Maurice A. Ramirez, DO, CNS, CMRO

What Would They Say Today?

Eighteen months after the terrorist attacks of 9/11, America’s healthcare leadership announced that while they had not been ready on September 11, 2001, now they were. On March 13, 2003, in a much ballyhooed statement, still sited to this day, the American College of Healthcare Executives announced:

“HOSPITAL CEOs SAY BIOTERRORISM PLANS ARE IN PLACE CHICAGO

Since September 11, 2001, hospitals have faced new challenges protecting and caring for their communities, especially the threat of bioterrorism. According to a new survey conducted by the American College of Healthcare Executives (ACHE), 84 percent of hospital CEOs agree that since 9/11, their hospitals have worked more closely with public agencies (e.g. fire, police, and public health departments). Further, 95 percent of the respondents said their hospitals already have, or within six months will have, a bioterrorism disaster plan in place, developed in coordination with local emergency or health agencies.”

Little did they know the sense of false security and the cooling of momentum this assertion would cause from that day forward.

The Clear View of Reality

Since 2003, multiple independent evaluations of hospital preparedness and hospital disaster planning have found the reality in each successive year to be far below that purported in 2003. A brief survey three reports by the Institutes of Medicine in June, 2006 serve as proof that any hint of hospital preparedness is false and that momentum towards preparedness has been lost. These reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Care for Children: Growing Pains, and Emergency Medical Services at the Crossroads found a disparity between self reported preparedness on multiple association and government surveys compared to actual preparedness measured across the five core indicators of hospital preparedness.

“Evaluations of ED disaster preparedness consistently yield the same finding: EDs are better prepared than they used to be, but still fall short of where they should be”

At first blush, this seems to confirm the ACHE assertions, but the report goes on to point out that hospitals lack patient surge capacity due to cost related downsizing, nursing shortages, loss of specialists, physical space constrains and overcrowding. Failures of planning and coordination were also identified and linked to erroneous planning assumptions.

“When a disaster occurs, the normal operating assumptions about patients, responses, and treatments often must be jettisoned. Depending on the type of event, some of the nonroutine things that can happen include the following:

• Victims who are less injured and mobile will often self-transport to the nearest hospitals, quickly overwhelming those facilities.
• Casualties are likely to bypass on-site triage, first aid, and decontamination stations.
• EMS responders will often self-dispatch. Providers from other jurisdictions may appear at the scene and transport patients, sometimes without coordination or communication with local officials.
• In some cases, local facilities are not aware of the event until or just before patients start arriving. Hospitals may receive no advance notice of the extent of the event or the numbers and types of patients they can expect.
• There may be little or no communication among regional hospitals, incident commanders, public safety, and EMS responders to coordinate the response region wide.”

The Institute of Medicine reports goes on to call for improved communications and integration across disaster response services including Emergency Medical Services (EMS), community emergency operations and most importantly the implementation of the standardized Incident Command System.

“To respond effectively, hospitals must interface with incident command at multiple levels and be prepared to deal with transitions between levels, for example, when incident command shifts from the local to the state or federal level. Each hospital should be familiar with the local office of emergency preparedness and know how hospitals are represented at the emergency operations center during an event, whether through the hospital association, the health department, the EMS system, or some other mechanism.”

They Didn’t Think of That Either

Beyond the problems common to all disaster care environments, special needs populations (children, elderly, mentally and physically challenged) have needs and preparedness issues unique to them. Unfortunately, the “one size fits none” approach taken by America’s hospitals has ignored issues highlighted by the Institutes of Medicine Emergency Care for Children: Growing Pains report.

“The needs of children have traditionally been overlooked in disaster planning. Historically, the military was considered the only target of potential biological, chemical, and radiological attacks, so the focus for training, equipment, and facilities was on the care of healthy young adults.”

“Younger patients require specialized equipment and different approaches to treatment in the event of a disaster. Children cannot be properly decontaminated in adult decontamination units because they require adjustments to the water temperature and pressure (heated, high-volume, low-pressure water). Rescuers also need to have child-size clothing on-hand for use after the decontamination.”

The problems are compounded for rural hospitals. Despite the fact that many both inside and outside hospital leadership believe that rural hospitals are at lower risk and thus require less commitment to preparedness, the truth is quite the opposite.

