Maurice A. Ramirez, DO, CNS, CMRO

Dreamer is Truely Dreaming

Dreamer in the comment to my March 6th post references two deceptively attractive solutions to the severe shortage of ventilators world-wide.

The first is an "open source" ventilator design to be built ad hoc and used for "over flow" ventilator capacity. Dreamer posted the concept on a blog (http://panvent.blogspot.com/2007/02/pandemic-ventilator-contingency.html) and advocates for its use. This is no better a solution than using transport ventilators for pandemic flu patients or having no ventilators at all. The problem is airway pressures. Transport ventilators and ventilators without feedback pressure control cause significant and fatal lung damage after excessive periods of use. Pandemic flu patients will already suffer high ARDS which is associated with high airway pressures. The idea of ventilating patients with ventilators that cannot regulate the airway pressures or the pressure curves is simplistic at best and irresponsible at worst. Since the end result of excessive airway pressures is the same as not ventilating the patient at all, it is a waste of valuable resources to attempt this solution.

Dreamer also references a plan to ventilate multiple patients with a single ventilator using specialized ventilator circuits. This concept was published in the prestigious Journal of the Society of Academic Emergency Medicine. Unfortunately this plan relies on a fact not yet in evidence, namely that the airway pressures and ventilatory volumes for each patient on a common circuit can be matched. There is also the aesthetics of this proposal, I doubt may patients or families will agree to a shared ventilator.

Unfortunately, Dreamer is dreaming of a solution that is not viable in the healthcare market of 2007.

Sorry for the Long Silence

Almost a proof of my admonishment to client hospitals that no plan is resistant to failure, my computer redundancy plan suffered a catastrophic failure twice in the past several weeks.

First, my primary computer suffered an operating system corruption that resulted in an almost complete loss of data. This occurred in mid January, but I had few worries as I maintain a second laptop with a full mirror image of the data on my primary computer. I never expected to lose more than one or two day's data. When my primary machine failed, I booted up the back-up and was horrified to discover that despite regular synchronization, only the last complete back-up was intact. I had lost 2 full weeks of data.

Despite this set back I resumed daily business with and reconstructed as much lost data as possible, instituting daily back-ups until the primary computer was repaired.

Steinbeck once wrote: "The Best Laid Plans of Mice and Men"

For me this would be obvious when the back-up computer began to fail in the same way that the first had done. Despite multiple negative virus scans, I began to think my computers had suffered the digital equivalent of the avian flu. Next came the feared "Blue Screen of Death."

I was computerless for a week, hence the failure to contribute regularly to this webspace. Once my primary computer returned, I restored the last data back-up only to discover that the system problem had corrupted every back-up since the 31st of December!

I am back, lacking some valuable data, but ready to write new articles and assist in your preparedness. Hopefully my next computer disaster plan works out better.

Remember, no plan is perfect.

The “Microbe Mule”

Paul Purcell paints a terrifying picture of the newest potential “dirty bomb” in his recent posting to www.disaster-blog.com (http://www.disaster-blog.com/2007/01/suicide_bombers.html). 

His concept is not wholly new although the application that he describes represents a concerning variation on an old Hollywood theme.  Movies over the past decade and books over the past two decades have described terrorist events ranging from the transportation of contaminated corpses to the kidnapping of a Ebola infected nun to create terrorist weapons out of human bodies. 

Mr. Purcell takes this concept to the next level.  Disaster medicine specialist such as myself have long been concerned about the possibility of hepatitis, HIV, and other infectious diseases being spread via the exploding remains of suicide bombers and their victims.  Even in the area of accidental blast injury area cleanup and contaminated bystanders has been a great concern.

Mr. Purcell’s article only confirms the concerns of such forensic greats as Cyril Wecht and terrorism response agencies such as the Israeli Musad. 

The reality is that the “microbe mule” is in all likelihood the terrorist combatant of the future.  The Department of Homeland Security and before it the Centers for Disease Control were concerned that terrorists infected with small pox would simply visit our shores and contaminate large groups in the population.  Unfortunately active disease is now no longer a requirement.  Simply infectivity will do. 

Paul Purcell has again outdone himself both with his understanding of the terrorist mind and the limitless bounds of the human imagination.

Will Social Isolation Work?

A comment posed by Peter in response to my December 17, 2006 post titled: "Setting The Record Straight on Pandemic Preparedness" opens the question of the effectiveness of Quarantine, Isolation and Social Distancing.

Unfortunately, the terms "Quarantine," Isolation" and Social Distancing" are often used interchangeably. This leads to significant confusion when trying to predict the efficacy of various pandemic plans. Further, both "Isolation" and "Quarantine" had ominous terms. To engage in an intelligent discussion, we must begin with a common vocabulary:

Quarantine - The separation of a potentially exposed group from a known unexposed population.

Isolation - The separation of a known ill group from a known healthy population.

Social Distancing - The process of maintaining both physical distance and physical barriers to decrease the probability of spreading a disease.

Examples of each of these are common in history.

Quarantine has been attempted since time immemorial. The most extreme example (and the one Hollywood likes best) is the method used during the second Black Death (plaque) in Europe. In this method of quarantine, an army would surround a village. Anyone attempting to leave would be killed. When most or all of the villagers were dead of the disease, the village would be burned. Unfortunately, the plaque carrying rats would escape and the disease spread.

