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Health Care Leaders

In the years following September 11, 2001, communities around the world have scrambled to address the threat of terrorism and protect themselves from its occurrence. Public healthcare in the United States is slowly gaining recognition as a leader in disaster response, largely due to its focus on prevention as the cornerstone of its emergency planning systems. However, a lack of nationwide standards, adequate resources, and community integration have hampered an otherwise promising response system.

Terrorism and Disaster Management is a collection of 13 essays, compiled by editor and medical consultant K. Joanne McGlown. Each essay discusses one aspect of emergency preparedness, planning, or action. With the help of experts from the medical, legal, and political worlds, the book provides a comprehensive look at U.S. emergency management — a field still in the early stages of development.

Preparing Your Healthcare Facility for Disaster (K. Joanne McGlown)

Since 1950, disasters have been occurring more frequently, affecting more people, and creating more economic costs. Because no healthcare facility is immune to these disasters, planning and preparing for their occurrence is of critical importance. In particular, hospitals in the United States have been shown to be woefully unprepared for terrorist attacks. Though the probability of an attack in one community is relatively low, the probability nationwide is high. Every hospital in the U.S. must take the threat of terrorism seriously, and create specific plans to achieve the highest possible level of preparedness.

Although the participation of the external community is vital to disaster preparation, the hospital must first be internally integrated to function effectively in extreme conditions. In the event of a disaster, communication lines are the first to become overwhelmed. Hospitals should make it a high priority to secure redundant phone systems, dedicated high-speed internet connections, and broadcast fax capabilities. Drills and testing are also vitally important tools; although staff training for biological or chemical attacks is widespread, the use of drills in U.S. hospitals is far less common. Drills allow the hospital to identify weaknesses in its disaster plans, and to make the necessary corrective actions. Hospitals must also be prepared for the psychological damage caused by terrorist attacks. For every one physical casualty caused by a disaster, there are at least four psychological victims. The hospital must consider those who lost loved ones, homes, businesses, or jobs, as well as rescue workers and witnesses.

The U.S. General Accounting Office has identified the nine entities which must be included to form an effective disaster plan:

  1. Emergency medical services

  2. Fire services

  3. Hazardous materials teams

  4. Law enforcement

  5. Hospitals

  6. Laboratories

  7. State and local government agencies

  8. Public and private utilities

  9. Public health

As of 2003, only 40 percent of hospitals reported contacting all nine entities in the development stages of their plans. Despite this alarming statistic, U.S. emergency management systems are now admired worldwide, due in large part to their focus on prevention as the cornerstone of disaster planning.

Eventually, the hospital must begin to form partnerships with members of its local communities. Until recently, most hospitals have done this with informal, “handshake” agreements. However, in the event of a disaster, vital services will first go to clients with formal, written agreements. This simple precaution can prove invaluable when lives are at stake. Partnerships between state governments are equally important, and similar measures should be taken to ensure that all obligations are fulfilled.

The New Threat: Weapons of Mass Effect (Jerry L. Mothershead)

Though the phrase “weapons of mass destruction” has been commonly used throughout the last decade, “weapons of mass effect” (WME) may be a more fitting term, due to the devastating psychological damage caused by such devices. There are five basic categories of WME:

  1. Chemicals

  2. Biological pathogens and toxins

  3. Radioactive material

  4. Nuclear devices

  5. Nonconventional high-yield explosives.

Chemical weapons tend to fall into three categories. The first is military chemical weapons, which include nerve agents and vesicants. Nerve agents are structurally similar to industrial insecticides. They cause injury and death by interfering with function of the nervous system. Vesicants, derived from compounds used in chemotherapy, cause painful death by means of destroying the proteins in cells. Second, dual-use chemical weapons are industrial chemicals adapted for military purposes. These include choking agents such as chlorine gas and phosgene, as well as blood agents such as cyanide. Choking agents were notorious in World War I, while blood agents were widely used in German concentration camps during World War II. Finally, toxic industrial chemicals are not developed for military use, but they produce deadly effects and are extremely dangerous in the hands of terrorist organizations.

Biological weapons fall under one of two categories: pathogens and toxins. Pathogens are bacteria or viruses with the potential to cause serious illness or death in humans. Though there are thousands of pathogens in existence, only about two dozen pose a significant risk to the public. Contrary to popular belief, the use of pathogens as a weapon would require enormous education, skill, and resources. Toxins, on the other hand, are more dangerous. Toxins are chemicals produced by living organisms; at present, no antidotes exist for any known toxins.