“The focus of emergency preparedness has been on urban areas in part because of the perceived increased risk of terrorism in these areas. However, there is a danger associated with neglecting rural areas. Indeed, one might argue that rural areas may be even more vulnerable to a terrorist attack. Many nuclear power facilities, hydroelectric dams, uranium and plutonium storage facilities, and agricultural chemical facilities, as well as all U.S. Air Force missile launch facilities, are located in rural areas and are potential targets for attack. Additionally, if individuals with infectious diseases, such as smallpox, enter the country through Canadian or Mexican borders, rural providers may be the first to identify the threat.”

A Problem of Their Own Making

The greatest indictment of hospitals by the Institute of Medicine Reports however dealt with disaster preparedness training and drills finding great variability in the training of even key healthcare personnel with even less training for non-clinical hospital staff.

“Serious clinical and operational deficiencies, fragmentation, and lack of standardization exist across a broad spectrum of key professional personnel (nurses, physicians, ancillary care providers, administrators, and public health officials) in both individual training and coordination of a team response.”

This failure to provide training not only effects patient care, but hospital employee safety. Despite public statements by hospitals that “safety is worth the cost” and “preparedness is priceless” The American College of Emergency Physicians (ACEP) and the Agency for Healthcare Quality and Research (AHQR) separately found a very different financial and leadership commitment to preparedness and training.

“Many hospitals report inadequate funding to cover the attendance costs (e.g., time off, tuition, travel) of training (ACEP, 2001). At the University of Pittsburgh Medical Center, a disaster drill in the Emergency Department costs $3,000 per hour in staff salaries alone (AHRQ, 2004).”

“Additionally, the failure of hospital administrators or Emergency Department personnel to recognize the importance of training can result in a lack of support (ACEP, 2001).”

Multiple agencies, including the Institutes of Medicine have called for an increased coordinated financial commitment to preparedness on the part of individual hospitals, hospital corporations, hospital management / holding companies, as well as local, state and federal governments.

“This lack of coordination is reflected in the haphazard funding of preparedness initiatives. EMS and trauma systems have consistently been underfunded relative to their presence and role in the field.”

“States and communities should play an important role in determining how they will prepare for emergencies. To the extent that they are supported in this effort through federal preparedness grants, the critical role and vulnerabilities of hospitals must be more widely acknowledged, and the particular needs of hospitals and hospital personnel must be taken explicitly into account”

Despite this, funding for preparedness has decreased across the board including congressional cuts in healthcare preparedness funding for 2007, 2008 and again for 2009. These cuts have been mirrored in state funding initiatives; meanwhile hospitals continue to believe that they are prepared despite evidence to the contrary.

So What Should They Say Today?

Given these realities leaders in the field of healthcare and hospital management must now confront the fact that self reporting on preparedness is a failed method, no different than asking a 10 year old to grade their own final exam. With the curtain pulled back it is time for healthcare and hospitals to say:

“It is our corporate and personal responsibility to ensure the safety and preparedness of our entire staff, clinical and non-clinical as well as prepare to respond to the needs of the patients we serve every day and the patients we will serve when disaster strikes.”

The problem is that healthcare and hospital leaders have done everything in their power to quietly avoid the need to make this statement much less bring this statement into reality. In the two years since the Institutes of Medicine published their reports, hospitals have lobbied first to delay and forestall the deadlines for both Joint Commission preparedness guidelines and National Incident Management System (NIMS) compliance elements. The effect of this has been to make such things as facility beautification a higher financial priority than facility preparedness.

What is Needed?

While the Institutes of Medicine and many other organizations have made recommendations to improve hospital disaster preparedness, the sad fact is that the only way to force hospitals to properly and adequately prepare is to enforce the existing guidelines, mandate meaningful external certification of compliance and engage the public in demanding local hospitals “just do it.” There is an old adage in healthcare law:

“No change in healthcare has ever come without regulation, legislation or litigation.”

