This Plan is Your Plan; This Plan is My Plan.

We’ve been looking down the barrel of a loaded “pandemic gun” all winter. We’ve been meaning to do something abut biological preparedness since West Nile Virus, Anthrax, and SARS (what I have no idea). So, here comes spring and were guided ever so gently by the media away from flu (avian or otherwise) and pointed towards gas prices, immigration, and the ‘who’s who’ list of ex-Bush team members. Although not without good reason and some value, we’ve forgotten about the “pandemic gun” or maybe just because the weather is warm here we figure that gun is no longer loaded.

Its spring; Do You Know Where Your Plans Are?
Just because we’re out of the typical flu season is no rationale whatsoever to put planning and training for such an event on the back burner. Numerous updates have surfaced in the last few weeks. Perhaps the most striking (if only in volume) is the Pandemic Influenza Implementation Plan published by the Department of Homeland Security in early May, 2006. The object of this plan is to outline the governments effort to prepare for pandemic influenza and identify the critical roles of state and local authorities, private sector, and communities to address the threat of a pandemic. I’ll be conducting a review of the DHS plan shortly. You may recall the Department of Health and Human Services issued their own Pandemic Plan in November, 2005. Please see Mitigation Journal archives for November 2005 for my review of the HHS plan.

I’ve been asked a number of questions recently pertaining to planning, preparedness and response capabilities. There is no easy way to address many of the questions. The sad fact is; that despite effort and dollars; most plans in most jurisdictions fall short of reality. The overtone seems to be that the health care community and public health are going in one direction and traditional response groups are not going anywhere at all when it comes to planning for a biological event.

Each of the plans I’ve reviewed share a number of pitfalls. These plans assume:

1. The ability to communicate will not be disrupted and accurate/factual information will flow
2. Power and transportation will be readily available
3. Personnel will be healthy enough and willing to report to work
4. Civil obedience will be maintained both in the community and at health care facilities
5. Patients will be able to be evacuated to neighboring facilities or regions.

In addition, these plans do not mention the fact that every-day emergencies will continue to come to hospitals expecting treatment.

Let’s take a look at each one of these at its own context.

Communications.

Each plan assumes that there’s going to be the ability to communicate. And further, the ability to communicate will be undisturbed throughout any given event regardless of the length or scope of that event. It is reality however; the day-to-day communication is difficult to maintain even under ideal conditions. Case studies of numerous large scale events in history of all services indicate the communications will be among the first piece of infrastructure to be compromised. Further, the ability to rely on information from any given point must be questioned. When communication systems have failed or are compromised alternate means of communication will spring up; and it is these alternate means of communications that will lend a false sense of communications security and ultimately yield unreliable and inaccurate information on which decisions will be made.

Emergency plans also indicate their reliance on power and transportation with little or no mention of alternate means of supplying electricity, light, heat, or a means of moving people from place to place. The reliance on public energy and public transportation are critical weak link in the disaster and emergency planning process. Power in transportation are linked together in the disaster planning setting; in any given instance if we have and reliable and hardened power infrastructure capable of producing climate control, light, and maintaining critical operations in a given facility we can reasonably assume that facility will remain habitable and functional during crisis. If the power supply is threatened or lost we will no longer be capable of sheltering in place throughout the crisis in decisions will have to be made concerning evacuations and alternative sheltering. Should the need arise to evacuate a given facility, especially a Healthcare facility such as nursing home or hospital, there will be our reliance on emergency medical service transportation to effect such an evacuation. EMS transportation vehicles may or may not be available in such a situation. One must understand that all traditional response groups, including emergency medical services, will have their resources stretched to capacity and beyond. Air and ground transportation units will be subject to the same problems of fuel, power, and communications disruptions as fixed facilities. Alternate means for power supplies and shelter in-place needs must be addressed by fixed facilities in addition to evacuation contingency planning.

Another fatal flaw in emergency planning is the assumption that personnel will in fact report to work. This consideration must be taken without regard to the status of roadways and transportation. A survey study conducted by Columbia University in September, 2005 demonstrates possibility of personnel, who are otherwise unaffected by crisis, refusing to report to work. In this study, health care workers were asked to indicate if they would be able to report for work or willing to report for work in the event of a mass casualty incident. 81% said that they would be able to go to work if there was an environmental disaster, yet only 69% said they would be able to go to work during a small pox epidemic. The study goes on to note that the willingness to report for work would only be 48% of health care workers during a SARS outbreak. Further, only 57% of health care workers would return to work in the setting of a radiological event. The fallacy in this stage of planning is to assume that Healthcare workers who have a perceived obligation to respond will, in fact report to work. Numerous sources have noted that the willingness to report for work in any situation may be impacted by concerns for the safety of the responder’s family. It is important for employers of public and private organizations to understand that the family care can be as vital as responder care. Workers fears will impact their willingness to work and administrators and company leaders must talk to their workers about these concerns regarding exposure and contamination and reassure them by planning to assure family and dependent safety. An example of such contingency planning would be the setting of avian flu or H5N1 pandemic. It is estimated in such a situation that nearly 30 to 40% of the American workforce would become stricken or ill and unable to report for work of any kind. And that percentage the number of persons engaged in critical infrastructure duties such as police, fire department, EMS, or other critical infrastructure positions failing to report for work and any given crisis situation can then be expected to be magnified.

In the above mentioned settings simple failures in the supply chain for routine maintenance can become catastrophic.

Another important point to consider is that of the lack of surge capacity in the concept of ripple effect deaths. Surge capacity is a specter of imagination as many Healthcare systems operate at or above capacity every-day. Just as the traditional response groups will continue to respond to the routine calls for service during a large scale event, routine requests for routine medical emergencies will continue to arrive at local hospitals. Lacking surge capacity will almost certainly cause some of these otherwise routine patients to destabilize and become critical or fatal. This can add to the death toll of any large scale event and further destabilize community infrastructure. Much attention has been given to triage in the appropriate use of medical resources such as ventilators. Triage of such medical procedures and devices is also unrealistic; consider that just a short time ago the health care community could not come to consensus on the triage of flu vaccine during a shortage and without the pressure of an actual event going on.

This Plan is Your Plan; This Plan is My Plan. Not.
Despite the fact that numerous of urgency service agencies and Healthcare systems have spent countless hours and dollars on the planning process few if any of these plans integrate with each other. There is little if any continuity between traditional response groups and Healthcare systems or any other community infrastructure for that matter. Failure of any agency or service to adopt or even recognize the existence of the national incident management system or NIMS will be the cornerstone of failure during a large scale event. Scant few services, either public or private, address, and planning needs or participate in any level of joint training. This unfortunate situation is perhaps the least expensive and easiest to implement, yet remains ignored.

What do we do now?
There are no clear-cut answers in any of these situations. However failure to acknowledge that such shortcomings exist in the planning process may themselves the largest obstacle to overcome. The setting of a biological vent weatherman made intentional or natural cannot be compared to acts of terrorism the American public has become familiar with. Any naturally occurring biologic event or intentional act of biological terrorism will force our change in perspective.
The good news is we have been dealing with biological events for quite some time. We have come to no and rely upon basic medical personnel protective equipment and procedures such as hand washing and respiratory etiquette. These protective measures which we employ every day will serve us well in the setting of a biologic event.