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!

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.   

Healthcare Recovery for the Gulf Coast

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

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

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

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

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

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

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

Managing Expectations at The Edge of Disaster

Steven Flynn’s recent book The Edge of Disaster has garnered the expected “inside the beltway” Washington response.  Finally today a senior official at the Department of Homeland Security (no doubt in the Public Information Office) began to spout the company line and tie it to Mr. Flynn’s book.

Point by point the Department of Homeland Security and the Federal Emergency Management Agency (FEMA) again remind the American public that a federal response is always more than 24 hours away, in fact, usually 48 to 72 hours.  The familiar theme of self-responsibility and self-preparedness are trotted out again for review of a distracted American public.

Unfortunately, both the Department of Homeland Security and Mr. Flynn are right.  In America, as soon as the catastrophe or a disaster has past we busy ourselves with the activities of every day life and forget the lessons that we learned when the most recent adversity struck us.  In short, we never develop resilience.

It is gratifying to me, having declared 2007 unofficially the year of resilience, that speakers and pundits around the country are now reframing their message not in terms of disaster preparedness or response, but in terms of resilience, the ability of a community or an individual to thrive in the face of adversity.  Dory Riceman characterized resilience as mastery against adversity and nothing could be more true.

The Federal Government, as is its habit, has turned disaster preparation into yet another unfunded mandate.  The cost for training and preparation often exceed $100,000.00 per facility falls completely on these private agencies and the individual practitioners within them.  Full scale disaster drills that are coordinated within the community can cost hundreds of thousands of dollars and are now a yearly requirement on all hospitals and healthcare facilities. 

The Institutes of Medicine have soundly criticized hospitals for not including communities, EMS, law enforcement and other responders in both their disaster plans and exercises.  The Federal Government has even gone to the point of setting the stage for several and even criminal prosecution of hospitals and healthcare facilities that continue to bill Medicare, Medicaid, Tri-Care, but are not in compliance with National Incident Management Systems and the National Response Plan.  These penalties were promulgated within the Federal Government, but by so doing became incumbent upon those who build a Federal Government under the Medicare, Medicaid and Tri-Care systems due to a little known clause which requires an attestation of compliance with “all regulations” promulgated by or upon CMS.

The problems do not exist just within healthcare, however.  Disaster preparedness and response are closely linked in the public mind, but separated in time by the event.  As the Department of Homeland Security regularly points out there is not sufficient resources within a one hour response time of every community in the United States. Communities cannot rely on federal assets or even state assets in the event of adversity. 

If resilience is mastery over adversity then that mastery is achieved through ensuring that resources never exceed needs.  Disaster is when you need to exceed your resources.  If you can prevent that single failure you can prevent disaster.

There is an unfortunate tendency to believe that disaster is unpredictable in its timing, scope and nature.  The Department of Homeland Security itself echoes this myth as does Steven Flynn and many other authors and “experts.”  The predictability of disaster is in fact absolute.  If your needs exceed your resources regardless of the nature of the adversity that you face, you have a disaster. Similarly, if your needs exceed all ability to respond, you will face a catastrophe. 

On the other hand, the same pundit’s government officials and experts state that resilience is severely lacking in America.  The 9/11 attacks proved quite the opposite.  Resilience comes to us in four areas of life: 

• Our physical resilience; that is the resources internal and external that we hold in reserve for moments of adversity.
• Our emotional resilience; that internal ability to draw on our experiences and our emotional strength garnered from our relationships that allow us to cope with the stress and impact of adversity.
• Our relationship resilience; those community, professional and family connections that we have nurtured such that we may tap into them to garner additional resources whether physical or emotional to assist in mitigating disaster.
• Our spiritual resilience; that strength that is gained from believing.  It is in fact not important what we believe, but that we believe because it is in the mere act of believing that we gain strength and resilience.

Government by its nature is reactive, not proactive.  It responds to the needs of voters, it responds to the needs of constituents, it responds to the needs of society and it responds to the needs of the law.  It is only natural that in their world, the narrow world of reactivity, disaster is unpredictable. 

Fortunately, the rest of us live in a world where we are proactive.  In a proactive world we use our personal and societal experiences to predict the likelihood of future events, even adversity.  By knowing the types of adversities we have faith in the past, we can prepare for those adversities in the future.  If our preparation is strong, if our preparation is strong, if it is comprehensive, if it is now, we will prevent adversity from becoming disaster in the future…  We will achieve mastery against adversity.

