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Rx For Bioterror

Since September 11, hospitals have been upgrading their disaster response. but when a man walked into Beth Israel Hospital in Brooklyn with a smallpox-like rash, the ensuing drama showed how far the system had come -- and how much remained to be done. A progress report.


SUITED UP: At the start of a recent chemical-weapons drill at Long Island College Hospital, the decontamination team is geared up and ready in the ambulance bay.  

Television season finales are infamous for their dramatic excesses. So it wasn't hard to guess what was afoot in the final episode of ER last May, when an American foreign-service officer and his wife, just back from a stay in Africa, brought their two young children to the hospital feverish and covered with spots that looked suspiciously like smallpox. Because the kids were wrapped in blankets, the family was left sitting in the crowded waiting area for several hours until a harried physician -- Noah Wyle -- finally got a good look at them. He rushed the family into an exam room, alerted the hospital, and the crowded ER was immediately locked down. This being television, a great deal of panic, confusion, insurrection, and personal discovery ensued.

Sensational as it seemed in May, this scenario is being taken more and more seriously in recent months. While the federal government, which controls America's entire stock of smallpox vaccine, tries to hash out a comprehensive policy, New York doctors and health-care workers who are the first line of defense in emergencies have been training for just such an event.

Consider an episode (life imitating art) that occurred in the city on a steamy Sunday in August when a 21-year-old Nigerian man walked calmly into the emergency room at Beth Israel Medical Center on Kings Highway in Brooklyn. It was a little past noon. The ER, which serves a large community of elderly Jews, was unusually quiet, and the Nigerian man was seen within minutes. Though he had been in the U.S. for just five days, this was his second trip to a doctor -- earlier in the week, the same ugly skin condition had sent him to a walk-in clinic.

This time, however, the triage nurse, who'd been told over and over in recent months, like most of the city's health-care community, to be vigilant to the point of paranoia about potentially contagious ailments, took a look at the rash on the man's face and immediately put him into isolation. A doctor examined the man about fifteen minutes later.

What she saw was someone who'd just arrived from overseas with an unusual, aggressive-looking skin rash and a fever. In the highly sensitized post-9/11 environment, her first thought was smallpox. She called in several specialists to have a look.

In the meantime, word began to spread both inside and outside the 200-bed community hospital that Beth Israel's Kings Highway ER had a case of smallpox.

When the news went out over EMS radios, a decision was made to divert ambulance traffic to other facilities. Walk-in patients were also turned away, and the ER was closed completely. Calls were made to the Office of Emergency Management and the city and state health departments. Police commissioner Ray Kelly and fire commissioner Nicholas Scoppetta were both given regular updates.

Like most other New York hospitals, Beth Israel is part of a large health-care network, and various company executives were urgently pulled away from the beach, summer barbecues, and a Mets game. The mayor, of course, was also notified. Chatter over the emergency radio frequencies alerted the media, and reporters began calling and showing up at the hospital; the scene was beginning to take on a frightening resemblance to the episode of ER.

Shortly before events began to unfold in Brooklyn that Sunday, Dr. Marcelle Layton, one of the city's deputy health commissioners, arrived at her office on Worth Street in lower Manhattan. Layton, a small, soft-spoken woman, is a communicable-disease detective -- there are stacks of boxes in her office with labels like ANTHRAX FORMS and WEST NILE QUESTIONNAIRES.

Layton had just gotten back from vacation and intended to take advantage of a quiet weekend afternoon to catch up. But as she began answering some of the hundreds of e-mails that had stacked up in her computer, near-simultaneous calls came in from the attending ER doctor out in Brooklyn and from the Office of Emergency Management.

The Beth Israel doctor detailed the case for Layton and her colleague Dr. Joel Ackelsberg, medical director of the health department's emergency-readiness-and-response unit. (Since the hospital didn't have a digital camera, the doctor couldn't e-mail photos of the patient -- a digital camera is now an essential piece of ER equipment.)

As the symptoms were ticked off, the two began to relax -- this almost certainly wasn't smallpox. But the situation at Beth Israel had continued to escalate. Shortly after 2 p.m., an announcement was made asking all visitors to leave the building. The doors were then locked, trapping those who took their time or missed the announcement. Tempers frayed. Full-scale panic was a distinct possibility.

So Layton and Ackelsberg decided to go to the scene. "Because the ER had been closed and word had gotten out and the media were involved," says Layton, "we decided the best way to defuse the situation was to go there."

The two also thought that seeing the hospital in the throes of a full-scale smallpox scare would be a valuable education -- a real-time simulation of one of the most dangerous threats the health-care system faces. "One thing was, how do you make sure the situation doesn't get out of control unnecessarily in the future?" says Layton. "Also, while the notification tree within the government agencies worked well, the chain of command was muddled, and this was a problem."

Diverting ambulance traffic and closing the ER were very significant decisions, and it was not at all clear the right people made them, let alone whether they were the right things to do.

On the drive out to Brooklyn, with a full lights-and-sirens escort, Layton worked the phones, telling the ER doctor to keep track of everyone who'd been exposed to the patient and also sharing information with the Centers for Disease Control. At the scene, Layton and Ackelsberg interviewed the various participants and took some photos. They put on protective gear and examined the patient -- it wasn't smallpox, but dermatitis. By 3:30, the ER was reopened and the hospital was back to normal operation.

"Clinically, we responded correctly from the time the guy walked in the door," says Gail Donovan, the chief operating officer of Continuum Health Partners, Beth Israel's corporate parent. "He was seen and isolated quickly so the staff and the other patients were protected. Could we have been a little sharper in some other areas? Sure. But every experience we have with a different type of event provides the opportunity to learn and adapt."

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