When Crisis Comes


One hospitalist spent three weeks without a break treating victims of Hurricane Katrina in 2005. Another couldn’t get to work when the I-35W bridge collapsed in Minneapolis on Aug. 1, 2007, but there were enough physicians on hand for that tragedy and fewer victims to treat than feared.

Yet another shudders when he recalls treating victims of an 89-car pile-up caused by a dust storm in southern Idaho.

Not all hospitalists have been in the trenches treating victims of disasters. But two emerging trends likely will put hospitalists on the front lines of preparing for disasters and treating victims.

The first is the increasing recognition that there are many threats to the safety of the public, including terrorism, natural disasters, disease outbreaks, and criminal acts like the mass killings a year ago at Virginia Tech in Blacksburg.

The second is the rapidly expanding role hospitalists have in caring for critically ill and injured patients.

“Hospitalists will be a key,” says Timothy Close, senior safety officer for the University of Colorado Hospital in Denver and chairman of its emergency management committee. “Because of their understanding of all hospital services and treatments, they can handle a multitude of clinical roles. Facilities should deploy hospitalists’ understanding of the organization to facilitate patient care.”

Close, who has 15 years of experience in planning and preparedness, urges organizations to implement plans “that are realistic and doable based on local resources and conditions.” He also urges facilities to conduct emergency drills and have hospitalists participate.

He has dealt with crises wrought by fires, workplace violence, severe weather, and abductions, but adds it is important to remember that “you never know what’s going to happen.”

Close helped treat the victims of the dust storm pile-up. “It was caused by an unfortunate series of events,” he says. “A new land owner plowed during a dry time, and when the winds came it was catastrophic. The cars ran right into the dust cloud with zero visibility.”

What to ask to be prepared

With hospitalists assuming key roles in the care of patients affected by disasters, all hospitalists should be well-versed in their facility’s emergency-preparedness procedures. Have answers to the following questions:

  • Ask to review the facility’s disaster plan, including details for specific events, whether man-made or natural. Ask if the plan is updated regularly;
  • Ask to review the plan for dealing with a disease outbreak because care of those patients would largely be medical rather than surgical—resulting in a large role for hospitalists in ongoing care;
  • Ask how you will be contacted if needed, including back-up communication methods;
  • Ask what specifically will be expected of you whether you are on the facility’s hospitalist staff or employed by an outside group;
  • Ask what the pay practices are for ongoing disaster service;
  • Ask what security plans are in place for keeping staff safe at the facility during the crisis;
  • Ask if child- or pet-care will be provided during the crisis;
  • Find out if the hospitalist staff has a representative or liaison with the facility’s disaster-planning group;
  • If there is no representative, ask if a hospitalist can be appointed to that role. The best candidates may be the head of the hospitalist group or someone with a specific interest in safety issues; and
  • In a teaching hospital, ask what role you will have, if any, in directing the residents.—KF

Prepare for the Unseen

Lisa Kirkland, MD, a hospitalist at the Mayo Clinic in Rochester, Minn., agrees disaster planning should be local in the sense of preparing for specific events. Tornadoes are the most likely weather-related crisis to occur in Rochester, she says, and the area is not a prime terrorism target.

Yet disasters don’t have to happen suddenly or involve mass casualties. “A disaster is anything that overwhelms the usual system,” she says. “Putting a community under quarantine during an outbreak of influenza or bird flu, for example, could require the initiation of disaster plans since staff couldn’t get to hospitals.”

In this sort of scenario, like during the SARS outbreak in Toronto in 2003, patient care would be largely medical, rather than surgical, so hospitalists would be key providers of treatment, Dr. Kirkland says.

Hospitalists would also be key in maintaining effective communication, internally and with the outside world because of their thorough knowledge of hospital services, she adds.

Some 75 miles away in Minneapolis, many victims of the I-35W bridge collapse were taken to Hennepin County Medical Center (HCMC). Glen Varns, MD, hospitalist program leader at HCMC, was unable to get to work because he lives on the other side of the bridge. But he says hospitalists played a critical role in dealing with the crisis.

