Maurice A. Ramirez, DO, CNS, CMRO

Another Season, Another Storm

We’ve all heard the predictions. Despite a restful 2006 hurricane season, nobody yet has forgotten the unpresidented 2004/2005 hurricane double whammy that battered Florida and the Gulf Coast. But before we look ahead to this coming season, let’s stop and take stock of the lessons we’ve learned from our most recent experiences and prepare our children for this year.

In 2004 and 2005, we pulled together as a community and did all the things good friends and neighbors do when the chips are down. We shared food, water, tarps, and cell phones, and we took time to connect with the strangers across the street. We reached out to those in need and made some great new friends in the process. We hunkered down, we weathered the storm, and together we cleared the deadwood.

We became accustomed to the blue tarps, and fortunately, “tarp city” is almost gone. So what can we do to prepare for this year? Certainly we cannot change Mother Nature. After all, few “mothers” allow her “children” to change her. However, we have now learned how to live with her. And that is the first step towards a safe season.

The good news is that most of the things hurricanes can damage have already been damaged and replaced. New roofs, stronger windows, and better structures mean less damage. The old trees are gone and the new trees are firmly rooted in their place. Our communities are now ready to come through the storm with minimal or no damage.

Yes, we’re ready. We all know what we have to gather, and for the most part, we all have our storm supplies ready. Sure, there are some things we can still do. For example, we can still have our plan of where to go when the phones are out. We still need to know where the closest shelter is.

Those of us with kids should consider going to visit friends or relatives when the next storm comes. After all, what better time is there to go on vacation than when a hurricane is in town?

We’ve all discovered that cell phones work during the storm, and we’ve all learned that if you can’t call directly to a family member, then we need somebody else to call—a central friend or message board—somebody out of town who can let everyone else know we’re okay. Don’t forget text messaging, email and SMS. Teens and even young kids with cell phones are expert at these technologies. Chaos is the only constant in natural disasters such as hurricanes. The answer to coping with the sense helplessness chaos brings is to take control of some aspect of the disaster. Even if you know how to text message, ask your kids to help you or even teach you to use these technologies.

The key to feeling safe and not worrying about this year’s storms is to be prepared and to have a plan. Make sure your children know the plan, have practiced the plan and can implement the plan without you. That’s right, the key to security is knowledge. After 2004, we have the knowledge and we have the experience. And as a result, we’ll get through this year’s storms far easier than we got through last year’s.

So when the wind blows and the rain falls this season, we’ll be warm, dry, and hunkered down. We’ll play games with our kids, talk with our kids and maybe even learn something about them as people.  We’ll hold your children close until the sun shines in Central Florida again. After all, they don’t call us the Sunshine State for nothing.

Hunker Down Again

It is 2007.  It is summer.  The sky is blue.  The sun is shining again over central Florida and you are enjoying one of Orlando’s beautiful spa and resorts.  The kids have met Mickey and Minnie, Pluto and Donald, Shamus and every character in Universal Studios.  You know because you have had to walk every inch of every park.  As you nestle in for a much deserved evenings rest you turn on the Weather Channel and there before you are the two red flags with those ominous black squares. 

Hurricane!

Your mind races.  What do you do? 

You are miles from home.  All your worldly possessions are safe but your most precious possession, your family, is here. 

Are you prepared?  I have a disaster plan for home.  You followed the D.I.S.A.S.T.E.R. acronym. 
* You know how to Detect. 
* You know how to find out who is In charge. 
* You know how to be Safe. 
* You know how to Assess the situation
* You know how to get Support. 
* You understand the concepts of Triage and Treatment, how to decide what is most important and how to get help if I need it.
But…
* You do not know how to Evacuate.
* And you are not part of any Recovery plan here. 

You are just a tourist. 

At home you are R.E.A.D.Y. 
* You know what you Rely on. 
* You have Educated yourself and your family. 
* You have learned to Appreciate those around you and those who will help you. 
* You have Drilled, Drilled and Drilled again.
* But in the end any disaster plan comes down to You and here you are in a strange place far from everything that you need; everything that you rely on; everything that is familiar. 

