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Hospitals begin to address shortcomings

By Stephen Smith, Globe Staff, 9/3/2002

   
Team leader
Dr. Gregory Ciottone of Beth Israel Deaconess Medical Center, who led a federal response team at Ground Zero, has not washed the dirt from the boots he wore there. (Globe Staff Photo / Jonathan Wiggs)


The rumor ricocheted through emergency rooms across Boston on that grim Tuesday morning, fed by a current of adrenaline and fear. Three-hundred walking wounded from New York, the rumor went, had been herded onto a train lumbering toward South Station.

It never happened, of course, but like so much that unspooled in the hours and days after two planes gouged the World Trade Center, the rumor of hundreds of patients bound for Boston served to permanently alter the topography of the city's hospitals, in ways big and small.

And then, barely a month later, came the anthrax panic.

Taken together, the events revealed in high relief weaknesses in the nation's public-health system, propelling a year of self-examination and a wave of spending by medical centers and government agencies.

"Sept. 11 clearly redefined the meaning of disaster," said Leslie Kirle, the Massachusetts Hospital Association executive presiding over efforts to make hospitals more prepared for calamity. "On that day, the unthinkable happened - and that meant the health-care system had to rethink what it was doing."

Portable decontamination units, laden with showers to douse victims of bioterrorism, were bought. A real-time surveillance system that tracks clusters of unusual illness among 250,000 patients was hurried into service, 10 months earlier than scheduled. Doors were locked, security badges checked, patients scrutinized.

The problem is, nobody can say with real precision for what exactly the health-care system should be preparing. Three epic disasters of the past decade - Sept. 11, the Oklahoma City bombing, and Hurricane Andrew, the nation's costliest natural disaster - yielded surprisingly few emergency room patients. In fact, one of the enduring images of last September was the tableau of doctors and nurses, clad in hospital scrubs, standing outside New York hospitals waiting for patients who never arrived.

So how do hospitals prepare for what is, in a sense, the unthinkable? And at a time when patients are being thrown off Medicaid rolls in Massachusetts and health-insurance premiums are rising, how is the need to prepare for disaster weighed against the imperative to prevent and treat the scourges more likely to kill most of us - cancer, AIDS, the flu?

"After Sept. 11, we now have a full-time person responsible for disaster planning and coordination," said Dr. Gary Fleisher, chief of the Department of Medicine at Children's Hospital in Boston. "After anthrax and 9-11, we felt we would be remiss if we didn't have such a person, even though the possibility that these kinds of attacks would affect us is remote.

"Yet someone who's uninsured and their kid's teeth are rotting will say: 'So they've got someone running around worrying about anthrax. What about my kid's teeth?' But if there's an anthrax attack, they'll say, 'Why didn't you have four people worrying about anthrax?' "

Deficiencies in the system

The morning of Sept. 11, like so many mornings before it, Nancy Ridley sat in her office at 250 Washington St. in Downtown Crossing, headquarters of the state's Department of Public Health. It is a spot, like so much of the city, framed by history on almost every street corner.

What would unfold that day was unlike anything Ridley, a veteran of more than two decades in public health, had ever witnessed. By midmorning, she and another public-health executive had climbed into a state-issued Chevrolet Cavalier, slogging through knots of traffic evacuating downtown Boston.

Ridley's destination: the state's emergency operations center in Framingham, a sprawling underground bunker reminiscent of the nuclear fallout shelters of the Cold War.

"At that point, everybody knew the planes had come from Boston," recalled Ridley, an assistant commissioner in the department. "Everybody was just looking up. We had no idea what to expect from a public-health standpoint or what support New York would need."

As it would turn out, Ridley spent three days at the bunker, along with dozens of other government and emergency-response representatives. Within 12 hours of the first plane's hurtling into the World Trade Center, hospitals in Massachusetts had canceled elective surgeries and discharged patients to specialty medical centers and nursing homes, opening 1,200 beds for victims of the attacks.

The beds would never be needed.

But that exercise, and the events of the next two months, displayed deficiencies in a health-care system capable of performing feats of surgical salvation but often deficient in dealing with such basics as effective communication. In New York, that proved to be a profound shortcoming, with a white paper issued last month blaming communication glitches for the loss of dozens of lives as emergency workers raced into the World Trade Center.

Ridley remembers sitting in the state car on the Massachusetts Turnpike, jabbing at the buttons of her cellular telephone in a fruitless quest to find an open line so that she could reach colleagues to spring them into action. And in the initial hours after the attacks, a laborious round of calls had to be made to each of the 77 full-service hospitals in the state in an effort to hunt down administrators.

"We didn't have a good system that had 24/7 numbers for every hospital administrator," Ridley said. "Yes, we could call every hospital and get them to find the hospital administrator, but it's a one-at-a-time thing."

