This bug without borders requires federal coordination, but don’t hold your breath
By Michael M. Barrick
Note: This is the second installment in a series on the Coronavirus pandemic. A link to the previous article is at the end of this post.
On March 4, 1933, in his first Inaugural Address, President Franklin Delano Roosevelt famously said, “It is my firm belief that the only thing we have to fear is fear itself.”
He was speaking to a more-than-anxious nation reeling from the stock market crash of 1929, the subsequent Great Depression, and the Dust Bowl, which devastated America’s farmland and led to a mass migration detailed in John Steinbeck’s “The Grapes of Wrath.” While in Steinbeck’s time, people had to move in abject poverty to an uncertain future, today, we find ourselves trapped in our homes, also uncertain about our future because of a bug without borders.
In the face of uncertainty, fear is natural. That is why FDR’s admonition is as relevant today as the day he said it.
However, for us to not give into fear, we must have strong leadership, and we as citizens must be knowledgeable. The obvious, dangerous ignorance and actions of President Trump in response to the Coronavirus pandemic are well-documented; hence, they warrant no further comment here except to say the consequences of his presidency have never been more severe.
Fortunately, several governors, mayors and healthcare professionals are offering desperately needed leadership. Citizens, meanwhile, as consumers of information, are being overloaded with information; much of it is sensationalized by news outlets that are as focused on profits as are the makers of N-95 masks.
What is maddening is that we’ve been here before. And before. The Coronavirus is not a surprise. We had a pandemic a century ago, a decade ago in 2009-2010 (fortunately less severe), repeatedly throughout history, and have been planning for them for 90 years.
Additionally, we’ve had more than one disaster in the last 20 years. In 2005, Americans watched in horror as residents of Louisiana, Mississippi, Alabama, Florida and elsewhere perished or were left stranded on rooftops or in hospitals by Hurricane Katrina. Indeed, Congress investigated and on February 15, 2006, the U.S. House of Representatives issued “A Failure of Initiative: The Final Report of the Select Bipartisan Committee to Investigate the Preparation and Response to Hurricane Katrina.” The Committee concluded that there were no less than 10 catastrophic failures in emergency preparedness and management at the local, state and federal levels that aggravated emergency response efforts for victims of Hurricane Katrina.
While a pandemic is not a hurricane, the following statement by The Select Committee is relevant to our current crisis: “No one anticipated the degree and scope of the destruction the storm would cause, even though many could and should have.” While much remains to be written in After Action Reports about our Coronavirus response, we can already say, sadly, that the Select Committee certainly describes our current crisis.
So, here we are. Because public health and/or emergency management is only in the news cycle when an emergent event happens, most of us lack a basic understanding of how these important functions work. So, now seems like an appropriate time to share some principles from the Emergency Management canon. Today, we’ll consider three:
- All disasters begin and end locally
- All roads lead to the hospital
- Apply Lessons Learned for the next — and inevitable — disaster
All disasters begin and end locally
New York Governor Andrew Cuomo recently told CBS News, “This is going to be one of those moments they’re going to write about and they’re going to talk about for generations.” However, the story that is ultimately told in New York or Seattle could be different than in other parts of the country.
The Johns Hopkins University map reveals that the outbreak, while widespread and alarmingly contagious and resistant, is also quite inconsistent from location to location. So, hospitals, public health agencies, emergency services, and first responders are — for now — at different levels of response. In short, it’s localized. (As of this writing, approximately 150,000 U.S. citizens have been infected with the Coronavirus; approximately 2,600 have died and nearly 5,000 have recovered). Clearly, testing and treatment varies between states, but nevertheless, at the moment, the number of cases varies significantly between different regions.
So, responses have begun locally, and ultimately will end locally. How your community recovers depends to a large degree on how well your community prepared for a pandemic in advance of this outbreak. We saw this correlation between a community’s recovery to preparation in shocking clarity after Katrina.
All roads lead to the hospital
Curmo’s overwhelming concern is that hospitals will quickly exceed capacity, causing physicians to make life and death decisions that are not theirs to make. Also, healthcare workers — and by extension their families — are among the more vulnerable populations to the Coronavirus.
We have heard of the shortage of ventilators and qualified staff to operate them. This is real, yet it is only one of the problems caused by a surge of patients. The bottleneck begins in the Emergency Department. The uninsured have become conditioned — because of our whacky healthcare industry — to first seek treatment through the Emergency Department rather than a family physician or urgent care clinic. While, at this point, an Emergency Department may be the entirely appropriate destination, there may be alternatives. One hospital in North Carolina has converted some of its physician’s clinics to respiratory care centers. The staff there are trained in triage, use of personal protective equipment (PPE), protocols for the Coronavirus, and are gaining valuable experience to be passed to others.