The P.L.A.N. acronym is all you have left. You have to start all over again. You need a new plan.
* Take inventory of the People participating, your family. Prepare each person for the disaster. If you have small children, you may need to talk to them about what is happening, and reassure them that everything will be all right.
* If instructed to Leave, when and how will you leave (evacuate)? Where will you go and how will you get there? Will your family or fellow evacuees meet before you leave or when you arrive at your destination? The decision to leave makes communication and your contacts outside the disaster zone critically important. How will you communicate while you evacuate and after you arrive at your destination? What are you going to do if you get separated? Operate on a buddy system; no one should be left alone. When you and your family or business associates become mobile, make sure everyone knows the plan.
* Anticipate plan failures and plan for the “what ifs.” This is a chance to brainstorm. Make a list of all the possible failures. What if the phone lines go down? What if your basement floods? What if you get caught in traffic? No “what if” is too extreme to consider. The only possibility that you can’t plan for is the one you didn’t think of. Once you’ve brainstormed possible failures, you need to Adapt to each one with an alternate plan. If the phone lines go down, can you use your cell phone? If your basement floods, can you seek shelter with a neighbor or in some other nearby location?
* Make sure you account for all your Needs for seventy-two hours. Be prepared to be self-sufficient during this time. Each one of your family members must have personal identification and photos of all others in your plan, one quart (liter) of drinking water, seventy-two hours of food, seventy-two hours of clothes, two weeks of medications, two weeks of toiletries, a supply of cash (credit/debit cards can’t be verified if phone lines go down), a flashlight, a portable radio, batteries, a signal whistle, white/silver duct tape, a first aid kit, prepaid calling card, and a list of emergency phone numbers.

Take heart my traveling friend.  As a professional speaker as well as a disaster responder, I travel every week. I can tell you that you are better prepared on the road than you are at home. 

First, you are already packed.  All those worldly possessions that you could not bring with you are waiting safely at home and all the things that you need to get through a trip whether for pleasure or disaster are already in conveniently packaged in suitcases, backpacks, duffle bags and we hope not a steamer trunk.  What you need is right there. 

Second, everything else you will need is conveniently located in one place, the nearest pharmacy. Flashlights and radios are easily obtained at any of the local drugstores and even at the local attractions.  Stay away from candles.  While they are safe at home where you know the environment and you control the environment, in a hotel you might get wet and not from the hurricane but from a sprinkler system. An inexpensive first aid kit is also a quick and easy item to obtain while on the road.  Again a simply trip to the pharmacy and you have what you need. 

Don’t forget water. You might be on your own for as much as 72 hours.  Most hotels have water in the room at an obscene price but while you are at the pharmacy or drug store picking up your handcranked radio and flashlight, your toiletries and filling any medications that you may need to have transferred in from back home, do not forget to pick up a liter of water per day per person and then you are ready to go. 

Pack it all in your suitcase and give up the items that may not be so important.  Leave them for the hotel to take care of. 

Third, make contact with the hotel.  Find out what their disaster plan in.  I assure you they have one.  They are responsible for you.  They no more want the bad press or the liability of someone getting hurt than you want to be that someone who is hurt. Ask them if their staff is trained in Disaster Life Support, the “CPR” of disaster response. This training is available throughout the United States. It is offered nationally by High Alert, LLC and several major universities. Here in Florida, this training is offered by National Disaster Life Support of Florida and several state universities.

Rely on your hotel.  They will provide for you.  Our central Florida hotels provided their guests extraordinary service and comfort during the last two seasons of hurricanes.  There is no reason to believe it will be any less so now.  In fact every facility is more prepared now than they were two years ago.  There was even a major medical convention last year during Hurricane Wilma and the convention went off without a hitch.  So will your vacation. 

Finally, resist the urge to try to go home.  Do not jam the airport full.  The airport is the last place you want to try to hunker down through a hurricane.  If you can get out and get on, do so.  Check out by phone after you get home.  This way you have a hotel room to come back to.  If your hotel checkout is already preplanned and the storm is some distance away, consider leaving for home early, before the travel rush.  Whatever you do, don’t rent a car and try and drive out of the state of Florida.  Unfortunately there are only a few major highway exits from our state.  We have been credited with the largest traffic jams in world history during the last several years’ hurricane seasons.  Only Hurricane Rita misplaced us from that number one position as Houston evacuated 1.2 million people over 48 hours on the highway.  If the airport is a bad place to weather a storm, a rental car is worse. 

