Feature

Rx For Bioterror

Another key issue is making sure that hospital staff feel comfortable and protected coming to work in an environment where exposure to a deadly, contagious disease like smallpox or Ebola is possible. Even small, everyday responsibilities become an issue. Health-care workers facing a potential hospital lockdown have to have a plan in place to handle things like child care in their absence.

"We're doing lots of things we've never done before, and we're doing some of them without any practical, hands-on experience," says Wiener at St. Luke's–Roosevelt. "But keep one thing in mind: Disasters come into the ER every day. Contagious people, people exposed to hazardous materials. So it's not like it's all new to us."

As part of the HEICS plan, managers are required to do a psychological evaluation of staff members to make judgments about who might be a problem. "Our preparation does have to account for unanticipated human response," Wiener says. "But we've been through fear with health-care workers before, with AIDS. And once people were educated, the anxiety went way down. A chemical or a biological attack is unquestionably very frightening. But when you break it down and look at the individual possibilities and how we're prepared, you start to feel more comfortable that you can handle this."

Everyone now knows from experience, however, that in the frenzy of a crisis, even the simplest things can become difficult. "We've learned that nothing works the way it works in theory," says NYU Downtown's Goldschmitt. Goldschmitt says his ER treated more than 1,200 people in the first hours on September 11 but managed to record barely 375 names. Even the standard triage tags became a problem.

When an ambulance first rolls up to a hospital, the ER doctor or nurse is handed a tag with a little string on the end and a place to write the patient's name. The tag has a colored tear-off strip. On bottom is green, which means treating the person is not urgent. If the green is torn off, there's yellow, then red, and then black, which indicates the person is either dead or beyond saving. The string is used to tie the tag on the person's finger or toe.

"This is as simple as it gets," Goldschmitt says. "It takes only a few seconds. But when we were outside triaging patients, people didn't have time to do it. We were getting ambulances that had ten and twelve people each."

A pesticide-contamination drill conducted ten months ago by Long Island College Hospital showed that the problems in controlling a fast-moving situation persist. "Anxiety was actually pretty high," says Kohl. "Pesticides are just like chemical weapons. Nerve agents in particular. Even the antidotes are the same. We learned a lot."

The drill began when the ER got the call that victims were on the way in. As the alarm was sounded and the staff rushed to get into their protective gear, their boots began ripping. Not only was the material too flimsy, the boots were too small. The plan was to suit up inside the hospital, then go to the ambulance bay and get the decon facilities ready. But the first ambulance came screaming up to the hospital while the staff was still dressing.

The warm-water decon showers worked nicely. But they didn't two days earlier when they were tested for the first time. It was a cold day, and as soon as the showers were turned on, the ambulance bay filled with steam. The doctors and nurses couldn't see a thing. Exhaust fans were quickly installed before the drill.

It is this chaos factor that has fueled the argument over whether an emergency department would have to be locked down if a patient came in with smallpox or some other highly contagious killer. The rationalist view holds that as long as those infected are moved quickly into isolation, there's no reason to close an ER.

Many doctors hold this view. They point out that with smallpox, there is a three-day window in which you can be vaccinated after initial exposure. So the worst case is, you make sure to get contact information for everyone in the ER at the time, so you can have these people come back to be vaccinated if necessary.

"It's difficult to imagine it's going to be nice and clean like that," says St. Vincent's Westfal. "Let's say just one person had unprotected contact with the victim and they panic. They sneak out of the hospital and go home and no one sees them. Over the next month, while they're developing the disease, they're contaminating family and friends and everyone else they come into contact with. That's the fear, and that's the reason you need to lock the hospital down."

Westfal worries about someone coming into the country infected with smallpox and spending several days sitting in Grand Central exposing untold numbers of people: the bioterrorism equivalent of a suicide bomber. "If there's actually an incident," he says, "I really think you can forget all this talk about keeping hospitals open and letting people come and go. In truth, I think it's gonna be a bit of a pseudo-military state."

Goldschmitt's nightmare is even worse. He worries about the Ebola virus or one of the other hemorrhagic fevers. Their mortality rate is about 90 percent, more than twice that of smallpox; they're highly contagious; and there is no known treatment. "The best hope if this happens is quarantine," he says. "And the really distasteful thing is, we'll even have to quarantine people who are only suspected of having been exposed."

Though all of the ER doctors can conjure unimaginably horrible scenarios ("If you really want to hurt a lot of people," Kohl says, "release mustard gas in the subways"), cognitive dissonance seems to be an attribute of the breed. Despite the chilling stories, they are all more or less sanguine about the future. They know how much preparation has been done, and they have hard-core, almost jocklike confidence in their own abilities.

"I actually feel pretty good right now," Kohl says as he shows me a $10,000 chemical-weapons detector the hospital recently purchased. "We've put a huge amount of work into this. In an overwhelming situation, are we going to do everything great? No. But the key is that everyone get good care. And that I'm sure we can do."