Enforcement of existing guidelines will require that the applicable government agencies including the Department of Homeland Security, FEMA, the Department of Justice, the Department of Health and Human Services and the Center for Medicare Services mandate full and complete NIMS compliance by the original September 30, 2008 deadline. Further, these agencies must be willing to use the full force of law to induce hospitals to invest in preparedness rather than pianos and fountains. Federal preparedness legislation carries with it implications of Medicare fraud, Sarbanes-Oxley violations and federal false claims issues. It is an unfortunate reality that government must all too often prosecute to create compliance.

The private sector has a responsibility to enforce preparedness guidelines as well. Joint Commission has repeatedly chosen to “partner with hospitals” rather than “punish” the recalcitrant faculties who repeatedly delay and curtail preparedness efforts. Joint Commission accreditation is a powerful force for change in hospital healthcare. The current tendency of hospitals to do as little as possible as slowly as possible necessitates that Joint Commission enforce the original preparedness compliance deadline in January of 2009 rather than permitting yet another extension.

Perhaps the best thing everyone in healthcare oversight and leadership can say to the American people is:

“We’re Sorry and We Will Do Better!

Basic and Advanced Skills for Disaster Healthcare

My company recently reviewed the existing core competency documents for disaster healthcare in light of the October 18, 2007 Homeland Security Presidential Directive (HSPD-21) which in part calls for:

“...the recognition of the unique principles in disaster-related public health and medicine merit the establishment of their own formal discipline.  Such a discipline will provide a foundation for doctrine, education, training, and research and will integrate preparedness into the public health and medical communities.”

Stakeholders in the development of the discipline described in HSPD-21 have proposed either publicly or privately a body of knowledge and skills core to such a discipline. This essential body of knowledge is codified as Core Competencies. To date the American Association of Physician Specialists (AAPS), the American Medical Association (AMA) and the American Osteopathic Association (AOA) have prepared core competency documents.

In the past, divergent core competency documents within a medical discipline such as emergency medicine or family practice have resulted in decades of division and discord within the profession and specialty. Ultimately, wherever such divergence has existed medical science and evidence based medical practice have resulted in convergence of the core competency documents and near universal agreement on the skills and knowledge that define and are essential to a distinct medical discipline.

Unfortunately, the United States and its citizens cannot afford to wait decades for the medical politicians and special interests to conclude that there is already agreement on the knowledge base and skills core to the discipline and specialty of disaster medicine. HSPD-21 places further impetus on resolving the issue of core competencies so that the disaster medicine discipline called for in HSPD-21 may advance with all alacrity.

The core competency documents from AAPS, AMA and AOA are each developed in differing taxonomy systems. This difference in taxonomy systems combined with differences in batching of skills and knowledge within documents complicated the extraction of commonly agreed upon core points of knowledge and key skills.

The complete review and core competency crosswalk is available for download here:

Download disaster_healthcare_core_competencies_review_crosswalk_25oct07.pdf

We propose a single summary core competency document presented as a “crosswalk reference” with the associated AAPS, AMA and AOA core competency documents. Given that the AOA currently has no core competencies to contribute, the crosswalk would require update when the AOA document becomes available.

It is our that this composite summary and associated “crosswalk reference” along with all three core competency documents form AAPS, AMA and AOA be recognized by the United States Department of Homeland Security (DHS); Department of Health and Human Services (HHS); Department of Defense (DOD); Institutes of Medicine; National Institute of Health (NIH); Centers for Disease Control (CDC) and Department of Education (DoE). This will establish the needed basis for the foundation of a distinct discipline in disaster healthcare as called for by HSPD-21 while bypassing the inherent delay in recognizing that all three systems enumerate the same core knowledge and skills.

Blink or Slight of Hand - Hospitals Beware!

A recent National Incident Management System (NIMS) update alert from the NIMS Implementation Center, included obscure reference to a frequently asked question (FAQ) document on the FEMA website.  This document, posted on April 20, 2007, like many documents before it was deeply buried within the FEMA website, accessible only to those who knew where to find it. 

The last two questions on this FAQ document dealt with a raging debate regarding the repercussions of failing to be NIMS compliant before the looming September 30, 2007 deadline. 

The first answered the question of whether the Joint Commission required NIMS compliance for accreditation.  The answers stated “Not at this time.”

The second question similarly was a response to inquiries regarding whether CMS required NIMS compliance for Medicare and Medicaid benefits and reimbursements.  Again the answer was “Not at this time.”