So enjoy your vacation.  Stay.  See the sites.  When the weather turns bad listen to what the officials tell you to do. 

We are good at this.  Trust in the people that have made the pleasurable part of your trip so great and remember in Central Florida the sun always shines again.  The sky is always blue again and we are

Volunteering in Times of Disaster - The Time is Now

Physicians come to their profession with a high sense of personal honor and a high sense of personal duty.  It is these two characteristics that spur physicians to contribute time, energy, talent and resources in times of local, regional or even national disaster. 

Whether hurricane Andrew, hurricane Charlie, hurricane Katrina, hurricane Rita, hurricane Wilma, the terrorist attacks on the Murrah federal building, the World Trade Centers or the Pentagon, whether forest fires or large automobile accidents whenever the healthcare system appears to be overwhelmed physicians and other health care professionals find themselves spurred to action.  Unfortunately they also find themselves spurred. 

It seems senseless whether the time of tremendous need physicians would be turned away from such places as Louisiana, Gulfport Mississippi, Port Charlotte, Florida, Oklahoma City, New York City and Washington D.C.  Yet a small understanding of how disaster response systems work explains this phenomenon. 

The first and most important thing that physicians and other health care providers must know is that if you are not part of a disaster plan, you are not part of a disaster response.  Even though it may seem chaotic when disaster relief professionals are working side by side with volunteers and bystanders to save lives and livelihoods, what you are actually witnessing is a wellchoreographed dance.  Long before the disaster struck plans were established on how best to respond in the event of a disaster.  It is in this planning phase that the use of volunteers whether lay persons or health care professionals is anticipated and integrated. 

Therefore if you wish to be part of a response, if you wish your valuable skills to be used to help stave off disaster and prevent catastrophe the time to volunteer is now. 

What Is The Disaster Life Cycle?

Disasters come in four phases:

• Interphase
• Adverse Event
• Response Phase
• Recovery Phase

With respect to most disasters we hope that interphase, that period between disasters, is the longest period of time.  It is during interphase that plans are reviewed, practiced, refined and practiced again.  It is during this period of time that it is most optimal for health care professionals to join the ranks of volunteers to be called upon when the disaster strikes. 

The Adverse Event is that brief moment in time when the disaster actually occurs.  When the levy actually breaks, the hurricane passes directly overhead or the bomb blasts. This discrete moment is defined by the event itself. There is little that responders can do except survive to lend aid when the event has past. Adverse Events cannot be prevented, but can be mitigated.  They will happen with little regard to what planning has or has not occurred.  Occasionally man made events can be preventive but by and large the event phase is inevitable. 

Immediately following the event begins the response phase.  It is this acute period that determines whether an event becomes a disaster.  Disaster is defined as need exceeding resource.  If during the interphase weaknesses in resource management, procedures or processes are identified such that needs never exceed resources, the event never becomes a disaster. Unfortunately, this occurs in precious few events.

It is in the response phase that defines whether a disaster goes on to be a catastrophe.  While a disaster is when needs exceed resources, a catastrophe is when needs excess all ability to respond.  When the response phase fails or the planning phase is found lacking catastrophe includes. 

Medical Reserve Corps – Your Chance to Serve

The Medical Reserve Corps (MRC) program was launched officially as a national, community-based movement in July 2002. It was formed in response to President Bush’s call for all Americans to offer volunteer service in their communities. The objective of the MRC program is to strengthen communities by establishing a system for medical and public health volunteers to offer their expertise throughout the year and during times of community need. More than just a corps of available healthcare professionals, the MRC is a full partner of the White House’s USA Freedom Corps and the Department of Homeland Security’s Citizen Corps.

Volunteerism for America’s healthcare providers has faced many obstacles in the days before the MRC. Issues of liability insurance, malpractice, worker’s compensation, injury insurance and many other serious concerns have plagued the medial volunteer effort in the United States for the past 2 decades. If insurance issues did not stand in the way of medical volunteers, licensure and accreditation issues stymied efforts to provide much needed disaster medicine services following disasters. 

The adoption of Emergency Medical Assistance Compacts (EMAC) across all 50 states and all United States territories was designed to address the majority of these concerns, but recent legislation introduced in congress shows that the EMAC’s are far from resolving the key insurance issues facing medical volunteers. Legislation is pending before both the U.S. House of Representative and the U.S. Senate to resolve the interstate worker’s compensation issue for healthcare providers who volunteer their services in time of disaster. In the near future, similar legislation will be proposed to resolve malpractice coverage issues for healthcare volunteers in disaster.