Radiological weapons use radioactive materials to induce sickness and death in their victims. When it comes to these types of weapons, experts are most concerned about radiological dispersal devices, or RDDs. An RDD is a conventional explosive which is laced with radioactive material. Though survivors of such an explosion would probably not suffer acute radiation sickness, the decontamination of the targeted area would be a long and expensive process.

Nuclear devices are, in fact, large-scale RDDs, but they deserve special mention. Even small nuclear devices can damage very wide areas, and radioactive dust can be spread for hundreds of miles, especially with the help of the wind. Experts assert that terrorists would probably not use such devices due to the difficulty in acquiring them. Furthermore, nuclear weapons are relatively easy to detect, compared to biological or chemical weapons.

Of the five types of WMEs, High-yield explosives are the least physically dangerous, yet they remain the weapons of choice for terrorists around the world. They produce small explosions which pose little threat to rescue workers or surrounding areas, but the psychological effects are devastating. High-yield explosives are easy to produce, and the resulting explosions are visible and terrifying. Frequent, small-scale attacks often produce long-term psychological effects, even among those not directly affected in any way.

Healthcare facilities must be especially prepared for terrorist attacks of all types. Biological and chemical attacks are particularly dangerous, since their effects are slow to appear, and a single victim could contaminate an entire ward. Because of this danger, hospitals must create specific plans regarding decontamination, staff protection, and patient treatment. Each of these topics is covered in detail in the later essays of the book.

Disaster Planning for Terrorism (Jerry L. Mothershead)

Healthcare systems as a whole are ill-prepared to handle any WME attack, even one of moderate size. An important first step in planning for these events is risk assessment. Risk is the potential for loss or failure to perform, and is the function of three variables:

  1. Probability of an event occurring

  2. Consequences of its occurrence

  3. Psychological, economic, or other effects of its occurrence

Risk can be assessed quantitatively or qualitatively. Quantitative assessment uses numerical values to rank hazards based on formulae. However, the data used in this type of assessment may be inaccurate or unreliable, and the low probabilities of an event can lead to complacency. Qualitative assessment is more useful and easier to perform. This type of assessment focuses on the identification of threats (situations that can go wrong) andvulnerabilities (susceptibilities of available resources).

The next step in planning for terrorism is the implementation of mitigation activities, or controls. Controls are the countermeasures associated with a given vulnerability. The four basic controls are:

  1. Deterrent controls – Reduce the likelihood of a deliberate attack by making a facility a less desirable target

  2. Preventive controls – Protect vulnerabilities by rendering an attack unsuccessful

  3. Corrective controls – Reduce the effect of an attack

  4. Detective controls – Discover attacks and trigger preventive or corrective controls.

When a hospital is sufficiently prepared for an attack, the planning stages can begin. An effective Emergency Operations Plan (EOP) must address the following 15 issues:

  1. Notification – Make the appropriate staff aware of the details of a disaster

  2. Decontamination – Decide who will perform decontamination, where it is to be performed, how wastewater will be disposed of, and other issues

  3. Facility physical protection – Make sure the facility is safe from contaminated individuals

  4. Evacuation – Decide when evacuation is necessary, and how it will be carried out

  5. Shelter-in-place – When evacuation is not possible, decide how to adapt the facility for various disaster situations

  6. Detection – Make sure chemical and biological agents are discovered as soon as possible

  7. Identification – Make sure chemical and biological agents are identified so that proper treatment can be prescribed

  8. Triage – Set up an effective system of prioritizing patients according to their symptoms

  9. Treatment options – Make staff aware of the various treatments and antidotes which may be applied to victims of WME attacks

  10. Surge capacity – Devise a plan to expand the hospital’s patient capacity in a disaster scenario

  11. Prophylaxis – Determine who will receive prophylaxis and at what priority, keeping in mind that unprotected staff may not agree to work

  12. Fatality management – Secure alternate sites to deal with large numbers of dead

  13. Counseling services – Make sure the large numbers of psychological victims are properly treated

  14. Integration – Form working partnerships with local or regional response organizations

  15. Law enforcement and forensics – Form working partnerships with law enforcement and investigators

Recovery is the final step in an effective emergency management system. Recovery can be divided into two categories: short-term and long-term. Short term recovery includes the restoration of power, water, and communications, the clearing of debris, the repair of public and private buildings, traffic issues, and more. Long-term recovery includes major reconstruction programs, the demolition of damaged buildings, economic issues, and political fallout. In general, recovery planning can be accomplished by using the worst-case scenario as a starting point.

