HEALTHCARE OPERATIONS IN A WME ENVIRONMENT

Weapons of mass effect pose a particular challenge to healthcare operations not normally seen in the response to technological or natural disasters. Most American disasters have been distinguished by significant property destruction, with relatively low levels of death or significant injuries. There have been only 7 disasters in U.S. history (excluding the events of 9/11) resulting in more than 1,000 deaths (Auf der Heide 1989). The single bloodiest non-war-related day in American history occurred when the Galveston Island (Texas) hurricane of 1900 claimed between 6,000 and 8,000 lives (Galveston County Daily News staff 2003). The terrorist attacks against the World Trade Center and the Pentagon on 9/11 resulted in nearly 3,000 lives lost.

These are extreme, and rare, events. Most disasters in the United States have resulted in fewer than 50 deaths, with injuries on that same order of magnitude. Healthcare operations in disasters typically were marked more by a temporary mismatch between supply and demand than absolute shortages: less than 5 percent of hospitals involved in disaster response suffer either personnel or material shortages, and few healthcare facilities are directly affected by those events.

On the contrary, a widespread disaster resulting from a terrorist attack using WME could, at a time when the demand for healthcare would be at a sustained high level,

• damage, destroy, or contaminate healthcare facilities;

• produce significant healthcare personnel losses through contamination, illness (among themselves or their families), or fear; or

• result in significant and prolonged material-resource deficits in critically needed items (e.g., ventilators, negative pressure isolation rooms, antibiotics).

One need look no further than recent history to understand the potential magnitude of these gaps. Two examples that easily come to mind are the effects of Tropical Storm Allison on healthcare operations in Houston in 2000 and the consequences of the terrorist posting of anthraxladen letters in New York; Washington, DC; and Florida in 2001. (See the case examples)

Hospital capacity to handle even relatively small surges in patient loads under more routine circumstances is a cause for concern. In a study commissioned by the American Hospital Association (The Lewin Group 2002), 62 percent of all hospital emergency departments and 79 percent of urban hospitals reported that they were functioning at or over capacity, and more than half of urban hospitals reported significant time on diversion (time during which patients had to be diverted to other hospitals) because of lack of available critical care beds in the hospitals. These hospitals report an increase in demand as high as 12 percent from 2001 to 2003.

Sidebar 2.1. Case Examples: Tropical Storm Allison and Anthrax Mailings

Tropical Storm Allison dumped up to 35 inches of rain over 5 days in June 2001 on Houston, Texas; killed 22 people; and left almost 15,000 people homeless and in shelters. Texas Medical Center lost all electrical power because of flooding. Two other academic medical centers, Hermann Hospital and Ben Taub Hospital, were without power and inaccessible. Shortages of ambulances and emergency medical service providers compounded the situation in which more than 500 critically ill patients in these facilities required transfer to other acute care hospitals already overwhelmed by the events (Cocanour et al. 2002).

Tropical Storm Allison was only one-third the size of a major hurricane, one that would bring storm surge and tornadic winds in addition to the rain. Consider the devastating consequences if a major hurricane were to strike Houston today: “hundreds of thousands dead, damage in the tens of billions of dollars and perhaps as many as 1 million left homeless, to say nothing of dismal long-term economics” (Berger 2002). In a Category 5 hurricane, “a dome of water, perhaps 50 miles wide and 30 feet high, would surge over nearly one-fourth of Travis County, flooding about 700,000. It would take 30 hours to evacuate this area, and as 10 percent of people traditionally don’t heed evacuation warnings, and of those left behind 10 percent die in a major storm surge, the math reveals a grisly death total of 7,000" (Berger 2002). The Federal Emergency Management Agency provided a total of $5.2 million to replace medical equipment from the Texas Medical Center hospitals (Associated Press 2002).

The anthrax mailings in fall 2001 resulted in illness in 22 persons who developed anthrax—11 inhalational and 11 cutaneous—and the death of 5 persons. Although this was a “small” terrorist attack, more than 30,000 people eventually received prophylaxis by way of official recommendations, and physicians throughout the country were besieged by patients requesting prophylaxis regardless of the minimal threat. The final costs of environmental testing and surety measures may never be known. The Brentwood Postal facility in Washington, DC, was thoroughly decontaminated in a process similar to that performed at the Hart Senate Office Building. The postal facility opened more than a year after the contamination (Royce 2002). The Florida building housing the publishing business contaminated in October 2001 has never reopened.

Even if a hospital were not directly affected by a terrorist event, it could indirectly become a casualty. As was clearly demonstrated in the Tokyo sarin incident, chemically contaminated but ambulatory victims might not wait for the arrival of hazardous-materials and decontamination units at the scene. Entrance of these victims into emergency departments would threaten existing patients and staff and might force closure of the department itself.

In one 2001 study conducted in the northwest United States, only 6 percent of hospitals surveyed had the capability to manage a hypothetical sarin incident. Although 75 percent of facilities responding had some decontamination capabilities, these were minimal and certainly would not be able to handle even a moderate number of contaminated casualties. Few hospitals had personal protective equipment appropriate for responding to a chemical incident, and in those that did, the equipment was minimal (one or two respirators or masks). Only about half of the hospitals polled had antibiotic supplies sufficient to provide prophylaxis to even 50 individuals for two days (Wetter, Daniell, and Treser 2001).

Improvements may have occurred since this study was published; however, it is unlikely that funding has sufficiently improved to produce a dramatic turnaround in these results in such a short period of time. Hospitals designated as receiving facilities for accidents at nuclear power facilities are required to have appropriate equipment, training, and testing to manage small numbers of casualties from incidents at these locations, but most hospitals in the United States do not.