Membership in the Medical Reserve Corps resolves all these problems now and without the need for special legislation. Medical Reserve Corps volunteers are credentialed and their membership in the MRC provides Eminent Domain coverage for malpractice as well as volunteer injury coverage in the event of an on duty mishap.

Who Can Volunteer for the Medical Reserve Corps?
MRC volunteers may include medical and public health professionals including:

• Physicians
• Nurses
• Pharmacists
• Emergency medical technicians
• Dentists
• Veterinarians
• Epidemiologists
• Infectious disease specialists.

In addition, volunteer interpreters, chaplains, amateur radio operators, logistics experts, legal advisors, and others may fill key support positions.
Most MRC response and recovery assignments are secured through local and state channels. However, opportunities for MRC volunteers to assist outside their local jurisdiction do arise. During the 2004 hurricane season, MRC volunteers were asked to support the American Red Cross (ARC) response activities in Florida. This was the first deployment of MRC volunteers outside of their local jurisdiction.

During the 2005 hurricane season, the MRC strengthened its partnership with the ARC. Prior to Hurricane Katrina's landfall, the ARC disaster operations staff requested MRC support for their sheltering operations. Policies and processes were developed to identify, assign, and activate MRC members willing, able, and authorized to respond. ARC provided transportation, logistical support, and supervision for the deployed MRC members who supported ARC health services and mental health and shelter operations.
MRC members also participated in response activities outside of their local/state jurisdiction through a mission to support HHS response and recovery efforts.

The first Federal activation of MRC volunteers occurred on September 15, 2005, when HHS needed staffing support for three special needs shelters in Louisiana. Subsequent mission assignments allowed MRC members to fill positions in Community Health Centers and health clinics on cruise ships housing evacuees in Mississippi and to perform health assessments in Texas.

For more information about the Medical Reserve Corps or to become a member, please visit the MRC website at www.medicalreservecorps.gov, or contact the Medical Reserve Corps at:

MRC Program Office
Office of the U.S. Surgeon General U.S. Department of Health and Human Services
5600 Fishers Lane, Room 18C-14
Rockville, MD 20857
Tel: (301) 443-4951
Fax: (301) 480-1163
E-mail: MRCcontact@hhs.gov

The National Disaster Medical System – NDMS the Nation’s Medical Ready Force

The National Disaster Medical System (NDMS) is a federally coordinated system that augments the Nation's medical response capability.  The overall purpose of the NDMS is to establish a single integrated National medical response capability for assisting state and local authorities in dealing with the medical impacts of major peacetime disasters and to provide support to the military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflicts.

The National Response Plan utilizes the National Disaster Medical System (NDMS), as part of the Department of Health and Human Services, Office of Preparedness and Response, under Emergency Support Function #8 (ESF #8), Health and Medical Care, to support Federal agencies in the management and coordination of the federal medical response to major emergencies and federally declared disasters.

Much like Army Reservists, NDMS members are volunteers who become government employees when they are deployed and must commit to two weeks service if called.
NDMS teams are essentially designed to be a rapid-response element that deploys to disaster sites with sufficient supplies and equipment to sustain themselves and care for patients for a period of 72 hours. In mass casualty incidents, their responsibilities include triaging patients, providing austere medical care, and preparing patients for evacuation.

In other types of situations, NDMS teams may provide primary health care and/or may serve to augment local health care staffs. Should disaster victims need to be evacuated to a different locale to receive more definitive medical care, NDMS teams may also be activated to support patient packaging, transport, reception and disposition.

The units are supported by a cadre of administrative, logistical, and communications personnel whose roles are vital to successful deployment. Medical members are required to maintain appropriate certifications and licensure within their discipline. When members are activated as intermittent Federal employees, licensure and certification is recognized by all States.

In contrast to MRC members, as Federal employees, all NDMS team members are paid while serving.

NDMS medical personnel includes many disciplines from physicians to pharmacists, ARNP’s and PA’s. The NDMS teams are also replete with an experienced pool of healthcare talent with diverse medical backgrounds, ranging from RN’s and LPN’s to Nurses Assistants. Paramedics and EMT’s, with years of training and daily emergency experience are also an integral part of the teams. Respiratory therapists bring yet another medical specialty to help round out the deep medical resources of an NDMS team.