The Edge of Disaster and Modern Healthcare

Stephen Flynn's recent book The Edge of Disaster, featured on national public radio this week, describes a number of large scale vulnerabilities across the United States.  His thoughts on pandemic flu, while certainly concerning, pale in comparison to the real numbers. 

Mr. Flynn describes 80 million infected with as many as 800,000 dying of the disease.  However, a review of Avian flu pandemic over the last 300 years shows that one-third of the U.S. population or 100 million people will be infected.  If this is not enough one half of these individuals or 50 million will require some level of hospitalization or institutional care from bone health all the way up to intensive care unit services.  As Mr. Flynn correctly pointed out there are fewer than 970,000 hospital beds in the United States far less than the 50 million that will be required. 

Of greater concern is the fact that half of those requiring hospitalization will develop a life threatening lung condition know as Acute Respiratory Distress Syndrome (ARDS).  Twenty-five million people requiring advanced lung care will quickly overwhelm not only the capacity of our hospitals but of our respiratory therapists and our nurses.  Of those with ARDS half will require ventilator support, unfortunately there are only 105,000 ventilators in the United States and only 16,800 are available at any given moment to treat these 12.5 million ARDS patients.  Of those that require ventilators, approximately 6.25 people.  This last number is eight times that predicted by Mr. Flynn and has been substantiated in multiple scientific reviews of the major pandemic of the past 300 years.

Mr. Flynn also spends a significant amount of time discussing surge capacity and when asked by his NPR host about the economics of increasing surge capacity beyond the pitiful 12 percent currently available nationwide Mr. Flynn simply said it was an investment in the future, an "insurance policy."  Those knowledgeable in healthcare surge capacity and healthcare vulnerability analysis differ with Mr. Flynn's otherwise star analysis of the other vulnerabilities of the United States.

Immersion Simulation based disaster training for hospitals and healthcare facilities results in a new protocol in the minds of those who are trained.  They learn to deal with triage on a moment to moment basis with every patient whether there is an ongoing disaster or not.  Those hospitals that adopt this model quickly learn that they can activate their emergency plan even when their hospital is only suffering from the daily surge of patients.  Hospitals in New York, Boston and Philadelphia have done this with increasing frequency when emergency room await times have been only two times the norm.  As a result the hospital activates its emergency operation center, calls in additional staff and increases the number of patient care areas in the hospital by re-tasking administrative and non-patient care areas to the treatment of non critical individuals.  These “green” treatment areas decrease the backlog in the emergency room lobby with surprising results.

• Fewer people leave the hospital without medical care because the wait has been reduced.
• There is an increase in hospital admissions because greater diagnoses are made by less stressed doctors, nurses.
• There is a net increase in hospital revenue despite the cost for staff and re-tasking facility.
• Patient satisfaction is improved with patient satisfaction scores on survey rising.
• The hospital saves money because a surge capacity emergency plan activation counts as one of the yearly required disaster drills.

In addition to Mr. Flynn's "insurance policy" approach to surge capacity there is a real world economic advantage for hospitals and healthcare facilities to participate in large scale disaster planning and preparation.  Every hospital in the United States has now accepted money from the federal government under HRSA grants or through various government based insurance payment programs.  As a result these facilities are now required to be compliant with the 17 elements of the National Incident Management System implementation plan for hospitals and healthcare facilities.  In addition, they are required to maintain a surge capacity equal to 20 percent of licensed hospital beds or 500 bed per million population in the geographic license area of the hospital or whichever is greater, less these facilities be guilty of fraud.

The stakes are high for healthcare not only because of the duty and responsibility they take on as part of their role in society but now as a result of the financial assistance they have accepted for the past five years as they were supposed to be preparing for all hazards and all disasters.

Mr. Flynn's book and the features on national public radio this week have brought the spotlight to bear on the vulnerabilities in America, the question is will we respond now or lament the next catastrophe?

General Honore Leads the Charge

Lt. General Russel Honore (for those of you who are not familiar with military ranks, that is a three star general) has a new mission. In addition to training new recruits for the urban combat environment of Iraq and Afghanistan, General Honore is now touring the country, speaking to churches and Rotaries, in town halls and community government auditoriums not as an ambassador for the United States military but rather as an evangelist preaching the gospel of preparedness.

General Honore served with distinction, pride, and true leadership in New Orleans, Louisiana in the days and weeks following Hurricane Katrina. In the year and a half since Katrina much attention has focused on the recovery effort, or lack thereof, in the ninth ward; but little attention has been paid to preparedness in Louisiana or elsewhere. Everyone believes that the Federal government will take care of preparing cities yet in the newest iteration of the free online education from the Federal government a prominent point in the first objectives of each lesion is the fact that the Federal government pays for none of the community’s preparedness plan.