It is critical that healthcare providers protect themselves to avoid becoming victims of secondary contamination. This can happen through direct contact with a substance, inhalation, ingestion, or contact with liquid droplets or aerosols. The most effective defense against contamination is personal protective equipment, or PPE.

PPE comes in four “levels” of protection, labeled A, B, C, and D. Level A is a total encapsulating, chemical-resistant ensemble, with self-contained breathing apparatus, gloves, and boots. Level B also contains a breathing apparatus, but is not airtight and provides less protection against vapors. Level C uses a filtering mask rather than oxygen tank, and only provides protection against splash damage from liquids. Level D is merely a work uniform with latex gloves and possible eye or mouth protection. It is important to note that breathing devices are not designed for workers without adequate training; a significant number of untrained individuals suffocate each year through improper use of such devices.

Decontamination is integral to the protection of a hospital and its staff in a disaster scenario. Gross decontamination involves showering clothed patients with copious amounts of water; this is most often conducted by a HAZMAT team with a fire house. Secondary contamination employs soap-like decontamination solutions as an extra precaution. Mass decontamination is gross decontamination applied to large groups of people; this is most appropriate in the case of a large-scale chemical or biological attack. It is important to correctly assess whether decontamination is necessary, and what type of decontamination should be used. It is also important that each healthcare worker be trained to decontaminate their PPE.

Finally, it may be necessary to evacuate the facility if there is a risk of extreme secondary contamination. To decide whether to evacuate or carry out shelter-in-place procedures, the following questions should be asked:

  1. Will shelter-in-place provide sufficient protection?

  2. Is there enough time to evacuate?

If the answer to only one of these questions is “yes,” the appropriate response has been determined. If the answer to both is “yes,” either option is satisfactory; the decision should be based on other variables, such as cost or patient disruption. If the answer to both questions is “no,” the hospital faces a serious problem and may have to resort to extraordinary measures. It is important to note that hospital evacuation is a complex and time-consuming process. Hospitals with high staff-to-patient ratios are able to evacuate faster, but other factors, such as the nature of the threat, greatly contribute to the speed of evacuation.

In disaster scenarios, there are several groups of civilians who may need extra assistance or special consideration. These “special populations” include, but are not limited to: children, the elderly, people with disabilities, people with mental illnesses, and non-English-speaking people. These groups are especially vulnerable to chemical, biological, or explosive terrorist attacks.

Children should be the first priority in planning for special population needs. Healthcare workers must be trained to adjust proper dosages for children, and all other protocol for pediatric patients. Psychological support should be provided to all children, and facilities must design a plan to reunite lost children with their families.

In the aftermath of a disaster, it is unlikely that the elderly can be properly cared for in a hastily-constructed shelter. In this case, the elderly should be moved to a nearby long-term geriatric care facility. These facilities include all of the resources needed for elderly care, as well as properly trained staff.

For patients who require special medication or equipment, it is important to keep track of such resources, especially in the event of a hospital evacuation. This information should be readily available to all staff, who may need to help in the evacuation of a physically or mentally disabled person.

Understanding the Government’s Role in Emergency Management (Donna F. Barbisch and Connie J. Boatright)

In extreme disasters, the government is expected to aid local communities in their efforts to minimize casualties and property damage. Since the attacks of September 11, 2001, two federal funding efforts have been established to address the threat of bioterrorism and other mass-casualty events. The first is the Health Resources and Services Administration (HRSA), which is run by the Department of Health and Human Services (DHHS). This organization aims to upgrade the preparedness of U.S. hospitals, focusing on the implementation of specific plans and protocols. The Centers for Disease Control’s Bioterrorism Cooperative Agreement similarly aims to increase preparedness, and focuses on the following six areas for improvement:

  1. Planning and readiness

  2. Surveillance and epidemiology

  3. Biological-laboratory capacity

  4. Communications and information technology

  5. Health information dissemination

  6. Education and training.

Due to programs like these, public health has been evolving in its leadership role for domestic disaster response, after many years of decay.