Administrative, Logistical and Communications experts round out an NDMS team and ensure that a fully self sufficient group of professionals is ready to deploy at a moment’s notice when requested by federal disaster declaration.

Most NDMS teams are also state disaster medical response teams providing reservist style medical support for their local communities as a supplement to MRC assets in an area.

For more information about the National Disaster Medical System or to become a member, please visit the NDMS website at http://www.oep-ndms.dhhs.gov.

So How Do I Participate?

First, get educated. The sad truth is that few physicians have spent even eight hours learning how to keep themselves, their families and their patients alive in the event of a disaster. Take a Basic Disaster Life Support Course or similar Healthcare First Receiver training. You are of no use to anyone if you fail to go home alive at the end of the day.

Next, get involved. Of the over 5000 hospitals in the United States, only a very small fraction have physicians on the hospital disaster planning committee. Of greater concern is that few if any of those physicians who do participate in hospital disaster planning have any formal training or certification in disaster medicine or disaster management.

Once you are educated and involved, become a resource. The 2006 Institute of Medicine reports on the state of emergency medicine in the United States soundly rebuked hospitals and healthcare in general for poor and ineffective planning, preparedness, training and practice. Throughout the evolution of healthcare disaster preparedness, physicians have been conspicuously absent from the table. It is well past time that those who have the ultimate responsibility for patient care and well being take responsibility for their role in disaster planning and preparation.

Finally once you have become educated, involved and a resource, volunteer. If you are fortunate enough to have a career which allows you the freedom to deploy for weeks at a time to locations far from home, consider becoming a member of an NDMS team. If your career needs and practice responsibilities require that you stay closer to home, join an MRC team in your area. Either way you will serve your community, your nation and your fellow man in a way not possible anywhere else in medicine.

The Other Side of The Stethescope

Dr. John Ruiz recently suffered a bit of culture shock. In his professional life Dr. Ruiz was a New York City physician on the cutting edge of detection and treatment of malignant melanoma, the most serious form of skin cancer.  He had recently flown to Florida to visit family hospitalized there and had entered the hospital unchallenged without even identifying himself when he entered the intensive care unit in Orlando’s most prominent hospital. In Florida he had seen children running up and down the hospital halls and family visiting anytime they chose. Far from strictly enforced, in Florida families challenged the authority of nurses and doctors to restrict visitation even to allow for patient recovery. Further, Dr. Ruiz had seen nurses publicly reprimanded by supervisors for enforcing visitation policies in Florida. He was seeing that the “All Hazards” preparedness and Situationally Sensitive Security to which he was accustomed to was far from universal.

A year earlier, at age 39, Dr. Ruiz suffered a heart attack while working in New York City. Like so many heart attacks in the north, his began while shoveling snow and ended on the operating table. Owing to his young age and the fact that he exercised daily, he did well and went home. His story would have ended there except Dr. Ruiz realized there was a stark difference between his reality and the state of healthcare safety in the rest of the nation.

Dr. Ruiz had always been one of those doctors who never saw the need for increased disaster preparedness for healthcare. Practicing in New York City after 9/11 it seemed to him that every hospital and healthcare facility had instituted “Situationally Sensitive Security” and “All Hazards” Disaster Plans. Despite the fact that he had family and friends involved in national preparedness he had always assumed that every facility was as ready as the ones where he worked.

Prior to his heart attack, Dr. Ruiz had never walked in the front door of the hospital. When he arrived as a patient, he entered the front door and was immediately asked for photo id. He showed his driver’s license and his wife was immediately stopped and asked for her id. For the first time he saw that no one entered the hospital without scrutiny and business at the hospital. This was such a contrast to what he now saw in Florida. Could it be that the rest of the nation was this unsafe?

Once admitted to the hospital, Dr. Ruiz learned that visiting hours were not only defined and restricted, but strictly enforced. Moreover, small children such as his own could not visit on the patient floor; he would have to be well enough to visit with them in the family spaces. What a difference from the world he now saw! How do the doctors and nurses work in such a place?