That is right, it is up to us.

Now it may not seem like an unusual mission for a 3 Star General to tour the country. Eisenhower, McArthur, and Patton toured the United States during the bond efforts of World War II. It is however an unusual mission for a 3 star general to tour the United States in support of humanitarian preparedness. General Honore calls this “a new normal.” According to General Honore we are in an environment now where terrorism, major natural disasters, and industrial accidents are unavoidable and due to the technological complexities of our society potentially catastrophic. General Honore points out that there is a “nine ward” in every city. A place where the infirm and the elderly, children and the disabled, the poor and the homeless live and are unable to help themselves in the event of disaster.

General Honore’s message: no government and no military no matter how strong or well prepared can protect an unprepared citizenry. General Honore advises that at Christmas and birthdays:

“Don’t give grandpa a tie, give him a weather radio.”

“Don’t give grandma a picture frame… give grandma a weather radio.”

To this I would add give mom a three day disaster pack with all of the clothes, food, water, and personal toiletries that she will need for 72 hours to ensures that she will see next mother’s day. Give dad an electronic personal medical records dive watch and ensure that if dad ends up in the emergency room or a field hospital and cannot speak for himself his electronic personal medical records speak for him.

General Honore’s mission reminds us that government can teach, government can reinforce our own preparedness, but it is up to each of us individually to prepare for the next Katrina or the next 9/11.

Who Will Run Our Prisons?

The fall 2006 Correct Care (Volume 20 Issue 4) is a must read! Correct Care is the professional journal for corrections medicine professionals (prison healthcare).

The article by Dr. Richard Garden titled Pandemic Flu:  Planning for the "What If" is an excellent overview of the concerns and issues that will face the correctional healthcare industry when pandemic flu strikes.  In fact the only point on which I can disagree with Dr. Garden is in the title.  It is not “if” but “when” the pandemic will occur.  History over the last three centuries has taught us that novel avian pandemic flu occurs every 91 years (plus or minus 3.5 years for antigenic drift).  Given that the last major pandemic was the 1917/1918 Spanish flu this means that we can expect a pandemic flu outbreak between 2006 and 2013.

It is a mathematical certainty.

I must compliment Dr. Garden on being the only other physician that I have heard discussing the impact on the healthcare workforce in accurate terms. He is absolutely correct that up to 50 percent of the workforce may not report to duty. The reasons are well demonstrated in the history of pandemics.

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 percent is 33 percent.
  • This is the “attack rate”. 
• Half of 33 percent is 16.5 percent. 
  • 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 percent is 8.25 percent.
  • 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 percent is 4 percent.
  • 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.

When these ominous numbers were scrutinized further, a far more dire picture evolved.  Research into the 1918 pandemic, as well as pandemics before and since 1918, have shown that the majority of illness and death occurred not in the very old or the very young, not in the sick and infirm, but in those who are in the "prime of life"; those age 18 to 40.

But there is a bigger problem for Correctional Medicine.

Because of the way that novel avian viruses (pandemics) attack the lungs and cause "immune system storms", the ultimate irony of a pandemic is that the younger and stronger you are the more likely you are to die.  In 1918 fully two-thirds of all those who became ill were in the age range of 18 to 40.  More distressing is the fact that 98 percent of all of those who died were age 18 to 40 years.  In fact, those over age 55 had no greater rate of illness or death during the pandemic of 1918 than they did in any other flu season in the years immediately before or after that great pandemic.  Similarly, those less than 18 years of age suffered no increase in death rate.

The implications for America's correctional institutions are inescapable.  Fully two-thirds of the active workforce will fall ill during the 16 to 18 months of the disease throughout the pandemic.  Twenty-five percent of the young workforce (the 18 to 40 years) will die in that 18 months.  Who will replace them? 

Dr. Garden is also correct that correctional institutions as well as the disabled and children have not been considered in local, regional or state pandemic planning.  In fact they are barely mentioned even in federal planning. As Dr. Garden points out it will be up to the correctional institutions and specifically correctional healthcare to contact State Homeland Security representatives as well as federal agencies and become part of the plan.

In June of 2006 the Institute of Medicine published reports on the state of preparedness but pointed out that even emergency services had been left out of much planning.  Even the Institute of Medicine did not mention the fact that institutional medicine including correctional healthcare are not even mentioned in these plans.

