Pandemic Dominoes: HCW’s Stand at the Apex

Yesterday Fla_Medic called attention to a piece that was released in JEMS:The Journal of Emergency Medical Services titled "Will emergency health care providers respond to mass casualty incidents?". Having my curiosity shot off the scale I spent roughly an hour tracking down the paper the JEMS article referred to and purchased it straight away. 

Before I dig into the very disturbing findings of this paper I would like to lay some ground work. 

I have been involved with the Cyber Flu Community for two years now in one way or another.  We are an interesting, eclectic group comprising professionals and laymen, deeply involved to casually informed.  When the issue of workers reporting to their jobs comes up two things have always been cited, the SARS response and the presumed illness attack rate.  The two figures mesh nicely, both pointing to a roughly 30% absenteeism rate at the height of a "severe" PanFlu event.  A thirty percent staff reduction in any industry or service would be extremely difficult to work around, but assumed not impossible. 

The thirty percent absenteeism in all Essential Services sectors is supposed to be one of the major points that their respective Influenza Pandemic Plans are to address… and that’s assuming they actually have formalized plans… a BIG assumption because many are still stuck at the "Plan to Plan" stage.  This paper points to the possibility that the 30% assumption may be grossly optimistic. 

As some who have read my Blog for awhile will know, I am acutely interested in PanFlu from an LEO’s (Law Enforcement Officer) perspective.  My only child is a street officer on a small city PD who has every intention of working during the PanFlu, should one materialize.  During a moderate to severe PanFlu police will be stretched as thin as HCW’s as they will be operating in situations that will facilitate infection, and at the same time not having adequate means of personal protection.  And, just as the Health Care System can not operate at 18-30% staffing levels, neither can Law Enforcement, so with that in mind, I will now introduce the actual paper this entry addresses. 

WILL EMERGENCY HEALTH CARE PROVIDERS RESPOND TO MASS CASUALTY INCIDENTS?

James I. Syrett, MD, MBA, John G, Benitez, MD, MPH, William H. Livingston III, MD, Eric A. Davis, MD 

ABSTRACT 

Introduction: Emergency response plans often call on health care providers to respond to the workplace outside of their normal working pattern. Hypothesis. Providers will report to work during a mass casualty emergency regardless of family duties, type of incident, or availability of treatment. Methods. Survey of emergency personnel needed to respond to a mass casualty incident. Two scenarios were presented: one involving the release of a nontransmissible biological agent with proven treatment and the other the release of a transmissible biological agent with no treatment. At critical time points, participants were asked whether they would report to work. Additional questions considered the effect of commonly used treatment dissemination methods. Results. A total of 186 surveys were issued and returned. (45 physicians, 29 nurses, 86 EMS personnel, and 20 support staff); 6 were incomplete and excluded. Initial commitment rates were 78%. The highest immitment rate identi?ed was 84% and the lowest was 18%. Any treatment dissemination method excluding providers’ family members led to decreases in commitment rate, as did agents identi?ed to be transmissible. Conclusions. As an event develops, fewer health care providers will report to work and at no time will all providers report when asked. This conclusion may be generalizable to several types of incidents ranging from pandemic in?uenza to bioterrorism. Identi?cation of the causative agent is a major decision point for providers to return to or stay away from work. Offering on-site treatment of providers’ family increases commitment to work. These factors should be considered in emergency planning. Key words: emergency preparedness; disaster response; mass casualty incident. PREHOSPITAL EMERGENCY CARE 2007;11:49–54

Even though the abstract states: Two scenarios were presented: one involving the release of a nontransmissible biological agent with proven treatment and the other the release of a transmissible biological agent with no treatment. What the body of the paper states is: 

The scenarios differed in two aspects. In the first scenario, there was an effective pro­phylaxis or treatment available, and the agent was iden­tified as being nontransmissible. In the second scenario, there was only an unproven experimental prophylaxis or treatment available and the agent was identified as being person-to-person transmissible. The final ques­tion in each scenario concentrated on specific methods of prophylaxis/treatment dissemination

So, as can plainly be seen, at no time does the survey ask the respondents if they would report to their assigned duties if there were no treatment available.  Since it is reasonably assumed that roughly two weeks into a severe PanFlu event there will be no supplies left to treat anyone this question would have been useful to have seen addressed.  In fairness, the survey seems to have been put together prior to the SARS HCW debacle or the general awareness of an Avian Influenza Pandemic.

One of the more disturbing aspects of this survey is the fact that it was administered at a hospital that had up to date training in response to a terrorist’s attack involving mass casualties since it is a designated decontamination and treatment facility.  The authors speculated that being informed on a higher level of the likely issues involved may have motivated some of the responses, on the negative side.

After reading the paper twice in its entirety I was deeply disheartened.  While no one can say with any certitude how they will or will not respond in any given situation of the magnitude of a severe PanFlu it is, I feel it is helpful to understand the thought processes of those we will be depending on, and how they will potentially play out.

Since it is safe to assume that any person who is dedicated enough, some might say stupid enough, to report to work during a situation such as is my focus will likely find themselves needing medical attention themselves at some point in the crisis how soon should we expect to see the drop off of Emergency Services personnel reporting?  I would venture to guess pretty quickly.

Will police, even those dedicated to their mission, risk reporting in a crisis situation, where the chances of injury and/or infection, are great knowing that there will be no treatment for them should they become injured or ill?  What if an officer has an auto accident while responding to someone’s urgent call for help and there is no EMS to transport him/her to the (unstaffed) Emergency Room?  The exact same scenario question could be posed for Truck Drivers as well.  Will they report knowing that if they become infected or injured there will be no one to treat them?  What happens if they don’t report?

Essential Services are called that because that’s what they are… ESSENTIAL.

I am not pointing an accusatory finger at Emergency Room doctors, nurses or EMS, EMS crews are "Brothers/Sisters in Blue" and as such I consider them equally members of my very extended "family", but I do feel obligated to point out… shout really… the nightmare cascade of consequences should the people that stand at the pinnacle refuse to "stand."  And I feel that I only addressed the superficial surface of the issues this paper brings to mind.

It would be prudent for Hospital… and County/City… Administrators to sit up and take note of this paper.  The problems it identifies could be blunted by bringing in a reasonable amount of PPEs (Personal Protection Equipment), planning to give priority treatment to the Emergency Responders… AND THEIR FAMILIES, and actually demonstrating that they care about the health and welfare of those they depend upon to perform these very important and ESSENTIAL functions.