Well actually I never did stop worrying, but that was then, this is now. Our current circumstances of poorly characterized enemies threatening poorly characterized mischief have heightened everyone’s anxiety. While, in January 2001 the JCAHO published updated requirements for emergency preparedness, since September 11 our hospitals have been asked to further improve their preparedness for emergency response to the use of weapons of mass destruction: chemical, biological, radiological, nuclear and explosive (CBRNE); a pretty horrible litany of potential death and destruction to our friends, families and communities.
Last autumn’s anthrax bio-terror and the 1995 experience of the Tokyo subway Sarin vapor attacks both remind us that preparation and effective medical response is possible for some of these events and that both community and hospital preparation can reduce casualties and mitigate the harm. Perhaps the signal example, of emergency physicians at Inova Fairfax successfully diagnosing anthrax and saving a postal employee, showed the effectiveness of the prepared mind in recognizing anthrax in an unexpected patient category and thereby saving at least one life. Those who would argue that no preparation is possible for any of these horrors would have to explain such a result.
So, how should one proceed? Yes, we in New York are especially pre-occupied, but every hospital, particularly those JCAHO accredited should be updating emergency preparedness plans and training staff to the hospital emergency incident command system. Bioterrorism will pose a particularly grave challenge to the hospitals as it is far more likely to manifest insidiously, than through public announcement as with the anthrax attack. The JCAHO consulting organization, Joint Commission Resources published a useful guide in December 2001 which can still be read on-line at http://www.jcrinc.com/subscribers/perspectives.asp?durki=1122.
Yet in this era of strained resources how to address these recommendations? Where are the people, the money and time to come from? Well, I’ve no easy answer, but if as is likely you’ve been charged with any of these responsibilities, make it clear to your leaders that you will not be able to meet the mandate without additional resources. Completing the paperwork and creating a manual can be accomplished by anyone given enough time, but a manual on the shelf will not truly establish the preparedness that may make a difference for your loved ones, organization and community. Training and alliances with community-based organizations are critical steps in this preparedness.
Training your staff in the following areas is the step that moves your program into reality. The JCAHO identifies six necessary areas for training: emergency identification, triage, decontamination, treatment, media and crowd control and stress management.
Regardless of resources and likelihood of seeing ED patient’s needing decontamination, addressing emergency identification is a process of identifying potential threats, planning for and training for the response to those threats. The “on the job training” provided through mailings, emails, websites and more to clinical staff during the anthrax bio-terror episode of last fall is an example of such training. Public health departments trained clinical staff in recognition of both the clinical syndrome and populations most at risk as anthrax was spreading. Early recognition and diagnosis clearly saved some lives.
Should a more widespread bio-terror episode occur, even non-urban emergency departments would see patients with illness or at least patients fearful of having contracted the disease spread by the attack. Our emergency departments are open to the community. It is in the nature of our work as a door to our community. Yet, planning for and training in media and crowd control should be an early effort since it helps assure the security of the facility and the safety of the staff. (As an aside, it has been said that in the event of a widespread bio-terror attack, it is not even clear that sufficient staff would come to work. Facility security would clearly play a role in reassuring staff of their safety at the hospital.) The JCAHO suggest that, “selected staff should be educated on how to handle a large influx of other people into a facility in the wake of an emergency. Large numbers of people present security problems and impediments to smooth operation if not handled properly. Included in this group are members of the media, families and friends of possible victims, and volunteers wanting to help.” This is fine advice, but if the alert is broadcast in the evening, marshalling the staff to direct the large influx of people away from the ED won’t be easy unless you have a call list prepared. The police and other public safety agencies are likely already over-committed; so anticipate that your initial response will in fact be your initial response, with little if any support from the larger community until hours have passed.
At the May 2002 Society for Academic Emergency Medicine Annual Meeting in St. Louis, more than three hours of program focusing on “the age of terrorism” and the EM response (The schedule and handouts are available) presented a sobering picture, particularly with regards to response from the outside. All speakers agreed that local communities must be self-reliant for at least the first 24 hours following any terror event. Many of us feel we have excellent working relationships with local police, fire and ambulance services, but all of these professional organizations will themselves be stressed in the event of terror attack. Do you know all of your local organizations? Is there a volunteer group you’ve not visited or invited to your ED that could be of service? Even in New York City such organizations exist and Hatzolah in our part of Brooklyn and the Bedford-Stuyvesant Volunteer Ambulance Service more to the north render service to their community and delight in a strong ongoing relationship with my hospital and others in their service area.
These community-based organizations would be a welcome ally in managing the many of challenges inherent to responding to a terror attack with a weapon of mass destruction. Actively engaging your local volunteer agencies and properly training your staff are critical steps for your hospital’s emergency preparedness.
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