When Dr. Ruiz returned home he decided to see if his perceptions were in fact correct. He again entered through the front door. Had it not been for his hospital id, he would not have gotten in. He learned that on this day there had been an incident at another hospital and the hospital had increased the level of security. For the first time he took note of the attitude and decorum of his own patient’s visitors. In sharp contrast to what he had seen in Florida, these New York visitors listened to instructions, obeyed visitor policies and followed the instructions of the nurses.

The Safe Work Environment

What Dr. Ruiz came to realize is what preparedness experts have been saying for years; healthcare has few well prepared institutions while the majority of healthcare has chosen to ignore the threats and the most obvious solutions.

The most important change is to incorporate security and preparedness into the daily regimen of every hospital function and every hospital employee. The Situationally Sensitive Security Dr. Ruiz encountered in his hospital ensures that the hospital staff as well as all visitors are accustomed to some level of scrutiny when entering the hospital. At the lowest levels, no more that an id check occurs, but as security concerns increase, the level of scrutiny and restriction increase. This type of daily routine ensures that when increased security is required, the baseline behaviors are in place and familiar. The same philosophy is the basis of Continuous Integrated Triage and several other “All Hazards” protocols.

Workplace safety has become as much a component of “All Hazards” preparedness and patient safety initiatives. Facilities that have instituted this expanded approach to preparedness have found that patient safety initiative, employee safety programs and “All Hazards” preparedness are a natural combination. Funding once used for just one program can be applied to all three areas simultaneously thus allowing a hospital or healthcare institution to benefit in all three realms for each dollar spent.

More importantly, Dr. Ruiz inadvertently identified the reason that many preparedness experts have failed to successfully persuade hospital and healthcare decision makers to spend money on preparedness. Like Dr. Ruiz, many of these experts practice in places where most of the preparedness lessons have been not only observed, but learned and acted on. These experts are assuming that those practicing across the rest of the nation have already made the changes found in communities like New York City. The sad reality is that the vast majority of the nation has not made these changes. The only question is what will it take for the majority of hospitals and healthcare institutions to make these changes.

There is No Nursing Shortage

An interesting conversation took place recently between a 45 year nursing veteran and her family. The topic of the day was the nursing shortage and the veteran nurse surprised all by announcing, “There is no nursing shortage, there is a hospital nursing shortage.”

She went on to explain that in the home health and non-institutional nursing fields, there is an adequate supply of nurses willing to work for employers who respect and value their services. According to this nurse who had worked in hospitals for much of her career, the problem today is that hospitals and other institutions see nurses and other professionals as replaceable rather than precious.

“No nurse my age is going to work for some young supervisor who believes that you manage people by threatening them or their license. There are too many jobs out there to deal with that nonsense.”

This veteran nurse struck on the key factor in any employee shortage, the relationship between employer and employee. Two contrasting examples of the value of the employer/employee relationship demonstrate the promise and peril facing healthcare in the future.

Steeley Corporation:
One of the two largest employers in a north Florida community, Steeley Corporation had once been one of the two most reliable employers in the region. Steeley Corporation was the unrivaled market leader in their niche and pay at Steeley Corporation was second only to pay at the paper mill. Steeley Corporation management was exclusively hand picked individuals who had proven their willingness to follow any order given by the company president. Steeley Corporation management believed in an authoritarian management model and the lack of other good paying jobs ensured that employees remained despite the poor employer/employee relationships.

As the economy of the area shifted from manufacturing to tourism, Steeley Corporation began to suffer financial difficulties. Convinced that the company could be profitable again if the employees would stand with the organization, mandatory overtime and shortened breaks were instituted to “save jobs.” Employees unwilling or unable to work past the end of shift were terminated and management further retaliated by giving poor references. As the company spiraled downward, payroll checks began to bounce and managers began threatening licensed employees with “reports to the state.” Employee resignations skyrocketed and families began leaving the community. Finally, the company collapsed and disappeared overnight. In the aftermath, hundreds of employees were owed millions of dollars.

Intuit:
The early days of the “dot-com” craze were characterized by a many great ideas that would flounder for years until rediscovered by a bigger company. Small software houses would create a fantastic product, but without the funds to run a start-up business, these products would either disappear or be purchased by larger companies. Microsoft was the biggest buyer of such innovative technology. It was into this environment that a small company with an electronic checkbook was born. Intuit began in a garage and grew quickly on money borrowed by the founders.

