Maurice A. Ramirez, DO, CNS, CMRO

I Will Watch My Friends Die

The most ominous words ever uttered by a disaster preparedness expert were voiced during a deep background interview. This expert stated simply that given the current state of hospital preparedness and the current rate at which facilities are becoming disaster ready, there will be no meaningful level of preparedness in this decade unless someone blows up a hospital. This may seem a bit extreme, but declassified documents show that Al Qaeda seeks to steal an ambulance and blow it up at a major American trauma center. 

Unfortunately, this scenario is based on the lesser of the threats currently facing healthcare. 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.

Dr. Richard Garden and others have begun to discuss the impact on the healthcare workforce in accurate terms. These pundits are 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.

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.

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 hospitals and healthcare 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. 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. 

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, 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.

The 2003 SARS outbreak also provided us a small scale example of the effects for a pandemic on healthcare. Following the outbreak of SARS in Canada, healthcare workers in 4 Toronto area hospitals began to fall ill. Soon nurses and doctors were looking through protective equipment at colleagues and friends. The disease had changed the normal “us and them” relationship to “us and me.” These professionals watched their friends die. The result of SARS on the healthcare professionals who worked in these 4 Toronto hospitals was that 50% left healthcare entirely.

What does all this mean for the healthcare industry?

• During the outbreak, up to 50% healthcare workforce absenteeism
• During the outbreak, up to 25% healthcare professionals death rate
• Following the outbreak, 75% of healthcare professionals still alive
• Following the outbreak, 50% of remaining healthcare workforce quits

The final outcome for healthcare:

• 25% will die
• 37.5% will resign
• 37.5% will remain

Lest healthcare embrace the lessons for preparedness this is the fate of us all.

Who Will Fill The Shoes?

OK, I quit!

I’m tired of beating my head against the wall in a healthcare system that believes that its most valuable resource, the healthcare professional is indiscriminately disposable.

Let’s face it; nurses have the hardest job in healthcare today. Hours are getting longer; job duties now include public relations, maid services, complaint resolution, cryptography and social work. Nurses are absolutely abused by the very hospitals that are in desperate need of nurses now and will soon discover the true meaning of the phrase “nursing shortage.”

The baby boomer's are aging and the current generation of healthcare professionals is aging with them. Healthcare needs more geriatricians, those physicians who specialize in the care and treatment of patients over 55 years of age, but as our physicians age, we will need more not only to replace those retiring, but also to participate in disaster care.

I’m a geriatrician as well as emergency medicine and disaster medicine and I’m out!

I’ve taught medical students and residents; given my specialties it will take 3 of them to fill my shoes. The problem is that most medical students are now gravitating towards the high pay, low stress, low time demand specialties. Surgical, Pediatric, Obstetrical, and Primary Care specialty residencies are closing for lack of applicants. In short, there is no one to fill my 3 sets of shoes.

Now I am not prone resigning from the field of battle. I’ve earned multiple degrees and multiple certifications. I’ve worked at the scene of many disasters at all levels of care. I’ve served every deployment to the end regardless of personal or professional issues that may have arisen. But enough is enough. I have recently seen healthcare take a turn that is not only unprofessional, but immoral and unethical. Money has always been a necessary evil in healthcare and I do not mind making a very comfortable living in medicine, but when outright extortion determines care, staffing and caregivers available, the stench of the system has become too great to stand.

I am not alone. I have spent the past several weeks with healthcare professionals from around the nation at a number of venues. The recurrent theme, they quit or are in the process of “phasing out.” Physicians are willing to spend well over $5000 per weekend for seminars on “Alternatives to Clinical Practice” but whine about spending less than $500 for continuing medical education. Programs in law, business and research aimed at nurses are full across the nation. None of these professionals are planning on returning to the healthcare industry after they graduate, they plan on non-healthcare careers.

Why are so many leaving? The same reasons I am, because our focus is no longer healthcare, its money. We are no longer partners with those who run the business side of healthcare; we are their opponent or their victim. Problems are no longer discussed; the business people mandate a specific solution and the healthcare professionals are expected to comply. The latest odious trend is policies that state that an individual nurse may NOT determine that he or she is in a patient care situation that endangers their license and the life of those for whom they care.

This is absolutely contrary to basic safety operations. On a railroad, on an airline, or in a mine, anyone from the baggage carrier to the captain of the jet can stop all operations for safety reasons. The Institutes of Medicine in 1999 pointed out the fact that medicine is the only safety sensitive industry in America where the ability to determine what is safe is restricted to those also charged with keeping the income flowing. This is an irreconcilable conflict of interest.

