Clinicians Respond to Emergency Preparedness

  1. From Medscape.com:
    http://www.medscape.com/viewarticle/456964?mpid=15178

    from Clinician News
    Posted 06/17/2003
    Melissa Knopper


    Jackie Osterhaus, PA-C, had to think twice when a little girl came into her office recently with flu-like symptoms and a peculiar rash with raised bumps. Osterhaus works in a family practice in Morrison, Illinois, a rural town near the Iowa border. But she also serves as a medical officer in the US Army Reserve. Fresh from a briefing on bioterrorism, Osterhaus wondered: Could this be smallpox? "Since the war in Iraq started, everybody is panicking about every little thing," Osterhaus says. "And the more you know, the more you worry."

    While searching for information about the patient's rash, Osterhaus realized how little information is available about biological agents like smallpox. "I opened up a dermatology textbook, and there were no pictures of smallpox," she recalls. Luckily, her story ends more typically than tragically: The little girl tested positive for strep throat and has recovered fully.

    Across the country, many health care practitioners are experiencing similar uncertainties and concerns, which are heightened every time the federal government places the nation on alert. Clinicians will play essential roles if there is another terrorist attack. Those in primary care will likely be the first to identify an unexplained illness. Those who work in hospital emergency departments will set up mass casualty triage areas and decontaminate victims of any chemical attack. School nurses will be responsible for the safety of thousands of children who could become trapped inside their schools. To provide clinicians with real-time information to help prepare for (and possibly respond to) terrorism and other emergency events, the CDC has launched a clinician terrorism and emergency response e-mail update service, available at www.bt.cdc.gov/clinicianreg.

    Treating - and Experiencing - Fear
    Many health practitioners have been counseling patients who are worried about terrorism, and in some cases, prescribing sedatives to calm their nerves. In schools and family practice clinics everywhere, clinicians are hearing from patients who are afraid. Because of this, primary care providers must also be good mental health counselors, says Lawrence Herman, PA-C, MPA, Assistant Professor/Senior Clinical Coordinator of the Department of Physician Assistant Studies at the New York Institute of Technology and a member of the American Academy of Physician Assistants' Clinical and Scientific Affairs Council. In his Long Island internal medicine practice, many patients have had increased anxiety levels since the war started, Herman says, especially those who lost loved ones on September 11, 2001. "We are prescribing more Xanax than ever before."

    Herman, who is a preparedness expert, advises patients not to go overboard and buy a dozen gas masks. "I would look upon this as preparing for a bad snowstorm or an approaching hurricane," he says. In his own home, he has stashed away a three-day supply of food and water. He has also stockpiled first aid supplies and two weeks' worth of prescription medicines for his family members. Like many, however, he is skeptical about some of the recommendations in the US Department of Homeland Security's citizen preparedness campaign (available at www.ready.gov). "The idea of duct tape gives us a false sense of security at best," Herman says.

    Many clinicians report hearing from friends and patients who are considering moving from major metropolitan areas to more isolated, rural areas-which they perceive to be safer. "I can't say I blame them," says LeRoy Holland, RPA-C, President of the New York State Society of Physician Assistants. "I was thinking of investing in some property in the Poconos [in Pennsylvania] anyway when this happened," he says. "It's obvious New York is a red zone for any type of terrorist attack."

    New York Practitioners Lead the Way
    Both patient and clinician reaction to the threat of biological, chemical, and other forms of domestic terrorism vary largely according to geographical location. "It's clear people who live in Missoula, Montana, probably feel much less risk of a bioterrorism event than those in Washington, DC, or New York," says William Schaffner, MD, Professor of Infectious Diseases and Chairman of the Department of Preventive Medicine at Vanderbilt University School of Medicine, Nashville, Tennessee.

    Hospital-based clinicians in the New York metropolitan area are ahead of their counterparts in other areas of the country who did not have to confront the realities of September 11 directly. "Most people in New York are hyper-aware when they are walking around. You'll think about taking the subway, then decide to walk the six blocks because it's safer," says PA Herman, who formerly worked in emergency medicine in the Long Island area and who lost 35 friends on September 11. "You can't ignore the reality when you come out of Penn [railroad] Station and see a Humvee with a machine gun mounted on top of it."

    Maureen Gaffney, RPA, who works in the Long Island area-at the Winthrop-University Hospital emergency room in Mineola, New York-did not have to think twice about getting a smallpox vaccination so she could better treat patients exposed in a potential biological attack. Since Gaffney (who is married to a New York firefighter) and her colleagues lived through September 11 and treated some of the "walking wounded" that day, they have a better idea of what a terrorist attack really looks like. "That feeling of unity and pride in how we worked together as a team gave us the confidence that we can do it," she says.