The April 20th update was posted almost exactly three weeks to the day after High Alert, LLC.  privately circulated a pre-released draft of its white paper on the association of NIMS, NRP, the NIMS Implementation Plan for Hospitals and Healthcare, the Federal False Claims Act (Qui Tam) and the Sarbanes-Oxley Act.  In that much circulated document, High Alert referenced several early positions by the Justice Department and the NIMS Implementation Center that placed hospitals and other healthcare facilities at risk of Medicare fraud and the repercussions of that fraud under both Federal False Claims Act and Sarbanes-Oxley. 

High Alert sounded the claxton alarm warning that failure to be NIMS compliant while still billing Medicare and Medicaid could constitute a violation of the Federal False Claim Act, thus opening institutions to significant legal repercussions. 

Several legal scholars had reviewed this potential and concurred with High Alert’s conclusions, adding that willful blindness regarding NIMS Compliance does not constitute a defense.  Similarly, the fact that Federal False Claims complaints are sealed for the first 120 days would by necessity mean that healthcare facilities and hospitals filing Sarbanes-Oxley Reports while under a Federal False Claims complaint would be guilty of a second violation, that being a false Sarbanes-Oxley Attestation. 

Several officials within the Department of Homeland Security, FEMA and Department of Health and Human Services requested copies of the High Alert draft document in the weeks prior to its official release in early April.  Within a week of the release of High Alert’s white paper the FAQ statements were posted to the internet. Interestingly, it was not until late June that the existence of these clarifications was publicized.

This raises the specter of a continuing plan to place hospitals and healthcare facilities in danger of violating of both the Joint Commission Accreditation guidelines and the Federal False Claims Act for failing to be filling NIMS compliance by the September 30 deadline. 

Hospitals and healthcare facilities can take a little solace in the fact that this FAQ document state “not at this time” in response inquires that the possibilities raised by High Alert’s document will result in actual federal prosecution.

There further persists the question of whether or not a private relator can bring Qui Tam action under the Federal False Claims Act, despite the fact that the federal government is currently disallowing any intention of bringing such claims on its own, “at this time.”

The history of the Federal False Claims Act demonstrates that enforcement has been primarily at the hand of private citizens acting in the function of “relator” bringing Qui Tam actions thus ever expanding the application and implication of the Federal False Claims Act.

The legal connections between liabilities under Federal False Claims and the Sarbanes-Oxley Attestation has been well-established both by High Alert and by others.  Thus when Qui Tam actions are successfully argued for failure to comply with NIMS hospitals and their corporate executives would face serious legal jeopardy.

Of even greater concern is the fact that even if a Qui Tam action were unsuccessful, the fact that the Qui Tam action may not be disclosed by any party requires that the existence of this potential liability be omitted from any Sarbanes-Oxley report filed during the corresponding time frame. This willful omission of a potential liability is the very definition of a Sarbanes-Oxley disclosure violation. Due to this legal “catch 22,” the CEO and CFO who signed the fraudulent Sarbanes-Oxley Attestation face civil and criminal prosecution.

The recent NIMS Integration Center alert and its associated FAQ document may allay the fears of hospitals as they move forward quickly to meet the September 30 implementation deadline. However, those facilities who view this document as reassurance that there are no significant repercussions for failure to be NIMS compliant may find that the copies of the High Alert document circulated at the Department of Homeland Security, FEMA, the NIMS Implementation Center and CMS served as a template for NIMS enforcement.

The ultimate question is, did the Federal government blink or is this a bit of informational sleight of hand?

One Great Solution for Improving Healthcare Preparedness

Our nation faces two interesting challenges when it comes to the healthcare response to disasters.  The first is that according to an Institute of Medicine report published in June 2006, hospitals have by and large failed to meet even the most basic standards for disaster preparedness.  In other words, they have failed to develop the relationships within their own communities, ignoring even EMS and community-wide Emergency Response Services thus failing to integrate these critical services into the hospital disaster plan.

