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What One Doctor Can Do to Prepare. (Three Steps To Volunteerism).

Your community is not prepared for a medical response to a terrorist attack.

Public health experts interviewed in the immediate aftermath of terrorist bombings in New York and Washington advise civic-minded physicians to take three steps to improve local readiness for a possible terrorist attack:

* Help to rewrite your local hospital's emergency response plan.

* Consider volunteering for a Disaster Medical Assistance Team.

* Educate fellow physicians and legislators about the need to protect hospitals from lawsuits if their actions are in keeping with the executive orders of the governor during declared state of emergency.

What is clearly needed, according to Dr. Richard Hoffman, is a massive reengineering of how hospitals respond to disasters, as well as how individual physicians and other medical professionals ready themselves to act in the event of a local disaster.

As former chief medical officer and state epidemiologist at the Colorado Department of Health, Dr. Hoffman was involved in a Centers for Disease Control and Prevention bioterrorism exercise in which Denver was the scene of a staged bioterrorist attack.

The key lesson learned from that exercise, in which actor-patients participating in a mock bioterrorist attack of Yersinia pestis (the bacteria that causes plague) began showing up in the city's emergency departments, was the importance of communication and disaster preparedness--having systems in place and charging people with the responsibility for following through.

The Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have disaster plans, but they were written to handle "bus rollovers and plane crashes, not terrorist acts," Dr. Hoffman explained. Community physicians need to step in now, make sure these plans are revised, and include the physician's point of view as well as the hospital administrator's.

Dr. Tara O' Toole, deputy director of the Johns Hopkins Center for Civilian Biodefense Studies, Baltimore, observed that "practicing physicians need to know what the local response plans are and if they haven't been told, they should clamor to be told." Yet the reality is that "there are no good plans anywhere. There are pieces of plans, and capable people, and earnest efforts, but for the most part the focus has been on conventional attacks."

The few bioterrorism preparedness programs that do exist have been geared to police officers and firefighters. Physicians have pretty much been overlooked for such training, she added. In most areas of the country, there isn't even a 24-hour hot line to the state public health department for reporting patients with suspicious health problems.

One hospital that has already taken the lead on disaster preparedness is the Washington Hospital Center. Dr. Michael Pietrzak is the director of the hospital's Project ER One, an undertaking to develop a state-of-the-art emergency department that could be used as a model for any hospital handling the medical consequences of terrorism, disasters, and epidemics.

"The one-time unthinkable threat of terrorism is now a stark reality, and there is now the realization that there will be medical consequences to terrorism," Dr. Pietrzak said.

Hospitals need to have options "other than what I call the parking lot solution," a reference to the fact that setting up showers in the hospital parking lot is the most widespread plan for addressing decontamination.

The hospital expects to receive $2.2 million in federal funding this month to begin the project, which was approved before the terrorist attacks.

The program will address everything from designing rooms with air flow systems for preventing contamination to an unprecedented informatics network that would give an ER physician real-time reports of work or school absenteeism to detect an epidemic.

Dr. Pietrzak expects the model plans will be complete within 12-18 months.

The terrorist attacks also marked the first nationwide deployment of the National Disaster Medical System's 80 Disaster Medical Assistance Teams of more than 7,000 private-sector medical and support personnel. Immediately after the attacks, Department of Health and Human Services Secretary Tommy G. Thompson activated the medical teams, which are called into action during natural disasters, such as hurricanes.

Five teams were deployed at the disaster site in New York; none were sent to the Pentagon where military physicians managed acute care, according to NDMS spokesperson Craig Stevens.

"As far as providing medical care, we are the organization. When the state gets overwhelmed, and they go to the federal government, that's us," explained Pete Podell, the national training officer for the NDMS program.

Participation on a team requires a rigorous application and clearance process. When deployed to a disaster region, team members must be willing to leave their jobs back home for a minimum of 2 weeks, during which time they are considered to be federal employees.

Mr. Podell's office alone received more than 1,500 inquiries from medical providers within days of the terrorist events. Applications are being expedited, but the procedure still takes time. The process can take up to 6 weeks under normal circumstances. A 125-hour online training course is optional.

Most physicians are likely to opt for volunteerism in their own backyards, Dr. Hoffman observed. When their governors declare a state of emergency, hospitals and physicians deserve to be protected from malpractice claims and EMTALA (Emergency Medical Treatment and Active Labor Act) rules that require patient assessment before release or transfer to another hospital.

Many states do not have such laws in place yet, according to Dr. Hoffman, but Colorado enacted such laws in March of 2000. Colorado House Bill 00-1077 established an "Emergency Epidemic Response Committee" that would advise the governor in a time of epidemic crisis and would do so with legal immunity. The legislation protects hospitals from legal recourse if their actions are in keeping with the executive orders of the governor. It also calls for adoption of standards for health care facilities responding to this type of epidemic crisis.

In a disaster, hospitals are where the action is, he said. That is where physicians will gravitate to volunteer care. Yet most states haven't addressed the liability issues. In a state of emergency no physician should be worried about credentialing out-of-state physicians and physicians who lack privileges at a specific hospital. The first concern should be the patients, not what the supervising physician is comfortable allowing the volunteer physicians to do.

In a state of emergency, "hospital physicians need help, and all the help they can get. They don't want to worry that when this is all over maybe we could get sued." Doctors should demand that legislators relax malpractice concerns in these situations. One option is to draft executive orders that can be signed off by the governor upon declaration of a state of emergency.

And in the event of a bioterrorist attack, there are additional concerns for the safety of the medical staff. "We don't want physicians and nurses dying on the job. ... You can't keep a community going if people stay home frozen by panic and unable to deliver services." By planning now, physicians can make the decisions that ensure there will be adequate supplies of masks, antibiotics, and protective devices in the event of bioterrorism, Dr. Hoffman said.
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Author:DeMott, Kathryn; Dales, Mary Jo
Publication:OB GYN News
Date:Oct 15, 2001
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