"In the Event of an Event:" Providers Prepare for the Worst

We live in an age when many of us not only dread a terrorist attack but assume that one will occur. How do we prepare for such an attack when we don't know what to expect, when to expect it, or where it might happen?

In the medical community, the approach is to prepare our health care system by putting into place a series of steps to be initiated in case of any "mass casualty event," says Ralph M. Schapira, MD, Medical College of Wisconsin Professor and Vice Chair of Medicine. Dr. Schapira, who is Chief of Medicine at the Zablocki VA Medical Center (VA), is involved in disaster preparedness and response - which includes terrorism medicine - and recently spent time in Israel at Hebrew University/Hadassah Hospital, taking workshops and gaining experience with other physicians from all over the world that addresses the practical and clinical aspects of medical care as it relates to terrorism.

"Terrorism medicine" is not considered a distinct medical field in itself, he notes, but an interdisciplinary practice combining nursing, surgery, radiology, internal medicine, emergency medicine, social work and psychology. In addition to its clinical aspects, terror medicine comprises diverse areas including research and teaching, he explains, "All focused on responding effectively to the most likely types of man-made mass casualty events."

And while most disasters are natural (for example, the recent earthquakes in China and typhoon in Burma), all disasters - natural or man-made - challenge the medical system, he says.

What Types of Incidents?
Although we can't predict the exact nature of future terrorism, we do have some idea based on recent history. Dr. Schapira says: "The terror events most likely to occur are those using conventional explosions, particularly those in confined locations; radiological dispersion devices - so-called 'dirty bombs' that use conventional detonation to spread radioactive pharmaceuticals - and bioterrorism, in which organisms are dispersed into the air." Anthrax and smallpox are considered the probable agents for this type of attack.

Due to the number of terrorist attacks that have already occurred around the world, many doctors and other health care professionals already know how to treat blast injuries and related traumas. "But a conventional explosion will be quite different than dealing with a radiological dispersion device," Dr. Schapira says. "Each type of terrorism has its own unique kinds of injuries and response issues. Based on the type of event, on-site intervention might be different."

For example, when a medical team arrives at the site of a conventional explosion, the initial goal is triage - assessing the severity of the injuries, stabilizing patients who can be saved, and getting them to the appropriate hospital.

"The response will be quite different in a radiological attack, where you need to decontaminate people and protect the responding health care workers before you even get them to the hospital," says Dr. Schapira. In a bioterror event, we'd need isolation and social distancing because you don't want people to infect each other. In that case, hospitals would need to be set up for isolation."

Health Care Surge
Even though doctors and other health care staff can learn to deal with injuries, other aspects of disaster response are beyond their control. A natural disaster or a terrorism event could bring a sudden influx of hundreds or even thousands of patients to a few hospitals near the site of the occurrence, quickly overwhelming the health care system.

"The federal government requires every hospital to have a disaster plan," Dr. Schapira notes. "Every hospital, along with its medical school partner and professional health care staff - doctors, nurses, psychologists, administrative personnel - must be educated to know what to do immediately to meet the needs of the affected population."

"The Federal Emergency Management Agency (FEMA), as part of the Department of Homeland Security, addresses every kind of potential event. FEMA works with the state, the state then works with the counties and cities, the health, fire, and police departments."

"Health care surge is an important issue. Even on a good day, hospitals have diversions from their emergency room to others and acute-care beds are in short supply. Every hospital has its own Incident Command system and a plan to deal with a surge of patients."

"We need the personnel, the supplies, the equipment to take care of the people seeking medical care. The basic idea is that elective procedures are cancelled, and patients who don't absolutely need to be in the hospital are discharged or transported to other communities where there are hospital beds. There's a sharing of resources. The VA, as the country's largest public health care system, has the authority to support the community hospitals with drugs, equipment and supplies in the event of a disaster."

Dr. Schapira mentions other issues as well. "Staffing of hospitals is also a very important issue in the event of a disaster," he says. "In the event of a flu pandemic (avian flu is the most cited possibility), some employees will be sick, and some won't want to come to work as they might be taking care of family or fear for their own health. How do you mandate that people work? What are the expectations of health care workers in such an event?"

"Out of the ER and into Specialty Areas"
Once disaster victims have arrived at the hospital, secondary triage takes place, according to Dr. Schapira. "Hospital staff decide where to send each patient depending on the type of injuries. Do they need to go to intensive care, radiology, the trauma surgery operating room? The emergency room can't be a long-term holding area. And the families of patients must be kept informed by the hospital staff."

The routine administrative processes in the emergency room such as insurance tracking will have to be streamlined or eliminated, Dr. Schapira says. "Patients have to be out of the ER as soon as possible and into specialty areas. Non-emergency patients go home; people who aren't life-and-death won't be seen promptly. Only the sickest people who need the most advanced care would stay."

Post-traumatic stress disorder (PTSD) must be addressed promptly. "In Israel, health care professional teams are immediately dispatched at the time of the disaster - social workers, psychologists, mental health nurses - to try to prevent PTSD, not only for the clinical reasons, but the effects of PTSD have long-lasting economic and social implications," Dr. Schapira says.

After the Event
The potential for large numbers of casualties and an immediate surge of patients might stress and limit the ability of emergency medical services, hospitals, and other health care facilities to care for the influx of critically injured victims.

Even after the immediate crisis has resolved, there will still be tasks waiting for completion. Patients who have been stabilized will need to be transported to community hospitals and healthcare staff will start caring for a next wave of patients. People who weren't injured as badly will begin to come in from the community for treatment. Hospital staff will have to rotate so some can go home. Supplies will need to be replenished. Plans will have to be put in place immediately for the next potential event.

According to the Centers for Disease Control (CDC), "The ongoing and increasing threat of terrorist activities, combined with documented evidence of decreasing emergency care capacity, requires preemptive action. Health care and public health systems, individual hospitals and health care personnel must collaborate to ensure that strategies are in place to effectively receive, evaluate, and treat large numbers of injured patients; to rapidly identify and stabilize the most critically injured; to evaluate these efforts; and to strategically plan for future incidents."

The United States has a basic, functional capability to respond to the surge of patients following a terrorist event such as a bombing; however, several critical areas must be addressed for effective surge capacity to occur.

The time to plan is now, Dr. Schapira says. "Hospitals and health care professionals need a whole new set of resources and approaches."

Eileen Early, BA, BSN, RN
HealthLink Editor

Dr. Ralph Schapira practices at the Zablocki VA Medical Center and at Froedtert & the Medical College of Wisconsin.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.