Further, most hospitals, now six years after 9/11, still fail to provide basic disaster response training to all of their employees. Basic Incident Command training that would allow their employees and care providers to integrate themselves into the community wide response, while required by federal guidelines, is still reserved for members of the administrative team. Most hospitals have even failed to hold or participate in community-wide Disaster Drills despite a four year old mandate for these drill each year. Although reasons cited by hospitals for their failure are many, they are also largely invalid.  Requirements have existed for such Community-Wide Disaster Drill since 2003 and since 2002, the federal government had paid for or provided free of charge the educational opportunities for hospital employees.  Unfortunately now, most of that federal funding has ended, the five-year grants have expired.

There is however one opportunity for the federal government to use existing assets, augmented by existing state government assets, to provide not only training but disaster drill opportunities to hospitals and other portions of healthcare.  The Natural Disaster Medical System (NDMS) has within its ranks Disaster Medical Assistance Teams (DMAT) who are trained in all aspects of incidents command, disaster vulnerability analysis, disaster planning, disaster response, and disaster recovery.  Individuals who make up DMAT teams are civilian healthcare professionals who, when not deployed by our federal government, function as unpaid reservers, part-time federal employees on stand-by status, receiving no pay while remaining on call and ready to deploy within two hours in the event of national disaster or terrorism.

DMAT teams represents the perfect opportunity for federal government to utilize an asset already in the federal budget to provide not only training to hospitals in the communities surrounding a DMAT team, but community wide, externally designed and graded disaster drills that would include not only the hospitals but fire rescue, law enforcement, local county and even state emergency operations integrated with state and federal disaster response assets in coordinated community-wide drills. In other words, the best possible practice model. 

Expanding the services offered by DMAT teams to their surrounding communities would also serve the objectives of the federal government by providing an opportunity for DMAT teams to hold Field Training Exercises (FTX’s) and to network with healthcare assets in the surrounding communities.  NDMS has sought for years to develop a network of participating hospitals who would accept patients from distant field disaster sites transported by military or other assets and requiring hospitalization outside of the disaster zone. 

The average hospital will spend between $90,000 - 180,000 per year in the coming decade just for disaster drills and training, and this does not include the cost of paying employees to participate in those drills and training opportunities. Participation in federally sponsored federally funded, DMAT based disaster training and exercises would represent a significant inducement to hospitals  to join the NDMS hospital system and a significant benefit to NDMS member hospitals. 

State medical response teams, known under various names in various locations, could provide a similar opportunity for the state to both build relationships between their teams and their communities as well as improve the operational efficiency of teams through exercises and education.

Conceivably, even Medical Reserve Core units (MRC) could participate by providing local leadership and coordination efforts for their hospitals and communities as the MRC provides the earliest possible disaster response, providing for healthcare needs in those initials hours after an event.

Certainly, there will be the challenges of Congressional funding and special interest groups claiming that the federal government is subsidizing programs that benefit for profit hospitals.  More importantly however, a program such as this would ensure that our healthcare infrastructure was maximally prepared for the next Hurricane Katrina, for the next Oakridge earthquake, for the next Americas Georgia tornados, for the next great river flood.  NDMS member hospitals deserve to receive some benefit for becoming an NDMS hospital and assuming the additional responsibilities that come, uncompensated, with agreeing to participate in America’s disaster healthcare response system.  Using DMAT teams to train, drill and evaluate America’s healthcare infrastructure will ensure that the survivors of disaster receive the best healthcare available while the rest of us rest assured that our community’s healthcare is truly prepared if the disaster comes to our doorstep.

Know How to Stop, Drop, & Roll? Then It’s Time to Rinse, Lather, & Repeat

Over the past 2 decades, who has saved more lives in home fire?

You may be surprised to learn that more children have saved their parents than parents have save children.

Nearly two generations ago, the National Fire Safety Council created the Stop, Drop, and Roll program for kindergartners. The theory was simple: Since adult education on fire safety was failing miserably, with home fire related deaths increasing year after year, the council decided to introduce fire safety to children, hoping the children would influence their parents and take the fire safety knowledge with them throughout their life.

The plan worked. Today, the majority of adults in their thirties, and even many in their forties, know exactly what to do in the event of a fire: crawl below the smoke; touch the door not the doorknob before opening a door during a fire; and, of course, stop, drop, and roll should your clothes catch fire.

Now that deaths due to home fires have decreased, it’s time for everyone to face the next big problem: Zero Resiliency.

