (HFR) has become the ruler by which hospitals and other healthcare institutions are measured.  While it is frustratingly difficult to get these audiences to come to class, it is immensely rewarding when they finally understand how important it is to be prepared, to be aware and to be able to protect themselves, their families, their communities, and their patients.  Much like the early days of CPR, it will take time for the nation to understand the importance of every man, woman and child knowing what to do when the wind blows, the buildings falls, or the whole planet sneezes at once.  Until then, we who teach these most precious skills will continue to strive to ensure that everyone goes home alive at the end of the day.

Will the Gulf Coast and New Orleans recover?

Certainly… in time.

The bigger question is will we ever learn to be D.I.S.A.S.T.E.R.  R.E.A.D.Y. & P.L.A.N.?

The Implication of Another Round of Bombings

Many awoke this morning to the news of a major Counterterrorism success. Conspirators in London were arrested for alleged participation in an apparent plot to blow-up an unknown number of American aircraft at an uncertain date in the not too distant future, perhaps even on the anniversary of
September 11th.

My short introduction points up the very nature of terrorism and disaster preparedness.  “Alleged participation” and “apparent plot” juxtaposed to phrases like “unknown number,” “uncertain date,” not too distant,” and “perhaps” emphasis the uncertainty of the information on which we must act and the need for vigilance and preparedness.

Six short weeks ago, the National Academies of Science here in the United States published 3 reports which pointed out just how unprepared America’s hospitals and healthcare industry is to deal with the type of mass carnage thwarted today or the catastrophe that was hurricane Katrina.

I am among that group of disaster response experts who lost colleagues and family when the towers fell. It is infuriating to know that five years later we who prepare the nation must still argue with corporations and healthcare institutions before they take responsibility for their part in our nation’s safety, security, and preparedness.  Those who teach these most critical skills remind our students that the goal is not to pass a test or gain career advancement. The goal is to go home alive at the end of the day. 

On those occasions when corporations and healthcare institutions bring in “the experts,” it is discouraging to see the room more than half empty.  In a nation whose businesses pride themselves on customer care, to see so few people interested in preserving the nation’s safety is demoralizing beyond words. 

Equally disturbing is the recent trend towards territorialism among medical specialties.  Since 9/11, every specialty has sought to proclaim itself the “Masters of Disaster”.  They fail to realize that most of the healthcare delivered after a disaster is simply the daily practice of medicine in more austere of conditions.  They also fail to understand that the majority of disaster medicine is practiced before disaster ever strikes.  Disaster Medicine specialists are essential to the integration of healthcare into the community disaster response, and the elimination of profession-specific silos of authority and knowledge.  What these other specialties fail to see is that in the planning, preparation, response and recovery from disaster, the healthcare community must be a seamless team, not a collection of egocentric individuals.  Rather than embracing the concept of board certification in the new specialty of Disaster Medicine, these territorial and fractious groups seek to stake their claim in this most critical part of our brave new world.  In short, they have learned nothing over the last five years. 

There is encouraging news. Disaster Life support (DLS) has become the de facto national standard for disaster preparedness of individuals, families, businesses and healthcare professionals and Healthcare First Responder training (HFR) has become the ruler by which hospitals and other healthcare institutions are measured.  It is immensely rewarding when participants “catch the bug” and understand how important it is to be prepared to protect themselves, their families, their communities, and their patients.  Much like the early days of CPR, it will take time for the nation to understand the importance of every man, woman and child knowing what to do when the wind blows, the buildings falls or the whole planet sneezes at once.  Until then, those who teach these most precious skills will continue to strive to ensure that everyone goes home at the end of the day.