At the same time that Ridley sat sequestered in the emergency operations bunker, Paul Baratta was in his waning days on the police force at the Massachusetts Institute of Technology. He'd already accepted the post of public safety director at Beth Israel Deaconess Medical Center but wasn't scheduled to start until late September.

On Sept. 11, he got a call from the hospital's executives. Can you start tomorrow, they wanted to know.

When Baratta arrived the next morning, what he found surprised him.

The hospital's campus was an open one, with multiple points of entry, and doctors, nurses, and visitors roaming everywhere. Elevators designated to be turned off at nightfall to limit access instead kept running. And most alarming to Baratta: High-security doors were left ajar, affording easy access to rooms housing medical machinery powered by radioactive material. Keys to cages protecting radioactive agents were left in unlocked drawers next to the machinery.

"There were a lot of areas where we had radioactive material where someone could easily walk into these labs - radioactive material that could be used as a dirty bomb," Baratta said. "I would see a door made out of solid lead and it had a peephole, but it was propped open in a radioactive lab just so it would be convenient.

"I thought, 'Well, those days are over.' "

Tracking bioterrorism

Long before most of the United States was wrenched from its slumber of complacency regarding bioterrorism, Kenneth Mandl and Richard Platt were devising systems to track the threat by monitoring the traffic flow in Boston hospitals and clinics.

For three years, the city's Public Health Commission has kept track of how many patients visit hospital emergency departments and urgent care centers, looking for unexpected rushes of business. Mandl and Platt, both physicians by training, sought ways to expand that data dredge, standing at the vanguard of a medical movement known as syndromic surveillance. The field has gained unprecedented currency since Sept. 11.

The Boston doctors knew it wouldn't be much of a secret if a bomb tore through a building or a plane knifed into the ground. But bioterrorism is wrapped in the gauze of stealth, with evidence of perfidy sometimes not manifesting for hours or days - often beyond the threshold when victims can be saved.

"For instance," said Mandl, an emergency physician at Children's Hospital in Boston, "a germ warfare agent could be released on a whole population in a subway, and the terrorists might not tell anyone. And the victims wouldn't find out until it was too late, until they were already mortally ill, and before doctors had begun to connect the cases."

So, a year ago, Mandl inaugurated a monitoring network at Children's to provide a real-time snapshot of emerging health trends. He knew that if doctors and other medical staff were asked to complete more paperwork in a field already drowning in documents, a tracking system was doomed to failure. Instead, computers at Children's and, for the past four months, at Beth Israel Deaconess Medical Center, were primed to cull admission records for telltale patterns.

The tracking system examines two categories: the patient's chief medical complaint and the billing code assigned to the case, which indicates the illness that's being treated. The information is entered directly into computer records and is reviewed, along with the patient's home address.

A daily tally of conditions is computed. But those data don't exist in a vacuum, because a report of a 20 percent spike in, say, respiratory cases wouldn't necessarily tell doctors much. Instead, the findings for that particular day for that particular condition are measured against 10 years' worth of medical history. That way, doctors know, for instance, if the number of respiratory cases on a Wednesday in the middle of August varies dramatically from past Wednesdays in mid-August.

Then, the computer hunts for geographic clusters of cases.

"It's one thing to say we're 20 percent up on our respiratory visits today," Mandl said. "But if I say we're 20 percent up and all the cases come from this one neighborhood in Watertown, that's very powerful."

Platt, acting head of the Department of Ambulatory Care and Prevention at Harvard Medical School, designed a similar system to follow patient visits to 14 Harvard Vanguard treatment centers. The story of its birth is a telling paradigm of life in the days following Sept. 11.

The system, completed in partnership with the state Department of Public Health and paid for with federal dollars, wasn't scheduled to start running until last month. "When Sept. 11 happened," Platt said, "you can imagine that the team I had assembled to put this together pretty much stopped doing whatever else it was doing to get this operational as soon as possible."

Connected to the public-health agency, the system came on line in late October, in the midst of the anthrax panic. Its sweep covers 250,000 patients, and the daily report of diagnoses generated from patient medical records is mapped onto 500 census tracts. Designing and implementing the system cost less than $500,000.

While the fear of bioterrorism accelerated the completion of the system, its greatest value may prove to have nothing to do with terrorists. The need for such a network was demonstrated in 1993, when Milwaukee's water supply was fouled by a microbe called cryptosporidium, the legacy of runoff from a cattle lot. More than 400,000 people became ill and 100 died - in part, because it took days for disease trackers to realize an epidemic was felling thousands.

Coping with calamity

Dr. Jonathan Burstein is fond of referring to himself, and colleagues of his ilk, as "weirdos." In a sense, they're the Chicken Littles of the medical world - if not predicting that the sky is falling, then at least urging the health-care system to be prepared just in case.

Burstein, director of disaster medicine at Beth Israel Deaconess, used to draw yawns when he tried to stimulate interest in small pox and other potential biological tools of terrorists.

"Since Sept. 11, people have realized that everybody in the hospital needs to know this stuff," Burstein said. "People have bombarded me with e-mails and phone calls."

