Friday, December 14, 2001

After the Disaster: Denial, Cognitive Dissonance and Preparing for the Next Time.

I had planned to write last month about the experience of "going live" with our electronic medical record system. We switched it on at 7:00 a.m. eastern time on September 11 and switched it off shortly after 10:00 a.m. and reverted to paper. Lisa Hoffman, Editor of EMN kindly allowed me to skip writing the column last month. Our small loss of time pales into insignificance next to the human tragedy and now wartime circumstances we find ourselves experiencing.

How well did we do at Maimonides, 7.5 ground miles and a 12-minute drive from what we now call "Ground Zero"? Given the small number of injured, mostly themselves rescuers, for whom we cared, it would have been difficult to have performed poorly. Yet, as I write this piece, newspapers and airwaves are full of alerts about Anthrax and the count of those exposed or sickened by the disease, while still in single digits, has grown daily. So too has the stress upon our ED staff -two nights ago I was paged at 3:45 a.m. to advise me that the ED had been "contaminated."

Perhaps the most important lesson I can offer from our experience of September 11 is that activating the disaster plan doesn't truly activate your plan-rather, the experience of caring for your first patient is the true activator. "Cognitive dissonance" is the term used by psychologists for describing the confusion and "denial" we experience in the abrupt wrenching from "business as usual" to attack and disaster management. Having experienced cognitive dissonance on September 11 and subsequently reflecting upon that experience has caused me some personal discomfort and simultaneously appreciation for our team.

It took me 60-90 minutes to recognize that the disaster meant shutting down the "go-live." Fortunately, it didn't take others as long. This wasn't merely because of my psychic investment in the project; rather it was cognitive dissonance and the consequent inability to actually incorporate what I was seeing in front of me. Because the attack occurred at prime work hours, our Vice-Chairman and Medical Director, Dan Murphy, who chairs the disaster committee and had been lead author of our hospital disaster plan was on-site and led our efforts. He knew that all non-essential activities--the very definition of a "go-live"--must stop. His experience at running drills and critiquing them gave him the assurance for necessary action. Practice made it easier--though still not easy--to change gears and move to disaster mode.

Our staff was and still is fearful. Less so as we train with personal protective equipment and review plans for responding to chemical-biological-radiological events. Sharing copies, in the "pit," of the actual faxes received from the New York City Department of Health containing authoritative recommendations for surveillance, patient evaluation and treatment may be helpful for some. Confidential conversations among staff members are reassuring for others. Strong support from senior management through regularly scheduled "Town Hall Meetings" and visits to patient units, including the ED also help. Yes, the passage of time helps, but I'm convinced that establishing a common frame of reference through focused training supported by authoritative sources gives a better result both for the individual and the organization than simply allowing people "time to heal."

In the aftermath of the collapse of the World Trade Center towers many individuals spoke about their desire "to help--to do something." Capitalizing on this helping impulse by improving your preparedness gives proof to your staff of their value to the organization as both individuals and caregivers, while simultaneously reassuring them about their personal safety and their capabilities as responders.

I also learned patience on September 11. In the early hours, even when I was ready for action--delayed though that may have been--not everyone around me was as prepared as I was. Other parts of the hospital were less willing to respond at first, many comparing the events of the day to the experience of responding for the 1993 World Trade Center bombing where very few patients arrived, yet all routine was disrupted. Our COO asked me to join the senior management meeting she convened (our CEO was on vacation in Europe) and I spoke directly to the needs of the hospital's disaster plan. Initial reticence to "changing gears" was overcome through discussion as all came to a group realization of the extraordinary, human tragedy unfolding. To their credit, administrators listened, changed their minds and acted appropriately and necessarily on behalf of the hospital and the community-doing so not precipitously, yet still timely. My leaders and colleagues did the right thing.

All of us now have been bloodied; our brains will shift gear more quickly the next time--"denial/cognitive dissonance" will be less likely. A delay in incorporating the consequences of terrorism won't be a feature of a response this week. However, as the days pass it is likely that the alertness you and we have developed subsequent to September 11 will diminish. Next time we may not have the luxury of more than an hour before the first patient arrives yet activating our disaster plan must help us "activate our brain and behavior" more rapidly than occurred on September 11.

I think that what helped the staff in the ED gain the proper mindset was seeing Dan Murphy standing at the corner of the nurses' station with the sight-line into the ambulance overhang and triage station with the only red binder in our ED--our disaster plan--open in front of him on the counter. All came to him; he did not roam. Locking down the ED also sent a message. We transferred ambulance patients onto our stretchers in the ambulance bay and did not permit EMS providers into the ED. Only our staff and police officers with badge and weapon were permitted into the ED. Hospital staff that did not have an ID badge coded for ED disaster status (a red border around their picture) were stopped by hospital security and turned away.

Responding to disasters is what we do in emergency medicine, one patient or many it's the career we've chosen, yet most of us are not trained for the battlefield itself. Acting effectively when cognitive dissonance and fear for our loved ones and for ourselves slows our response and requires new and additional preparation we are just undertaking, and we must.

This column is dedicated to the memory of my first cousin, Barbara Ellen Pollard Silverman, 40, a life-long advocate for social justice who was manager since 1992 of the Ronald McDonald House of Washington and at her death was grants coordinator for Ronald McDonald House Charities of Greater Washington. She died of liver failure September 15 awaiting a liver for transplant.

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