It is imperative that healthcare professionals of all stripes become expert not only in pandemic planning but in the "All Hazards" approach to disaster and catastrophic event planning.  Whether it is a pandemic, a hurricane, an earthquake, a forest fire, or a terrorist event that threatens the community in which a correctional institution exists, bitter experience has taught us that concentrations of individuals living in institutional settings whether in prisons, military barracks or university dormitories become the "cave canaries" of society. 

In 1918 Spanish flu outbreaks, which actually began in Kansas, were first seen in epidemic form in U.S. military barracks.  The outbreaks of measles in the 1980s were first seen in university dormitories across the United States.  And the largest concentrations of the recurrence of tuberculosis, as we all know, is seen in correctional institutions.

In the same issue (Volume 20 Issue 4), Dr. Scott Savage reviews medications that he believes every institution should have for pandemic flu planning. His insightful article disclosed that Dr. Savage is not only a skilled director and physician but has a great understanding of the all hazards approach.

While writing his article specifically for pandemic flu planning with a title that would suggest a review of antiviral medications, Dr. Savage correctly links pandemic flu planning for the greater need for overall disaster planning based on mechanism of injury.  In short, Dr. Scott Savage is introducing an “All Hazards” approach to disaster planning in the correctional healthcare industry.

As Dr. Savage clearly knows, disaster is when needs exceed resources and his article provides a basic list of resources that will help stave off disaster in a correctional healthcare institution. His list of medications covers the waterfront for first responders and the all critical 72 hours of a disaster.

Whether it is Dr. Savage’s extensive military training or his experience in disaster medicine, Dr. Savage’s article displays and understanding of the fact that like all aspects of healthcare, corrections medicine must not only plan for a pandemic but for all 14 mechanisms of injury in the case of an adverse event with the intention of preventing that adversity from becoming a full fledged disaster.

Resilience is when you have sufficient resources to prevent needs from exceeding those resources.  By following Dr. Savage’s advice, corrections healthcare professionals will take a giant leap towards resilience.

Dr. Garden, Dr. Savage and the editorial staff of Correct Care are to be complimented for publishing some of the few articles to consider planning for the impact of the coming pandemic not only on our patients but on our colleagues and our society.

Kudos!

Even in Hometown Kissimmee

This morning’s news that the threats to bomb various targets in Kissimmee, Florida and Greater Osceola County are tied to the discovery of actual bombs and bomb making materials proves yet again that the Kissimmee and Osceola County are not as safe as many would have us and our county government believe. Even more concerning is that much of the critical equipment needed to respond to a Chemical, Biological, Radiological, Nuclear, Explosive (CBRNE) event are kept in Orlando. This equipment, known as a “Push-Pack” is stored with other interagency response equipment and may only be release with the consent of Orange County’s Emergency Operations Center.

The purpose of a “Push-Pack” is to place equipment near areas where the need for such equipment can reasonably be expected. Today’s announcement is further proof that Osceola County’s equipment belongs in Osceola County.

Add to this yesterday’s announcement of the first confirmed attempt to sell weapons grade uranium. American officials attempted to reassure the public by stating that the amount of uranium offered for sale was less than that required to create a nuclear warhead.  It is of note that they did not deny that this was in fact weapons grade uranium. 

Intelligence officials, terrorist and response experts, and those of us in the disaster medicine community have long feared the verification that weapons grade uranium is available on the terrorist market.

While government officials attempt to placate appropriately concerned citizens with the platitude "it's too little to make a nuclear bomb", anybody who has put together a Thanksgiving dinner knows that if you can’t get enough sweet potatoes at one store you just go to another.  The terrorists are not stupid and little bit of weapons grade uranium here, a little bit more there and soon they have the critical mass to actually achieve critical mass. Then there is the claim of the seller that the sample in his possession represented a much larger quantity. 

Many security experts and almost every local disaster preparedness professional points to the fact that building a successful nuclear device is technically difficult. Unfortunately, a first year undergraduate physics student in the 1980’s proved that with minimal research it is possible to design a viable nuclear explosive. If a terrorist, foreign or domestic, were to attempt a nuclear detonation and fail, the resultant dirty bomb would still cause as much havoc and hysteria as the actual mushroom cloud.

The medical community and the emergency management community throughout Central Florida needs to ramp-up their response capability, decentralize their resources through strategic deployment of assets and move the level of preparedness into the 21st century.

It finally happened! The Cold War is Back… With a Twist

Russian officials today announced that the arrest of a man attempting to sell weapons grade uranium.  That's right, the type of uranium used in a nuclear bomb.  In reply, American officials attempted to reassure the public by stating that the amount of uranium offered for sale was less than that required to create a nuclear warhead.  It is of note that they did not deny that this was in fact weapons grade uranium. 