Isolation is a daily event in hospitals around the world because is it is easy. A person who is sick is easy to identify among a group of well people. This  sick individual (or group) can thus be separated from the health group in an attempt to decrease spread of the disease. The problem with isolation is that many diseases (including pandemic flu) ware contagious before the infected individual shows symptoms. This makes identification far more difficult. Further, isolation is equipment and staff intensive owing to the need to treat the sick patient without contaminating staff or others outside the isolation area.

Social Distancing is the method used in Singapore and Toronto to slow and eventually stop the spread of SARS. This method worked for several reasons. First and foremost, the healthcare systems in both countries allowed for enforcement of Social Distancing of healthcare workers at home as well as at work. This meant that healthcare personnel maintained their N95 masks and a minimum 2 meter separation from everyone even when off duty. The penalty for violation of this public health rule was sanction or imprisonment. In the words of one Toronto nurse,

" Imagine smelling your own stale breath as you tried to sleep alone in a separate room with your N95 mask still in place. My child was 5 years old... do you know how often you hold your 5 year old? I couldn't hold my child for that entire time."

Peter points out a valuable piece of planning information, Social Distancing (which he referred to as isolation) worked in 1918 and in 2004. The conference video Peter recommends proposes solutions not unlike those proposed by panels and committees on which I have proudly served. The point missed by all of these individuals, committees and expert panels; the point I missed until it was illustrated for me by James Shultz, Ph.D. at the University of Miami's Disaster and Extreme Event Preparedness Center aka DEEP Center (http://www.deep.med.miami.edu/). Dr. Shultz points out that Quarantine, Isolation and Social Distancing are "Separation by Prescription" and thus have significant psychological and social impact.

Separating people from their support systems, both personal and societal results in a loss of resilience. Resilience is the one tool we each have to turn a disaster around; it is through resilience that we ensure our resources exceed our needs.

There is a famous saying that was born in the early 1900's, "Don't throw the baby out with the bath water." In my original post I urged common sense in our approach to pandemic planning. I recommended against stockpiling medication and food. I recommended for good personal and public hygiene. Now I urge that we not throw out the baby of resilience with the bath water of preparation.

My original post: http://www.disaster-blog.com/2006/12/setting_the_rec.html

Peter's comment: http://www.disaster-blog.com/2006/12/setting_the_rec.html#comment-26952586

What a Great Idea!!!

Kevin Freking, of the Associated Press reports on the first major corporate sponsorship of portable electronic medical records. Applied Materials, BP America, Inc., Intel Corp., Pitney Bowes and Wal-Mart will enroll employees in a central database to maintain health records in an effort to eliminate duplication, omission and error.

This is a concept that is supported by President Bush and the National Academy of Science - Institute of Medicine. Not only with the system collect medical record information and reports to a central repository, but individuals will be able to provide personal and family information to augment the record. This type of system is envisioned by the Whitehouse as a national standard by 2014 and is a requirement for implementation by medial providers by 2008. The problem with this on-line repository database is that it is internet dependent and while accessible from any internet portal, it is not truly portable. You cannot carry it self contained in your hand.

But, what if there were a way to carry a copy of such vital data in the palm of your and, or in a watch, wristband, pocket card, etc.?

W. David Stephenson of Stevenson Strategies made a fantastic suggestion in his September 26, 2006 blog entry. He suggested that people carry their medical records on secure U3 enabled USB drives. Such devices are already imbedded in credit card sized wallet drives, wrist watches, necklaces, key rings, pens and every manner of business sundry.

As an Emergency Room physician, I'm not sure I would look for a USB drive in the pockets of a patient in the emergency room, but a USB drive watch, wrist and, pendent or wallet card would be useful. What a wonderful merger of form and function that could now save your life! David ends with the statement:

"This sounds like a real win-win technology that hits my sweet spot: convenient and usable every day (no more lugging laptops home from the office!), and, in a disaster, a literal and figurative lifesaver, because you'd not only have your medical records in hand, but also all of your critical applications and business files as well. It wouldn't be ideal, but, in a worst case, you'd still be able to do limited business if you had access to a shared computer in a shelter -- and, for emergency workers themselves, smart drives are going to be essential supplies."

Currently there are 8 companies selling a solution similar to what David is suggesting. Unfortunately, none of these take advantage of the U3 technology David describes. One of the 8 companies is planning a U3 version in 6 months. Although all 8 companies claim password protection for the user interface, only one of the systems uses encryption to safeguard the data files from direct access by other software.

Also needed is the ability to ensure that the patient does not deliberately or accidentally alter the records, especially if they record includes notes from medical professionals as several of the systems do. Another nice feature would be the ability to synchronize with the electronic medical record (EMR) at the doctor's office. Here, the existence of the type of central repository described in Kevin's report serves not only as a primary data source, but an ideal back-up for the USB data.

There are a few problems that are still to be addressed including ISO-9000/CMS-EMR standards compatibility and linking to the coming central medical records repository, but one company is already cracking that nut too.

All in all, Kevin & David propose a great idea!

Kevin's article can be read at: http://www.wilmingtonstar.com/apps/pbcs.dll/article?AID=/20061207/NEWS/612070357&SearchID=73265339316299

David's complete blog entry can be read through the permalink: http://stephensonstrategies.com/categories/profitableCorporatePreparedness/2006/09/26.html#a9