Probably one of the most effective government programs for disasters of all kinds is the National Disaster Medical System (NDMS), a section of the Department of Homeland Security. This system is essentially a network of medical professionals who have agreed to assume certain roles in disaster scenarios. These professionals undergo comprehensive training programs according to federal standards. In a field response setting, NDMS members are divided into several types of specialty teams, which are as follows:

  1. Disaster Medical Assistance Team – Includes physicians, nurses, and other support staff

  2. Disaster Mortuary Operational Response Team – Includes funeral directors, medical examiners, and forensic experts

  3. Specialized Disaster Medical Assistance Teams – Includes physicians and nurses with specialized training, such as burns, surgery, or mental health

  4. National Medical Response Team – Includes physicians and nurses specially trained for disasters involving weapons of mass effect

  5. Management Support Team – Includes leadership and administrative support staff

  6. Veterinary Medical Assistance Team – Includes veterinarians and support staff

  7. National Nursing Response Team – Activated for situations specifically requiring nurses

  8. National Pharmacy Response Team – Activated for situations specifically requiring pharmacists

The NDMS also provides specific protocols for disaster scenarios, including the increase of surge capacity, evacuation, and recovery. During a disaster, a hospital’s link to the NDMS system is one of many Federal Coordinating Centers. These centers oversee NDMS bed capabilities at Veterans Administration (VA) or Department of Defense (DoD) medical centers throughout the United States.

Although the federal government undeniably can play a significant role in disaster response, it is critically important to recognize that all disasters start as local events. Hospital preparedness will always be the most important step in effective disaster response. In the most extreme scenarios, government resources may be unavailable, or needed elsewhere, so it is critical to plan and educate effectively.

Public Health Aspects of Weapons of Mass Destruction (Eric K. Noji)

The Centers for Disease Control (CDC) has been responding to public health emergencies for decades, but has only begun to address the threat of bioterrorism and other new weapons of mass effect. The CDC has outlined a long-term strategy which is based on the following five focus areas:

  1. Preparedness and prevention

  2. Detection and surveillance

  3. Diagnosis and characterization of biological and chemical agents

  4. Response

  5. Communication

To prepare for or prevent mass-casualty disasters, the CDC recommends that a national distance-learning program be established, so that health care workers have access to the most up-to-date information regarding biological and chemical terrorism. The organization also suggests national guidelines and performance standards on terrorism preparedness, for use by state and local health agencies.

To detect a possible attack as quickly as possible, the CDC calls for new algorithms and statistical methods for searching medical databases in real-time. This could reveal medical trends relating to suspicious events. Surveillance must be upgraded at the local and state levels, in order to detect injuries and illnesses due to substances on the bioterrorism critical-agents list.

To diagnose and characterize a biological or chemical agent, the CDC suggests a multilevel laboratory response network that will help healthcare facilities quickly identify the source of a suspicious illness. Regional chemical terrorism laboratories would also help to provide extra diagnostic capacity during a terrorist attack involving chemical agents.

To effectively respond to an attack, the CDC recommends a national stockpile of pharmaceutical supplies, set aside for quick deployment in the event of an attack. The CDC also asserts that procedures must be in place to ensure the rapid mobilization of federal terrorism response teams, such as the NDMS.

For communications systems, the CDC recommends an upgrade in public health’s electronic infrastructure, which would make for quicker exchange of emergency health information. The CDC also calls for a comprehensive website which provides healthcare workers and the public with the most up-to-date information regarding biological and chemical terrorism.

Integrating Civilian and Military Medical Resources and Response Capabilities (Donna F. Barbisch)

The military’s medical system is built upon clear objectives, well-defined authority, consistent protocol, effective planning, and specific training criteria; notably, these are the very traits that are called for by civilian healthcare leaders for the nation’s hospitals. The military medical system has two missions: to provide healthcare to members of the Armed Forces during military operations, and to provide healthcare to the entire military population, including the families of military members and veterans. The military’s managed program, called TRICARE, comprises more than eight million beneficiaries, making it the largest managed care organization in the United States.