Healthcare professionals are also leaving because they are tired of being cannon fodder. With the coming pandemic those of us in healthcare know we will die in the line of duty just as our colleagues did in Toronto with SARS. We simply won’t sacrifice our lives for a system that no longer values us, our positions, our education or our experience.

What impact will all this have on healthcare?

If I am the only one who leaves, no one will care, but I’m not alone and the pandemic is coming.

Will you let us leave?

If you do, who will fill our shoes?

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!

Why Won't Quarantine Work for Pandemic Flu?

The State of Florida, Department of Agriculture, this week lifted the quarantine on horses in South Florida.  This was welcome news to the competitive horse breeding industry which has spawned many of the recent champions of horse racing.  Equine herpes virus, a disease fatal in horses, was the cause for the quarantine and officials lifted the quarantine because this it had stopped the progression of the disease through the horse-racing community.

But if quarantine is so effective in animal diseases, not just equine herpes but mad cow and other diseases, then why will it be ineffective when the avian flu pandemic strikes?

Answer comes from the very nature of quarantine for animals.  The diseases for which animal quarantine works are diseases that are not easily transmitted to humans.  Since all animals exposed to the disease, except humans, are maintained within the quarantine area and humans who are not capable of caring the disease out of the quarantine area, the ability for the disease to spread is absolutely stopped.

So why doesn't this work in humans?

When the pandemic strikes it will be human nurses and human doctors who will be caring for human patients.  That means the doctors and the nurses are just as likely to contract the disease as the people for whom they are caring.  Even with the best personal protective devices (PPD), the ability to contain the disease will be non-existent. 

Further, in quarantine, you take everyone suspected of being exposed and separate them from everyone believed to have never been exposed.  This raises two problems.  One is the inherent uncertainty of knowing who has and has not been exposed and the second is the fact that in a pandemic ultimately everybody is exposed.  Once you reach a certain level, quarantine makes no sense because there are more people in quarantine than not. In fact, statisticians have determined that once there are more than 31 cases worldwide, quarantine will no longer be an option.  We are well over that number now. 

The second problem inherent to quarantine is that it is a deliberate restriction of personal liberties.  In fact, it is separation by prescription if not legislation.  The reason quarantine has been such a great subject for Hollywood is that such restrictions violate basic tenets of our society and seeing the hero overcome those restrictions makes for good cinema.  Attempts at quarantine for human disease throughout the ages have failed, even as quarantine has succeeded for narrow non-human diseases in domestic animals.

The South Florida Horse Racing Industry was fortunate this year.  They were able to quarantine animals, separate those animals that would die of the disease from those who never developed illness and ultimately wait for the disease to burn itself out.  Their industry survived. 

When the avian flu pandemic strikes, all of humanity will be forced to find a way to decrease transmission while still maintaining the basic functions of society and of humanity.

In The Kill Zone

Imagine arriving at work and two-thirds of your employees are out sick.  Now imagine that you are the manager of a large supermarket or a WalMart or a Super Target.  This is exactly the situation that America's retailers and manufacturers face with the coming avian flu pandemic.

The avian flu will be a novel virus, one never seen before by the human immune system.  The current disease of concern is the H5:N1 strain of avian flu.  However, any novel avian flu will have the same effect as was seen in 1918.  In 1918, one-third of the United States population fell ill.  Half of these sick individuals required some form of institutional care (hospital, infirmary, or quarantined home care).  Of those in institutional care, half developed severe pneumonia and half of those with pneumonia died. In short, 33% got of the total population sick and 8% of the total population died.

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.

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 retailers and America's manufacturers 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?  Where will American industry, America's retail sector, and American business find employees?

America's employers have become accustomed to a ready workforce.  If an employer finds that they have a job vacancy, no worries! They have become complacent knowing that they can readily replace an employee with the help of such services as Monster.com and other job-matching tools.  Take away 25 percent of the workforce due to death and two-thirds of workforce due to illness and you will see a dramatic shift in the balance of the employer-employee relationship.  When there are not enough employees, salaries will rise, prices will rise, and customer service will fall.

The solution?  Plan now. 

1. Those of us who have sought jobs are all too familiar with the refrain:  "I'll keep your resume on file." Now employers must do exactly that.  This is the time for employers to not only develop a ready pool of applicants, but to stay in touch with them in the same way that they stay in touch with their most valued customers.  Employees will find other jobs in the interim, but when employees become scarce, it is the employers who have shown a genuine interest in the person and the success of perspective employees who will prevail when the bidding wars begin.