What is Zero Resiliency? It means that the majority of people today are dependent on the community or federal government to help them in the event of a natural disaster, even though every municipality, state, and the federal government tells people that they need to have an evacuation plan ready and they need to be able to survive for 72 hours on their own before outside help arrives. Billions of dollars have been spent in an attempt to educate people about disaster planning, but few are taking notice.

Think about it…If a natural disaster were to strike your location right now, this moment, are you prepared? Do you have your evacuation plan mapped out? Do you have a three-day supply of food and water available for each member of your family? Is your emergency backpack stocked and ready to go? For most people, the answer to each of these questions is “no.”

Unfortunately, having zero resiliency is a byproduct of our current economy. Many businesses have and promote a “just in time” mentality. Even marketers encourage consumers to adopt a “just in time” outlook. Few people these days buy a week’s worth of groceries anymore. Instead, they stop by the grocery store every night on their way home from work and purchase enough food for the evening meal and next morning’s breakfast. So we’ve gotten away from even having a week’s worth of food in the house. As such, few people can self-sustain in times of disaster.

Rinse, Lather, & Repeat: New Training for a New Era
Since educating adults about disaster planning is having as much success as the old fire safety messages that targeted adults, it’s time to shift our educational dollars to the youngest of Americans—the kindergarteners. That’s where Rinse, Lather, and Repeat comes in.

Rinse, Lather, and Repeat is a new program that seeks to duplicate the successes of the National Fire Safety Council’s Stop, Drop, and Roll program. Like its predecessor, Rinse, Lather, and Repeat is a one-week educational curriculum for kindergarten-age students that focuses on five core activities:

1. Preparation and maintenance of a three-day travel pack
2. Knowledge of where to obtain reliable news and evacuation instructions
3. The memorization of local and out-of-state phone numbers for friends, relatives, or family
4. The location of local shelters and local evacuation routes
5. The appropriate self-decontamination procedure whether at home in a household shower or at a hospital or other community facility

One of the core, hands-on activities children will engage in during the Rinse, Lather, and Repeat program is the preparation of a three-day travel pack. This kit, which the children will actually assemble, includes:

• Three days of clothing including underwear
• Thee days of energy bars or shelf-stable packaged food items chosen by the child
• Three days of water
• One week’s toiletries, including toothbrush, hairbrush, toothpaste, and toilet paper
• A two-week medication case (without medications)
• A USB flash drive containing medical records and a document inventory device
• One roll of quarters (for pay phones, which are self-powered)
• Photos of each family member
• List of each family member with age and contact telephone numbers (cell phone)
• List of two local and two out-of-state family members, friends, or relatives with addresses and phone numbers
• Backpack to place all items within.

In addition to assembling the backpack, children will review local information sources, including cable television, weather services, local access cable, local government cable and television sources, local information radio, and local print media. They will also memorize the four relatives with their associated phone numbers, as well as practice the use of the various information channels that they chose. 

Homework assignments that get the parents involved will include the location of the closest appropriate evacuation shelter for the family. In some communities this may be the family basement, while in other communities it may represent a Red Cross shelter or even a special-needs shelter established by local government or health department. Children will also learn on a map the appropriate evacuation route for their community.

Finally, children will learn the crux of the Rinse, Lather, and Repeat program, which is how to decontaminate themselves. Contamination can occur for a number of reasons, including raw sewerage if the levee breaks flooding their town, household chemicals like bleach or cleaning products may be splashed on them at home, there may be an industrial accident in their community, or even a biological or chemical weapon scare.

Unfortunately, health care workers still struggle with how to decontaminate a child. After all, we teach children never to get naked in public, so you can’t expect them to disrobe in front of people in bio-suits and walk naked through a decontamination unit. However, every child can be taught how to take a simple shower, which is really all decontamination is. They just have to learn to Rinse well, to Lather well (not just wander around in the bathtub as so many kids do), and then to Repeat the process one time.