Military doctrine makes it clear that using military assets should not be the first option in a local disaster response. Though the Department of Defense (DoD) recognizes its obligation to the public, the system is not designed for domestic support. In extreme disasters, the military will be the last support in and the first support out. As commander-in-chief, the president can order the military to provide assets in domestic emergencies.

In order to access military medical support, there are a number of important considerations and steps to be taken. If a state’s resources are overwhelmed, the state can request federal assistance through the Department of Homeland Security; specific requests for military assistance go through the DoD. When submitting a request to the DoD, it is important to request a specific military capability rather than a specific unit.

Contrary to portrayals in the media, the military is not programmed to “take over” a city in times of need. Military assistance in a disaster falls under the direction of civil authorities, and merely provides support functions. It is important to consider that under extreme conditions, military support may not be available, or they may be needed elsewhere.

Legal and Ethical Considerations in Disaster Situations (William R. Wayland, Jr., and Marjorie H. Brant)

Natural disasters and terrorist attacks are extremely complex events, especially when it comes to ethical and legal issues. Under extreme conditions, seemingly insignificant decisions can have tremendous consequences. While many legal issues remain unchanged in emergencies, special exceptions sometimes exist. It is important for physicians and administrators to learn the best ways to provide care and minimize legal risk.

In certain times of crisis, patient confidentiality may be broken. If a healthcare provider believes that disclosure of patient information is necessary to prevent or lessen a serious imminent threat, they are allowed to do so. In certain states, patients may be detained, quarantined, or even medicated against their will under certain conditions. Arizona and Georgia grant health officials with the power to compel vaccinations among the public; six other states are allowed to quarantine individuals who refuse vaccination.

During a disaster, the potential for malpractice liability does not change (with the exception of Good Samaritan laws in some states). Physicians still must act reasonably within the limits of their knowledge and skill. Though physicians dealing with disasters would most likely be held to lower standards in a court of law, they cannot act recklessly and hope to justify unreasonable measures on the basis of extreme conditions. Hospitals are expected to be reasonably prepared for disasters, though it is understood that no hospital could prepare for the infinite number of possible disaster scenarios.

Physicians may refuse to treat patients, even during a disaster. However, if treatment is begun, they may not stop the treatment or leave the patient worse off than before. Refusal to treat may violate ethical canons or result in licensure action, but will not result in legal liability.

It is inevitable that medical professionals will volunteer during a disaster; these workers are held to similar standards and must be used with care. To minimize the risk of legal action, many hospitals give volunteers simple jobs which have low potential for error.

Availability of Disaster Assistance from the Federal Emergency Management Agency (Ernest B. Abbott)

In the aftermath of a disaster or terrorist event, the affected state’s governor will almost certainly request help from the federal government. After this request is received, the president may declare a “major disaster” or “emergency” under the Stafford Act, which has been in place since 1988. FEMA’s assistance can only be triggered after such a declaration.

Emergency declarations may be applied to nearly any type of event; in the past they have included wildfires, outbreaks of West Nile virus, the space shuttle Columbia disaster, and extreme snowstorms. The governor must first request such a declaration, with one exception: if the United States exercises “preeminent authority” over the affected region or organization. A notable example of this exception would be an emergency involving nuclear materials; the U.S. assumes primary responsibility for such materials under the Atomic Energy Act.

There are several criteria to determine which projects are eligible for FEMA funding. Every healthcare facility owned by a public authority is eligible for funding. Non-profit organizations that provide “essential government-type services” are also eligible, as are facilities that provide “critical services” such as power, water, sewer, and communications. For-profit hospitals, however, are ineligible for funding. Only certain costs are eligible, especially for healthcare facilities. Eligible costs must be directly caused by the disaster, and include things like overtime costs for staff, extra medical supplies consumed or contaminated in treating victims, increased security, and debris removal.

For the best chances of acquiring FEMA assistance, healthcare facilities should:

  1. Apply for assistance as soon as possible, certainly within 30 days

  2. Ensure that federal grant requirements and bidding procedures are followed

  3. Document expenditures and the eligibility of the work performed

  4. Ensure that FEMA understands the limitations of “other” support, including insurance

  5. Develop a good working relationship with FEMA and state officials

  6. Not be afraid to appeal a rejected cost if you feel it is eligible

Knowledge of FEMA’s capabilities and restrictions is an essential part of hospital preparedness. In times of great need, FEMA can be the lifeline which allows critical medical services to function effectively and save lives.

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