AAOS Now

Published 7/1/2009
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Peter Pollack

“A failure of the trauma system equals failure in disaster care”

Former DHS leader discusses the need to plan for mass-casualty events

“Is your community ready for a large-scale disaster?” Jeffrey W. Runge, MD, asked members of the American Orthopaedic Foot & Ankle Society during their 2009 Specialty Day meeting. “Do you understand the requirements of your healthcare assets in your community during and after a disaster? Do you have plans, training, and equipment, and how often have you exercised the plan? I would venture to say that doesn’t happen very often, even now, in this country, even experiencing what we’ve experienced.”

From 2005 through 2008, Dr. Runge was employed by the U.S. Department of Homeland Security (DHS), first as its Chief Medical Officer, and later as Assistant Secretary for Health Affairs. He shared his thoughts on disaster preparedness.

Who’s in charge?
“A few years ago, I asked an association of surgeons, ‘Do you know what happens if the bomb goes off in your town square? Do you know who’s in charge in your community?’ All their hands went up. I said, ‘That’s great. Now, how many of you think that you’re the one in charge?’ Again, all their hands went up. Wrong answer,” said Dr. Runge.

Although the odds of a disaster due to terrorism or a natural event may appear remote, events such as Hurricane Katrina and the Oklahoma City bombings demonstrate that the medical community must be prepared for a sudden situation in which the demand for medical services greatly outstrips the supply.

“The time to exchange business cards is not in the middle of a disaster,” he said. “You’ve got to know who the players are in your community ahead of time.”

Having a good plan in advance means that responders are more likely to show up to assist, noted Dr. Runge. In the case of a radioactive event, for example, some medical personnel might be hesitant to interact with exposed patients unless they have been properly prepared and know what to expect. Having a framework that addresses expenses and legal issues also leaves less room for argument later.

Low-tech, high-consequence
Dr. Runge explained that the federal government generates plans in order to predict what could occur during a mass-casualty event. The possibilities are broken down into five basic scenarios, often referred to by the acronym CBRNE (chemical, biologic, radiologic, nuclear detonation, and explosives). Of these, he is most concerned about the potential for a biologic attack with an aerosolized organism.

“We use anthrax [as an example] because it’s the nastiest,” he stated. The organism is fairly easy to obtain, cultivate, and move, as previous alerts have shown.

In one “plausible, high-consequence scenario” envisioned by DHS, an attack on a large city in the eastern United States, given ideal weather conditions, could expose more than 3 million people to the disease. In the absence of chemoprophylaxis, such an exposure could result in more than 200,000 patients who would require intensive care.

“What if the region had only 480 ventilators and a smattering of people who could actually take care of people on a ventilator?” asked Dr. Runge. “It would not be difficult to completely denude an urban area of its medical resources.”

All hands on deck
Dr. Runge admitted that the circumstances of such an event may be outside the direct specialty of orthopaedics. Nonetheless, such a disaster would require the mobilization of all medical resources, regardless of a healthcare provider’s area of expertise.

“In an untreated and unprepared community, pulmonary anthrax can rise to very large numbers, and fatalities would rise and peak rapidly,” he explained (Fig. 1). “So we would have to act quickly to distribute antibiotic prophylaxis. Surgeons, dermatologists, and all manner of healthcare providers are going to be called into action.

“The idea here is to provide mass prophylaxis for the entire community in just a few days. That can save huge numbers of people, assuming this is a drug-sensitive organism.

“Under this scenario of 3 million exposed, for every day that we fail to start delivering prophylaxis, we lose 70,000 more people. I don’t have to tell you that this could be a nation-changing event,” he said.

Now is the time to prepare
Dr. Runge outlined the following steps physicians can take to ensure their communities are prepared for a mass-casualty event:

  • Ask local law enforcement and emergency managers to brief the medical community so that physicians understand the magnitude of the threat in the area.
  • Develop a plan of action by identifying capabilities, actions required, gaps, and budget requirements.
  • Equip, train, exercise, and revise disaster plans for both the community and the family.
  • Protect the workforce and make sure it will show up in the event of an emergency; plan and discuss what protective actions will be in place for them, whether the incident is an infectious agent or a dirty bomb. Encourage people to keep home medical kits on hand.
  • Make sure everyone understands their roles and responsibilities under the Incident Command System.
  • Develop a legal framework to support disaster care, including credentials and privileges where you might not have them, and changing standards of care in an austere environment when demand exceeds supply.

Manage nationally, prepare locally
Although certain aspects of disaster management are federal in nature, Dr. Runge stressed that preparedness is local. Ultimately, local responders and the local population must deal with and experience the consequences of the disaster. Physicians, law enforcement personnel, fire officials, emergency management teams, emergency medical services, and others must have a plan for working together. Although public groups have made some progress in drafting response plans, the private sector of medicine has often been left out of the equation.

“The incident command system applies to everyone, and we need to understand where we are in that universe,” explained Dr. Runge. “A failure of the trauma system equals failure in disaster care.

“Hospitals are closing and trauma systems are under siege,” he continued, “yet we have been asked to create surge capacity. This is an issue that is going to require, not just a federal solution, but local solutions.”

Additional resources:
Federal Emergency Management Agency National Response Framework

National Incident Management System Basic Incident Command System

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org