2. Hire now across a spectrum of ages.  Many employers concentrate their workforce in certain demographic age groups because they believe that their customers will identify better with these demographics or because of an age-based bias that convinces the employer that certain employees are better suited to certain work, certain work environments, or represent greater or lesser degrees of reliability.  The coming pandemic lends a new variable to which employers must adapt.  Employees less than 18 years of age and greater than 55 years of age are less likely to be ill during the pandemic and less likely to die.  Providing a more homogonous mix of employee ages will statistically decrease the impacts of the pandemic on the wise employer's workplace.

3. Finally, workplace health promotion programs and health benefits, as well as a strict adherence to hygiene and clean workplaces will decrease the impact of the pandemic on the employees, the workforce, the employer and ultimately the place of business.

We cannot avoid the coming pandemic.  We cannot avoid the coming impact on men and women alike, old and young alike, rich and poor alike.  But we can prepare now, we can make our jobs and our workforces resilient.

Setting The Record Straight on Pandemic Preparedness

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

Let's set the record straight.

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

As we all know now from the media, influenza virus mutates over time.  Small mutations are known as antigenic drift while large mutations are known and antigenic shift.  These drifts and shifts slowly change the virus from something that the human immune system can recognize and therefore protect against to something that is novel or new to the human population – a pandemic. In short it is something that the human immune system has never seen before.

In 1918 the H1:N1 strain was seen.  Like all of pandemics before, it struck with a predictable infection rate (attack rate); approximately 1 in 3.  Of these 1 in 3 on average in the population half would become seriously ill.  Half of those would develop severe lung disease and half of those with the severe lung disease would ultimately die. 

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

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

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

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

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

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

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

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

So what can you do? 

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

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

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

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

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

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

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

Tamiflu Psychosis

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

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

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

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

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

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

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

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

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

Where’s the Technology?

Where’s the Technology?
The last ten years of medical advance has promised again and again the ability for physicians to remotely examine and even treat their patients.  Federal government states and universities have spent that millions of dollars in the development of examination stations and “robots” to provide stereo two-way voice communication, stereoscopic video and even remote stethoscope capability to patient bedsides in remote hospital communities.  This new science of telemedicine has brought advances to hospital and emergency room based medicine for those remote communities.

But what about the average consumer?  The coming pandemic looms ominously on horizon.  But this ominous shadow may actually be a new dawn for telemedicine. 

The SARS outbreak in Toronto and Singapore proved that quarantine does not work but that “Social Distancing” does.  The message in Toronto was clear and simple.  “Don’t go to hospitals and healthcare institutions unless you want to catch SARS.  That’s where the SARS is.”  In Toronto it worked.  The SARS epidemic fizzled out after only a few short weeks of social distancing. 

But in the United States, emergency rooms, hospitals and urgent care centers are the destination for the treatment of after-hours illnesses and sudden onsets of the flu.  Pandemic flu will strike like a blitzkrieg across the world.  People will fall ill in a matter of hours not days.  Doctors’ offices will be overflowing with the sick and those who are afraid that they will become sick.  The default will be the urgent care centers emergency rooms and hospitals of the nation.  This is where the disease will be concentrated and like with SARS in Toronto this is where it will be most likely that you will become ill.

Here’s where telemedicine has the advantage, if somebody, anybody can produce a telemedicine technology solution within a reasonable price range for the average consumer to buy.  What would be needed would be a high resolution web camera and a simple handheld stethoscope-like device that could produce high fidelity sound in real time.  A web based portal for physicians would also be needed.  The examination would need to be completable in real time. 

Imagine a simple device with a webcam and a modified microphone similar to that already found on electronic stethoscopes used by physicians coupled with an electronic blood pressure cuff. Now imagine this device providing information in real time to the physician a rudimentary medical examination, a kind of “telemedicine triage.” With this consumer priced equipment, an examination could be performed and basic healthcare decisions such as the need for home healthcare nursing, antiviral medication prescriptions, or simple chicken soup could be made.  This “telemedicine triage” would ensure that only the sickest of the sick would go to the hospital guaranteeing that the spread of the disease was decreased because fewer people would be sent home from the hospital not sick, but now contaminated. 

Of course Medicare, Medicaid and other healthcare insurances would have to begin to actually pay physicians to perform telemedicine services.  While the codes exist reimbursement is slow and difficult.  Telemedicine takes more time than a regular examination and time does have a value.

Will anybody step up to the plate?  That depends on demand for “telemedicine triage” by the public, the demand for a consumer telemedicine product and, unfortunately, the ability of physicians to get paid for what they do. On the other hand, the cost if telemedicine triage does not become is that the future pandemic will rage on.

The Industrialized World Isn't Safe From Pandemic

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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