The brightest days for Intuit were quickly followed by sudden financial darkness. As larger software developers entered the “personal finance” market, Intuit found itself in financial trouble. The company founders made the employees an extraordinary offer based on the value they placed on the employees and the relationship with each as a person. The employees were offered an opportunity to work for partial ownership of the company. Those who chose this option would become shareholders with the potential of making millions if the company survived to be a publicly traded company. Employees who could not afford to forego being paid received a guarantee that their job would be available if they chose to return when the company was again solvent.

Intuit management had cultivated caring relationships based on mutual respect with each employee. There was no “management by intimidation” at Intuit and the company was rewarded when financial disaster loomed large on their horizon. Most key company employees opted to stay, unpaid, in exchange for ownership. A small group of employees were unable to forego an income. Intuit management guaranteed their jobs and honored these guarantees when these employees returned. Over time, Intuit became the dominate personal and business finance software manufactured (Quicken and QuickBooks), even staving off a take over attempt by Microsoft.

Healthcare has become a split marketplace with institutional care (hospitals and nursing homes) separated from non-institutional care. Nurses are gravitating to non-institutional care despite lower pay because of the factors that Intuit and others have come to appreciate. Employees care more about the relationships than the money. Veteran nurses remember being respected and appreciated for long hours and selfless dedication. It was not expected or required, it was given freely and accepted graciously. Even in a “materialistic society” people want to be loved and cared for, respected and valued.

There is no nursing shortage, there is a relationship shortage.

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?

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.

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!

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.

The Greatest Show on Earth

Today something common happened.  Something that happens two or three times each weekend day in two or three cities around the United States each week. 

Today something common happened.  Something that I had never thought of before, never really noticed before. 

Today something common happened and I finally noticed.

Today I took my family to the Ringling Brothers and Barnum Bailey Circus in Orlando, Florida.  We strolled among the animal enclosures admiring Asian elephants and several variety of tigers.  We stood in awe of beautifully groomed horses and somewhat obstinate zebras.  As the animals were prepared for their part in the show the humans were herded towards the arena.  There circus performers of every type mingled with the audience giving autographs, posing for photographs, smiling and waving.  This was every day Americana. 

When the lights were dimmed and everybody found their seats was when that something happened. One of the top ringmasters in the world, Tom McFarland, officiated. Tom McFarland is a ringmaster extraordinaire.  He has the presence of the most highly paid motivational speakers in the world.  When he enters the arena, you can almost see P. T. Barnum himself standing before crowds ushering them into the greatest show on Earth.  Mr. McFarland's singing voice is a rich baritone, but when he walked out he was not singing.  He walked out humbly despite his grand and sequenced ringmaster's uniform.  Like the General he is (at least at the circus) Tom McFarland strode out in a single white spotlight.  On the huge television screen appeared, the Ringling Brothers “We Support Our Troops” ribbon. 

The audience was hushed as a humble ringmaster stood and announced that he would like to thank the troops, those serving in foreign lands, those serving here at home and those in the Orlando audience.  Mr. McFarland stated that he had served his country proudly for 12 years in the United States Army and wanted to invite one of his co-performers, a former Air Force Reservist to come forth.

Without fanfare the curtains parted and hoof beats could be heard.  Like the Calvary of old, the single rider, galloped into the arena carrying our nation's flag.  She stood erect in the stirrups as her steed halted and Mr. McFarland extended a hand. He invited the audience to rise and join him in the National Anthem. This is a scene not uncommon in American sports; a lone singer invites an audience to stand and for a moment we are all joined in support of our nation, our neighbors and our troops. 

But today was somehow different.  As the words began to ring across the arena, small children began to sing at the top of their lungs. Heard even above the amplified voice of Mr. McFarland and the brass of the band who accompanied him, little children sang: 

"Oh say can you see by the dawn's early light.  What so proudly we hail at the
twilight's last gleaming…"

In all my various professional roles, I have learned to avoid emotional displays, but tears streamed down my face as my voice joined the voices of hundreds of people saluting our nation and those 3,000 plus who have given their life for it in just the recent years. 

Today, something beautiful happened and in words of the ending song to the Ringling Brothers and Barnum Bailey’s Greatest Show on Earth, "Anything is possible."