Intelligence officials, terrorist and response experts, and those of us in the disaster medicine community have long feared the verification that weapons grade uranium is available on the terrorist market.

While government officials attempt to placate appropriately concerned citizens with the platitude "it's too little to make a nuclear bomb", anybody who has put together a Thanksgiving dinner knows that if you can’t get enough sweet potatoes at one store you just go to another.  The terrorists are not stupid and little bit of weapons grade uranium here, a little bit more there and soon they have the critical mass to actually achieve critical mass. Then there is the claim of the seller that the sample in his possession represented a much larger quantity. 

Nuclear events come in two forms known as criticality and noncriticality. 

A noncriticality event is when radiation is released without a fission or fusion detonation.  In short, the event is local.  Dirty bombs fall into this category.  Most of the radiation comes from direct contact or direct exposure to the source.  There have been some very large noncriticality events around the world usually a result of improperly discarded radiation sources from medicine or industry. 

Criticality events have always been the result of the action of large governments.  Hiroshima and Nagasaki were criticality events.  The recent nuclear testing in North Korea was a criticality event.  The great fears of the Cold War were not a fear of noncriticality radiation but a criticality event and its associated gamma radiation and fallout. 

The intelligence community has proven that the terrorists have the ability to get weapons grade uranium.  Now we must add criticality events and the hazards that come from them to our list of concerns both for national security as well as disaster medical response.

The lessons of the Cold War, at least those that deal with preparing for the hazards of criticalities must now be dusted off and added to the 2007 standards of care.

Will there be a criticality event within the United States? 
Will somebody set off a nuclear or thermonuclear device as a terrorist statement? 

As we prepare for this possibility let us all hope that those charged with our security will continue to have the success that they announced today. 

Bipartisanism and Silos of Authority

The new balance of power in Washington, DC, has sent pundits scrambling to predict how the Republican Party and the Democratic Party will interact.  Conservative pundits tout theories that the Democrats will be forced to the political center, if not slightly to the political right by a conservative President Bush.  Simultaneously, liberal pundits are celebrating the projected migration of a hawkish Executive Branch from the radical right to the conservative left. All this while our elected officials go to great pains to promise they will work in the 'spirit of bipartisanism' and that there will not be 'gridlock' in Washington, DC.

In the disaster field office, we learned long ago that it is not business or even political theory that insures the rapid inefficient movement of information and eliminates political or bureaucratic gridlock.  The process that works best for eliminating gridlock and territorialism comes to us from a Harvard in the early 1980’s.

Gergen and Marcus described a concept in economics known as 'silozation'.  In this groundbreaking theory the author is positive that traditional business models allow for the progression of information from the base of the 'silo' up to the highest levels of management at the top of the silo or the dissemination of information from the top of the silo downward, but prevents communication between organizations (silos) through the wall at any middle level of management.

This model, they claim, prevented the development of relationships between various levels of an organization or even a division within a single corporation.  It also resulted in 'choke points' for communications.  Communication between organizations has to funnel through the top to the bottom of the silo before it could be disseminated to the other members of each organization.  Gergen and Marcus recommended that in business and economics that the silos be cut or totally removed.  By doing this, organizations could communicate risk, benefit and opportunity, relying on their unique capability to insure customer loyalty and market success.

Commander Peter Marghella, USN (Ret.) has introduced this theory to the disaster field office.  Commander Marghella correctly identified that individual professions within disaster medicine and individual organizations within emergency management maintained thick walled silos that prevented cooperation and efficient in austere environments.  The recommendations to remove the silos were impossible and cut through them where they could not be completely removed has improved the efficiency in responding to disasters large and small.

Washington, DC and our nations elected officials need to remove their silos.

The artificial divisions created by classifying candidates as Republican or Democrat, conservative or liberal helps poorly educated voters select from often near identical choices.  However, once elected, candidates represent all of us and they must work with every other elected official in government, even if they do not agree with them.  It is only by removing the silos that pen them in that our elected officials can do the work through which we, their constituents, have charged them.

The government is not a college football game and Washington, DC is not a bowl stadium.  Republicans and Democrats cannot and should not don partisan uniforms, strap on helmets and prepare to do battle.  As the people who place them in office, we cannot sit on the home or visitor's side of the stadium, paint ourselves in our favorite team's colors and scream for the blood of our opponents.  If we do, in the end, the blood on our hands will be our own.