Therefore, the steps to and logic behind Rinse, Lather, and Repeat are as follows:

1. Disrobe, thus removing 87% of all contaminants
2. Rinse their body thoroughly, rubbing all portions of their body with their hands to remove any contamination (now reducing contamination by 97 to 99 percent)
3. Lather well, utilizing soap, shampoo, or other decontamination supplies, to wash every inch of their body. This means total-body washing and scrubbing every aspect of their body well with their hands
4. Repeat the rinse, fully removing all soap or other decontamination materials

The Rinse, Lather, Repeat process can be taught utilizing comic books and/or coloring books with children in the classroom while fully dressed. In addition to providing the necessary skills to care for themselves in the event of a chemical accident, children will also learn to maintain good hygiene by learning a skill seldom taught by their parents: how to take an effective shower. This skill will also assist healthcare in the future by providing basic decontamination skills to children and ultimately to the adults that they will grow to become.

Rinse, Lather, and Repeat week will culminate with the children taking their new three-day travel packs home to be placed proudly in a closet or in the trunk of mommy or daddy’s car. Now the child is ready in the event that they must shelter in place or evacuate with the family.

Implement Rinse, Lather, and Repeat Today
Currently, no school in the United States implements the Rinse, Lather, and Repeat curriculum. And as we saw with Hurricane Katrina, that needs to change. People need to be prepared for a disaster, and Rinse, Lather, and Repeat is our best defense to drive the message home.

By implementing the Rinse, Lather, and Repeat program, within a 20-year period, we will return the United States to the same level of resilience we saw during World War II, during the Korean War, and during the early days of the Cold War, without the hysteria, and without burdening our schools. In fact, Rinse, Lather, and Repeat will solve the national problem of Zero Resiliency with almost no effort.

So the next time your child comes home with a Stop, Drop, and Roll assignment from school, ask the teacher when the next Rinse, Lather, and Repeat program will take place. After all, Rinse, Lather, and Repeat is our best opportunity to augment the level of national disaster preparedness by increasing self-reliance and the individual resilience of each American citizen.

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.   

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.

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.

When Worlds Collide

John, a veteran of the Fire Department of New York had “retired” to his southeastern home several years ago. Unable to sit and fish all day, John soon joined the county fire service and became a resource for his department and his community. Loved by everyone for his jovial nature John was admired by the rookie firefighters.

One bright summer day, a chemical tanker truck caught fire in front of the regional trauma center. The trauma center was upwind and in no direct danger when fire and hazmat teams arrived. The fire was quickly contained and the hazmat team set about the work of clean-up.

As operations began, John’s first duty was to establish contact and coordination with the hospital. Smiling he turned to the rookie assigned to him for training and said,

“This will be fun, watch their reaction when we ask to speak with their Liaison Officer. They won’t have a clue what I’m talking about.”

John and the rookie walked into the hospital still smiling and asked the security officer at the front door to contact the Liaison Officer. Much to John’s surprise, the security officer immediate called for the Liaison Officer to come to the front lobby. Moments later, a young woman arrived and introduced herself to John.

Unfortunately, John’s experience is still the exception rather than the rule when community response services interact with hospital services. Too often these interactions are seen as either a threat to hospital autonomy or as a public relations exercise. As with most problems of culture and communication, the fault lies on both sides of the relationship.

Hospitals are for the most part private businesses with the duel mission of providing care and delivering a profit. Unfunded mandates and social pressures have created a complex web of regulation and oversight that is largely resented by those in the healthcare professions. Any aspect of the business that is not regulated is seen as an opportunity to distinguish oneself from the competition and is thus jealously protected. Until this year, that included hospital command structure during a disaster.

Fire/Rescue has been steeped in a system of command and control born of the need to ensure that lives and property are not placed at undue risk. Unlike healthcare professionals, Fire/Rescue professionals know that a breakdown in command decision making will cost their life or the life of one of their colleagues. There is no room for individuality or customization of the system in the mind of the Fire/Rescue professional.

These worlds collide in the modern era of disaster preparation and response. By mandate, hospitals and healthcare facilities are now required to use the same incident command system that Fire/Rescue has used for decades. The relationship is further complicated by the fact that this mandate reverses the traditional lines of authority and knowledge in which Fire/Rescue has always taken instruction and guidance from healthcare as regards Fire/Rescue’s medical operations. Now healthcare must take instruction and guidance from Fire/Rescue.

As with any realignment of a relationship, the integration of hospitals and healthcare institutions with the larger community response will ultimately strengthen the system and the nation’s preparedness. Until then professionals on both sides will do their best when their worlds collide.