In the year since the attacks, hospitals and public-health agencies have taken the measure of their ability to cope with a calamity, especially terrorism involving biological or chemical agents. Sometimes, that has resulted in the embracing of humility in a medical community renowned for its hubris.

"You don't do this by yourself," said Massachusetts General Hospital executive Ann Prestipino, chairwoman of the hospital's Emergency Management Committee. "As rich as we are in resources and the expertise of the people who work here, there's no single institution that could address this kind of a problem."

That's why hospitals that are normally ferocious competitors are drafting compacts that would allow their staffs to work on enemy turf in the event of a crisis. Identification cards might even be issued in advance, so that emergency physicians from a hospital rendered useless by attack could take their skills to a functioning ER.

"That to me," Burstein said, "is a huge breakthrough in the attitude of people working at different facilities."

Those hospitals are destined to receive decontamination units that would be used to cleanse victims of bioterrorism. Each of the state's hospitals with emergency departments will get one, as will 15 fire departments, meaning 92 decontamination trailers are bound for Massachusetts at a cost of $60,000 each.

The units are designed to be independent from the rest of the emergency department, with their own showers and heating units and ability to store contaminated water runoff.

"People who are contaminated, you don't want them walking into your emergency room because then you wind up with contaminated ERs, and you have ERs shutting down when you need them most," said Betsy Stengel, executive director of the Conference of Boston Teaching Hospitals, an umbrella group.

The single biggest infusion of cash into the state for medical emergency preparations comes from two federal agencies, the Centers for Disease Control and Prevention and the Health Resources and Services Administration. Each state was promised a federal grant based on a set formula, but no state would get that money until it completed an elaborate proposal. Massachusetts' share is $22.5 million, and in June it was among the first states to win unconditional approval of its plan.

The state's blueprint sends at least 60 percent of the money back to local and regional agencies to aid in their preparations for bioterrorism.

Changes during the past year have ranged from the profound to the prosaic.

At Beth Israel Deaconess, the security director, Baratta, reduced the number of entrances into the hospital and issued an order mandating that doors remain shut in rooms containing radioactive material.

At Mass. General and the other hospitals that constitute the Partners HealthCare combine, the argot of disaster has been standardized to bring order to the disorder of tragedy. For instance, each hospital had a different name for its command post during a disaster. At Mass. General, it was the Disaster Headquarters. Now, every Partners hospital uses the same nomenclature: Incident Command Center.

At Tufts-New England Medical Center, it took two hours on Sept. 11 to gather computers and telephones for the conference room hurriedly converted into an ersatz command center. Now, there's a communications crash cart freighted with six computers and a dozen phones.

"We learned a lot of logistical things on that day," said Dr. Brien A. Barnewolt, chief of Tufts-New England's emergency department. "And in the year since, we've learned a lot about what we still don't know."

Most fundamentally, hospitals and the nation's public-health network still don't know exactly what kind of attack to prepare for. They have been training for decades to handle a plane crash with survivors or a bus crash with dozens of injured, wailing children.

But the Sept. 11 attacks demonstrated that historic disasters often yield little work - at least in the short term - for hospital emergency rooms.

"The World Trade Center event was the kind of event where either you ran away from it or you perished in it," said Dr. Gregory Ciottone, a Beth Israel Deaconess emergency room doctor who leads a federal disaster team that responded to New York. He has been commissioned by the United Nations and the World Health Organization to write a book detailing disaster management for terrorism events.

The knowledge that they may be spending thousands of hours and millions of dollars preparing for an event that will never happen fosters a subtle tension in hospitals struggling to find enough nurses for day-to-day staffing.

"We don't have a hospital full of patients from disasters," said Karen Brouhard, codirector of the Center for Violence Prevention and Recovery at Beth Israel Deaconess. "The vast majority of our work goes to caring for patients with the flu and the other illnesses that bring them to our doors."

One of the most significant lingering fears for hospital and public-health authorities surrounds the health system's ability to sustain itself if a crisis mode arced from days to weeks to months. That scenario most frequently crops up during discussions of bioterrorism.

"A lot of the planning that's going on is what's going to happen beyond that first 12 to 14 hours," the state's Ridley said. "We can run on adrenaline. I can work 24 hours a day for so many days and so can my people. But you can't do that forever."

On that Tuesday nearly a year ago, that Tuesday when the trainload of 300 wounded never materialized, Boston's famed network of hospitals and public-health institutions glimpsed a horrific potential few had ever imagined. It would forever alter their vision of the future.

Paul Baratta, the former small-town cop who would become security chief of a major US hospital, began signing his e-mails with a Latin phrase.

Para Malum, Spera Meliorum.

Prepare for the worst, hope for the best.

Stephen Smith can be reached at stsmith@globe.com.

This story ran on page A13 of the Boston Globe on 9/3/2002.
© Copyright 2002 Globe Newspaper Company.





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