Rx For Bioterror

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.Photo: Ken Schles

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.”

Terror Resources
Terror Survival Guide
Checklist of everything you’d need to survive an attack in New York City. (August 12, 2002) Exit Strategies
Buying a parachute or a gas mask might seem paranoid – but some folks aren’t taking any chances. (October 8, 2001)

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.”

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.”

Rx For Bioterror