“Since our hospitalists are most familiar with the inner workings of the facility, they played a huge role in determining who needed to be hospitalized and where in the hospital they would best be treated,” he says. “This included reviewing the existing patient census when the collapse happened so we could discharge and transfer inpatients appropriately to ensure that the hospital was in the best position to deal with the collapse victims.”

Because the bridge collapsed during the early evening, there was plenty of staff on-hand to treat the victims, including residents who worked hand-in-hand with hospitalists in making admission and transfer decisions.

Challenge for Hospitalists

In smaller facilities where there are no residents, or in small emergency departments (ED) and intensive-care units, hospitalists will and should have even more critical roles in handling disasters and planning for them, Dr. Varns says.

He believes all hospitalists—but especially those in small, nonteaching facilities—should get triage training. “Hospitalists have a very broad skill set—especially with increasing responsibility for co-management of surgical cases—but they should develop triage skills,” says Dr. Varns, who suggests hospitalists take a two or three-day advanced trauma life support course.

Steven B. Deitelzweig, MD, FACP, system chairman, department of hospital medicine and vice president of medical affairs for the Ochsner Health System in the New Orleans area, agrees.

“I think the folks who are closest to guiding the care should be offering input into triage decisions,” he says. “Hospitalists can be invaluable in doing triage of inpatients. They provide objective detailed information.”

Dr. Deitelzweig, who experienced the three-week lock-down following Katrina, suggests hospitalist groups create a system of prioritizing evacuation of patients—including what kind of support they’ll need.

He believes hospitalists will be invaluable during crises because they are “front-line decision-makers, along with ED physicians and intensivists.” Hospitalists should be on disaster-preparedness committees and a key part of communication during an actual crisis, he urges.

“Communication is critical during a crisis—and hospitalists know their systems,” he continues, noting that Ochsner has out-of-state cell phones, satellite phones, ham radios, spectral light phones, radio frequency antennas in secure places, and more.

In addition to equipment and supplies, hospitalists need to be prepared to do whatever is needed in a crisis, Dr. Deitelzweig says. “In a disaster, you might have to do a procedure usually done by a specialist—with supervision—to extend that person,” he says. “You also may have to go past the physician role. That’s where leadership shows. Our CEO served food in the cafeteria during Katrina. During a disaster, you have to be a flat organization and just do what needs to be done. That gives emotional support to everyone.”

Still, the need to prepare before a disaster cannot be overemphasized, he says.

Ochsner now has two teams of pre-selected physicians, including hospitalists, dedicated to working through specific types of crises. Having the list of essential personnel online at all times is intended to prevent last-minute scurrying around to find the right people, he says.

In addition, providing balanced scheduling—especially in long-lasting crisis situations like Katrina—is important, says Dr. Deitelzweig. “Timing for release must be included, and having more staff on hand than necessary can help alleviate stress,” he advises.

Lessons of Katrina

Neal Axon, MD, an assistant professor at the Medical University of South Carolina, says he and his colleagues learned from those who went through Katrina as they prepared for the most likely disaster in Charleston: a severe hurricane.

Dr. Axon, a senior hospitalist in his group, says the facility has a system that generates e-mail, pages, text messages, and cell phone calls to keep hospital staff informed about potential crises. He also says the preparedness plan provides for relief of staff working for extended periods.

In addition, the hospital has trailers and inflatable tents to extend its facilities if there is a surge in patients. It also has a facility to provide decontamination for exposure to chemicals and radiation.

Brian Bossard, MD, director of Inpatient Physician Associates and medical staff quality designee at BryanLGH Medical Center in Lincoln Neb., says preparedness plans should be tested and updated regularly—especially the systems used to call in staff.

Dr. Bossard strongly believes hospitalists should be involved in disaster planning: “Every day hospitalists work hospital systems. We have a broad scope and perspective. That’s what you need in a disaster.” TH

Karla Feuer is a journalist based in New York.

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