Emergency Departments have limited capacity. If it gets full, then it may be forced to divert ambulances to other hospitals. From there employees in radiology, the pharmacy, the lab, the medical/surgical floor, ICU, environmental services (housekeeping), food service and maintenance could all be overwhelmed and potentially exposed to an infected person if proper precautions are not taken. Naturally, sick employees put a greater strain on the remaining staff, further compromises the hospital’s capacity, and exposes others in the community to the illness. Yet, the disease, for many, must be fought in the hospital setting; exceeding capacity will lead to increased morbidity. That has already been proven.
So, if a hospital’s rules about visitation and even routine diagnostic, medical and surgical procedures are annoying, they are very likely in place for good reasons. All roads are leading to their Emergency Departments.
Lessons Learned from the H1N1 response
While the current federal response is one that has been inconsistent at best, that doesn’t mean it was inevitable. We’ve witnessed countless dedicated public health professionals being handcuffed by the president. They should be allowed to operate as they have trained to do.
Strong leadership from the White House guiding coordination of resources has been done before. I know because I was serving as the Emergency Preparedness Coordinator of a 350-bed hospital during the H1N1 pandemic of 2009-10. Fortunately, it turned out to be less severe than predicted. But we did not know that as it began. So, it is instructive to take a look at how President Obama’s administration coordinated the nation’s resources in response to the outbreak and how we responded locally.
- On April 23, 2009, our hospital staff began getting notifications from the CDC of a novel flu outbreak in Mexico with a high infection and mortality rate.
- On April 26 President Obama held a news conference with the heads of DHC, CDC and others. He declared a national health emergency, which led to the release of the Strategic National Stockpile (SNS). The SNS includes PPE, medicine, vaccines, supplies,equipment and materials a hospital would need for various disasters, especially those causing patient surges and/or exposure to nuclear, biological or chemical weapons.
- On April 27, we assembled our Incident Management Team (IMT) at the hospital. This included an interdisciplinary team of staff from infection control, administration, the ED, the pharmacy, lab and others. Together, this team, using the pandemic plan already in place, established infectious diseases surveillance and protocols.
- On April 28, the IMT met again to establish additional command and control objectives. Facilitating communication between and among departments topped the list, as well as ensuring that the ED, pharmacy, lab, radiology, nursing and support services were all provided situational awareness. Additionally, assessments were made of employee health and continuity; triage and surveillance; crisis communications; facility access; the antiviral plan; inventory of critical medicine, supplies and equipment; and, surge capacity for the ED, med-surg units, and the ICU. Plans for isolation and PPE protocols were also activated.
- On May 1, the Hospital Incident Command Center (HICS) or emergency operations center was set up. The IMT determined to operate on 72-hour operational periods based on the information being provided by the CDC and health officials at the state and county levels. We began ongoing, constant communication with our community partners. We held a news conference to educate the public. An infectious disease physician, the Chief of Staff, the CEO and others spoke to share information about H1N1 with the public, but also to assure the public that the hospital was prepared to deal with the situation. We also launched a disaster response website (which had already been built for such scenarios). Using it, we kept staff and the public informed on current information. Vulnerabilities were identified — for instance, converting outlying sites to patient care areas should the surge exceed our capabilities.
In short, within days of hearing of the first case, we had a declaration of a national emergency and the mobilization of the SNS. Within hours of that, our hospital IMT gathered and four days later, we set up our command center, never letting our guard down until the threat was gone.
Finally, nearly a year later, when we closed down our HICS, we conducted an After Action Report. Obviously, there were many lessons learned. One that stands out is that we determined that we, as a hospital, needed to exercise an initiative of leadership in our community. First, because the community learned that all roads lead to the hospital. And, we were reminded how much we need one another, so we focused on strengthening relationships with our public health and first responder partners, even though they had proven indispensable and strong throughout the response.
I am sure we were not the only ones. That is one reason that I believe you see governors and mayors stepping up to make sure their communities are protecting their vulnerable citizens and supporting hospitals, nursing homes, home health agencies, first responders and public health experts who are, again, at the very tip of the arrow among responders.
They — we — understand that we are fighting a bug without borders. We know not to count on the cavalry. So, in every hamlet and hollow, we’ll care for one another. It’s what a community of caring people does. We’ll be stronger when we get through this. And, one can hope, smarter.
PREVIOUSLY PUBLISHED IN THIS SERIES ON THE CORONAVIRUS
© Michael M. Barrick, 2020. Man in mask photo by Ashkan Forouzani; Masks photo by Mika Baumeister; ‘World is Closed’ photo by Mika Baumeister — all on Unsplash. FDR photo by Leon Perskie (in the public domain).