    Needless to say, Gaffney and her colleagues did not drag their feet when putting together a disaster response plan for the hospital. "It seemed like such an overwhelming task to prepare for all of the possibilities we thought could ever happen, but now there is such a sense of urgency," she says. "It's not hypothetical anymore; it's a reality, and we can't be caught by surprise." Since Gaffney's workplace, a teaching hospital, is full of transient residents and medical students, it is the NPs and PAs who form the real backbone of their emergency response team. "What's great about PAs and NPs is we tend to be a very resilient bunch and also very mature and pragmatic," Gaffney says. "I think the hospital is realizing who they can count on in situations like these."

    Meanwhile, at Harlem Hospital Center in upper Manhattan, Holland and his coworkers have been meeting regularly with firefighters who work across the street to make plans for a separate decontamination area in case of a chemical attack. They are stockpiling antidotes to nerve agents, like atropine-and antibiotics, like ciprofloxacin and doxycycline, used to treat anthrax and other infectious diseases terrorists could unleash. Gas masks and protective suits are also part of the plan. And the hospital is hiring seven more PAs to make sure staffing is adequate in case of an attack. Most importantly, he says, the staff at Harlem Hospital Center has had multiple drills to make sure they work out the kinks and get to know first responders from other agencies in the city.

    In Rural America
    While the odds of an attack in rural Appalachia are lower, retired family practice NP Elizabeth Meiler is approaching disaster preparedness with just as much dedication as her colleagues in New York. "We are located 90 miles north of Atlanta in the Blue Ridge Mountains, and we are in an area that would probably get a lot of people coming up if they had to get out of the Atlanta area," Meiler says. "I've got the time to give, and I wanted to take the opportunity to do the best I can to keep my community as safe as possible."

    Meiler is coordinating the Appalachian Community Emergency Response Team, which is part of the federal government's Citizen Corps program (www.citizencorps.gov). Meiler, who worked for years as an intensive care trauma nurse, believes PAs and NPs are well suited to serve in the emergency preparedness effort. "We became NPs and PAs because we have within ourselves the confidence to make decisions to get things to happen," she says. "You have to be pretty gutsy to be an NP or a PA anyway, because you have to stand up for your patients and get them the care they need."

    Back in rural Illinois, Citizen Corps volunteer PA Osterhaus, who is a member of the Whiteside County Bioterrorism Task Force, has been setting up a plan to inoculate health care workers in case of a smallpox outbreak. In her state, however, public health officials put a halt to the vaccination program due to reports of severe adverse effects. After the incident with the little girl's mysterious rash, Osterhaus also volunteered to put on a smallpox and bioterrorism continuing education seminar for her fellow health care workers in northwest Illinois. She feels confident her county would be ready if something awful happened. "We've done about as much as we can," Osterhaus says. "Things are pretty much down on paper, spelling out how it would work and who does what first. I just hope we never have to use it."

    In the School Setting
    Members of the National Association of School Nurses (NASN) are also doing their part. The organization published a preparedness training manual that has been distributed to school nurses across the country and will be part of a seminar scheduled for their upcoming national conference. "Many of our school nurses have been involved across the nation in the preparedness effort," says NASN Executive Director Judith Robinson, PhD, RN, FAAN. "We've met with key congressional leaders related to first responders, and with local community leaders, to educate them about the role we play in a school setting if there should be an act of terrorism. We've worked very hard to inform them it's critical for school nurses to be involved in the planning."

    Like hospital-based clinicians, school nurses are stockpiling 72 hours' worth of medications, antibiotics, first aid supplies, food, and water for their students. They are setting up decontamination zones and reading up on the symptoms of smallpox and SARS. They may also be responsible for training teachers within the school district to administer first aid, since they cannot be present at every school at the same time.

    Unlike someone who works in the emergency department, school nurses will not be done with their jobs after the event has passed. They will continue to treat long-term effects, such as new asthma cases due to environmental exposure to debris or chemicals. And they also will treat the emotional impact of the terror. "The school nurses in New York City were sort of silent heroes," Robinson says. "They provided a lot of mental health counseling for the kids after the September 11 attacks."

    Still a Way to Go
    While most experts agree the United States is more prepared for a terrorist attack than it was prior to September 11-and PAs and NPs have played an important role in that effort-they also believe we have a way to go before all citizens can be adequately protected. Monica Schoch-Spana, PhD, a senior fellow at the Johns Hopkins University Center for Civilian Biodefense Strategies, said the federal government's www.ready.gov campaign was a good first step, but it did not go far enough because it focused only on what individuals can do to prepare.

    "It would be nice if there were clear guidance on what neighborhoods, schools, and large workplaces can and should be doing to prepare," she said. "It shouldn't be about people hunkering down in their basements with their windows taped up."

    So while PAs and NPs-and plenty of other citizens-have stepped up to help, the government's preparedness network of Citizen Corps, school, and hospital disaster programs is not quite off the ground, according to Schoch-Spana. In many communities, preparedness volunteers could be doing a lot more, but they are waiting for the funds. "Plans are in place in bits and pieces, but there is still a lot of inertia," she says. "The federal government needs to be sending more money to the front lines."

    Melissa Knopper, Contributing Writer
    Clinician News 7(4):1, 22-23, 2003. 2003 Clinicians Group, LLC
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