DECON: The first time the new hot-water decon showers were used, they created so much steam no one could see.   (Photo: Ken Schles)

The scare on Kings Highway and the series of decisions that ensued raises the critical issue: Is the city's health-care system prepared to handle a nuclear, chemical, or biological attack? A single suspected case of smallpox is one thing -- but what if there were ten cases or a hundred or even thousands? In the thirteen months since September 11, the city's hospitals have spent enormous amounts of time, energy, and money to get themselves in shape for the new reality. Doctors and other health-care workers are being drilled in what to look for, how to react, and what their responsibilities would be. They're learning new skills, like how to quickly put on protective gear, set up quarantines, and handle once-unfamiliar supplies like nerve-gas antidotes and chemical-weapons detectors.

Hospitals have also begun upgrading their physical capabilities, making sure they have things like isolation rooms with their own air supplies, and working decontamination facilities. Communication, which was a serious problem on September 11, has also been addressed. Using the Internet and 900-megahertz two-way radios, the hospitals have set up a system that will keep them connected in a crisis not only within their own network but with other hospitals and city agencies as well. They've also put in place a master citywide patient directory that will, they believe, avoid a repeat of the nightmarish 9/11 scenario in which families were forced to wander from hospital to hospital looking for information about missing loved ones.

"The key is really going to be early recognition," says David Goldschmitt, head of emergency medicine at NYU Downtown Hospital, which, only a few blocks from the World Trade Center site, treated more than 1,200 people in the first hours after the attack.

"If you don't pick up on it early, you will end up watching the first wave die, and that's what'll tell you there's a problem. Then you work on saving the second wave. With smallpox, there is literally a patient zero. That one person can pass it on to ten people, who pass it to ten other people, and it spreads exponentially. You can potentially contaminate an entire population with one person."

Recognition is such a difficult problem that hospitals are preparing for the possibility that the first cases will be misdiagnosed. "We did a drill where we sent a smallpox patient home, which is a possibility since it doesn't look like smallpox until the patient's pretty sick," says Lewis Kohl, head of emergency medicine at Long Island College Hospital in Brooklyn.

The city Health Department has begun its own version of Compstat -- they call it syndromic surveillance. While the NYPD collects daily crime data from the precincts, the Health Department has started collecting data from emergency rooms, ambulance services, 911 calls, and now even pharmacies. It is looking for clusters of people with flulike symptoms, unexplained fevers, outbreaks of diarrhea, or any unusual increases in a particular area of certain symptoms.

At the core of hospital planning is a framework for disaster response called the Hospital Emergency Incident Command System (HEICS) -- an organizational table that lays out titles, jobs, and responsibilities for everyone in the hospital. The terminology is recognized by the Fire Department, the EMS, and other agencies, enabling everyone to speak the same language. (Some hospitals use basically the same program with a different acronym.)

HEICS breaks all hospital functions into five uniformly structured groups: command, operations, logistics, planning, and administration. The operations group, for example, which is in charge of the emergency department, has a decontamination team, a triage team, a medical team, a supply team, a nursing team, and so on. And each team is directed by a predetermined leader.

"In the past, when a disaster happened, everybody wanted to help, so they all responded to the ER -- surgeons, EMS workers, transporters, housekeeping staff," says Dan Wiener, head of emergency medicine at St. Luke's–Roosevelt. "Now we want everyone to report to staffing areas. Post-9/11, we realized that with the nuclear, chemical, and biological threat, this could potentially expose a lot of people to whatever was coming in our door. So we need to control the flow of people, and securing the emergency department is critical. This is a major change in the response culture."

As devastating as the 9/11 attack was, it was still what disaster experts refer to as a traditional explosive event -- albeit on an enormous scale. "We could see the towers falling, and we thought we knew what we were facing," says Donovan. "Then came the anthrax incidents a few weeks later, and with anthrax, you didn't even know what you were looking for."

Recognizing there was a new reality, Donovan got on the phone within 48 hours of the Trade Center attack with Susan Waltman, one of the leaders of the Greater New York Hospital Association, a nonprofit industry-advocacy group: "I pushed her to think about how we could work on comprehensive regional disaster planning."

The result was that several weeks later, a group that included area hospitals, the city and state health departments, OEM, the NYPD, and the FDNY began to meet almost weekly to share information and work on disaster preparedness. Their first order of business was to go over what they learned on 9/11: which long-held assumptions were completely wrong, what kinds of things were never anticipated, and, moving forward, what they needed to do, given the momentum that was there, to get their institutions in shape.

"I remember on a Friday night last October, after anthrax had been found at NBC," says Rich Westfal, associate director of emergency medicine at St. Vincent's. "We had 400 people from the community who had head colds or allergies who came into the hospital terrified. We put on extra doctors to explain the situation to these folks and to reassure them. That really lit the fire under all of us. We knew it was up to us to get organized. We knew we couldn't wait for the federal government."

Routine hospital purchases now include once-exotic items like Geiger counters, chemical-weapons detectors, HAZMAT suits, nerve-gas and chemical-weapons antidote kits, and, yes, digital cameras.

Most institutions have also updated, replaced, or expanded their decontamination facilities. Once little more than some PVC piping buried in a hospital utility closet, decon showers are now often permanent fixtures that require only minutes to become fully operational. Some, like the six new ones installed at Long Island College Hospital, even have hot water (not insignificant considering people have to strip naked and shower outside even if it's February). The showers have to be outside so that whatever contaminant people have been exposed to is not brought into the hospital. (Contaminants can range from anthrax spores to nerve gas to chemical weapons to radioactive particles.)

Smaller hospitals that have little room for decon facilities have to improvise. To understand the level of seriousness about this, consider NYU Downtown's crisis decon plan. Since it has room for only one decontamination shower -- one shower can handle about ten people an hour -- it has made arrangements with the Fire Department to hook up soaker hoses on a rooftop above its ambulance bay. In an emergency, it will simply hose people down as necessary.

For the hospitals, decontamination is also part of the larger issue of making sure that in a nuclear, chemical, or biological incident, their facilities are not compromised. "We've focused on our physical capabilities," says Donovan, "because we realized it would be very easy to get shut down if you exposed your staff or your air-handling system to a dangerous substance."

All of which means hospitals must be able to control who gets inside. "Especially at the hospitals close to ground zero, there was a rush of people on 9/11," says Donovan. "It wasn't an orderly thing. We need to be able to keep the people out who need to stay out."

Many hospitals have already installed security gates or garage-type doors to shut down access to ambulance bays and emergency departments. "We're trying to get the staff used to this idea," says St. Vincent's Westfal. "It's going to be a real challenge if the staff has to stay inside the building and others have to stay outside." A massive education program has also been undertaken by the city's hospitals. Continuum, for example, has schooled 800 of its employees as trainers, able to teach their 16,000 co-workers. At St. Vincent's, they've put together an intensive four-hour seminar for staff that covers the symptoms to look out for, decontamination skills, how to handle and administer antidotes, and putting on protective gear.

And the education efforts are not just for medical staff. "People are beginning to realize the importance of training nonmedical staff in the hospital, particularly in areas like recognizing a contaminated person," says NYU Downtown's Goldschmitt. "Because once someone reaches a doctor, they've already contaminated people inside the building. Security people, housekeeping, volunteers at the desk, all have to be prepared."