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Supreme Court Reaffirms Affirmative Action Policies Institutions Grapple with New HIAA Regulations "Operation Tipoff 2" Bioterrorism Exercise Offers Educational Lessons Family Medicine: Trying to Fill the Ranks Current & Choice: 'Prime Time Innovations in Medical Education: The Arts as a Teacher A Word from the President: Educational Diversity is a Compelling Interest Viewpoint: Loan Help for Researchers
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"Operation Topoff 2"
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Photo courtesy Harborview Medical Center |
The mock crisis began around lunchtime on Monday, with the detonation of a radioactive "dirty bomb" near a coffee roasting plant in Seattle. ER staff at all 17 King County hospitals immediately swung into action, directed by Harborview Medical Center's Emergency Services Department. Staff were able to follow the crisis on a virtual TV network set up exclusively for the drill.
"We were Hospital Control, so we got the first call," says Administrative Director of Emergency Services Chris Martin, R.N., chair of Harborview's Disaster Committee and one of two "point people" designated by the Washington State Hospital Association Emergency Preparedness Committee. "We were told the fire department was on the scene of an explosion and we were to expect 200 or more casualties through the ER." Martin quickly relayed the details to the other hospitals via short-wave radio, and updated the hospital's emergency information Web page.
A short time later, Harborview staff learned the explosive device contained radioactive material, "although we didn't know what kind," Martin reports. The decontamination team - designated ER medical staff, plus engineering and public safety personnel - was called in and began setting up a heated decontamination tent on the road by the hospital's ER wing.
"It took our engineering staff only about 30 minutes to assemble the decontamination tents, but it was excellent practice since it was our first time" using them, Martin says. Then staff pulled out their response cards and donned protective gear.
"We knew from our training that the best way to decontaminate a patient is to remove their clothes, so we made sure to have a radioactive waste container ready," she says. Patients who were critical were to bypass the tent and go straight to the OR, where they would have their clothes removed and their hair washed. "We made sure the water was safely contained and disposed of by our nuclear medicine staff," she adds.
Then they waited. "That part was a little disappointing," she recalls. "It took a long time for the patients to get to us from the field. Only six people arrived in the first 90 minutes of the crisis, and the rest trickled in later in the afternoon. We were expecting a flood - that's what drives the ER in a mass-casualty situation. I would have liked to have been really challenged by the numbers." In the end, Harborview treated about 30 patients, all of whom "survived."
Just 24 hours later and halfway across the country, the scene was quite different as very sick people began turning up in ERs in Chicago and across Illinois. Their devastating symptoms were quickly diagnosed as pneumonic plague, unleashed in a biological attack by the same terrorist group.
Thirty-six people "died" among more than 300 infected. At hospitals across the state, infected patients - volunteers wearing bright yellow T-shirts printed with "Role Player" - mixed in with real patients to test hospitals' ability to meet the crisis amid business as usual. Every once in a while, a volunteers would produce a card indicating they had died.
Even more victims were represented by faxes pouring into the hospital containing a name, a diagnosis, a brief medical history, and a summary of physical findings. These "paper patients" were triaged through ER and treated as live bodies, subject to the same hospital resource allocations.
Richard Fantus, M.D., Chief of Trauma Services at Advocate Illinois Masonic Medical Center on Chicago's north side, acted as incident commander for his hospital. "We knew early on that something unusual was going on because of what was coming across the mock news network, and the communications we received from the public health department."
But he noted that diagnosing all the ER arrivals was not as straightforward as expected. "Victims came in with various symptoms, many having nothing to do with plague. Some had had heart attacks, some were pregnant, some had the respiratory symptoms of SARS. Just as in real life, we had to identify who was likely to have been exposed, and triage them according to respiratory symptoms," he says. "Staff were gowned and masked and everyone suspected of exposure immediately went into respiratory isolation."
Just a few miles away, at Advocate Lutheran General Hospital in Park Ridge, Ill., Douglas Propp, M.D., chair of Emergency Medicine, was learning firsthand the unique challenges a bioterror incident presents as a mass-casualty event. The hospital treated some 80 infected patients, with only a handful of deaths.
"The real eye-opener was that the institution's response has to be significantly different for a potentially communicable disease," he says. "Usually mass-casualty events are about managing volumes - which we had to do - but the placement and movement of patients throughout the institution had to be controlled so carefully."
He reports that several panicked "patients" tried to gain access to the ER by bypassing security, "which I think is consistent with a real-life situation. That's a scenario we've never had before. We are now revising our emergency plan because of what we learned from TOPOFF."
Propp says that he purposely chose not to engage residents and students very deeply in the exercise, feeling that it offered a better opportunity "for more senior people to get involved. I did not want to delegate anything so I - and our expert on bioterror - could get the first-hand experiences we needed to." Nevertheless, the lessons of those days in May will be applied to the hospital's academic mission. As a clinical associate professor of medicine at the University of Chicago, Propp says the experience "will be an important part of my teaching."
"Quite frankly, I don't think disaster response has been given its due in the medical school curriculum," says Nancy Pasieta, RN, director of EMS and chair of Advocate Christ Medical Center's emergency management committee. She agrees that TOPOFF offers a rare opportunity for students, residents, and even faculty physicians, now and for the future.
"They got firsthand knowledge of large-scale triaging and isolation to prevent contamination to caregivers and other patients in the facility," she says. In today's times, anyone might be called upon to make quick decisions about contamination, and they need to know how to protect themselves on a sustained scale for a whole week, she believes.
"TOPOFF really opened a lot of people's minds to what they could learn, and I think they learned a lot. Even the virtual news network was very well orchestrated. There were lots of events breaking simultaneously, requiring us to shift our attention and use critical thinking skills moment-to-moment. It was fortunate for the residents who had a chance to participate," she adds.
Thanks to the rumor mill that was in full swing before the drill even began, Christ Medical Center chief resident Prechtel was able to cram on pneumonic plague in advance. He was ready when the first paper patients began pouring from the fax machine. "That Wednesday morning started as normal, and I was seeing patients when I was approached by a nurse with a piece of paper, detailing a patient in shock and respiratory distress, with impending organ failure."
Prechtel reports that caring for paper patients condensed treatment time considerably, but he was struck with the realization that "each of these patients would have taken up at least 30 minutes of my time to stabilize. I had a sense if they had come in at the same time, it would have been the start of a very bad shift."
At about 3 p.m., "the real patients started coming in," Prechtel says. "Mostly [they were] local firefighters volunteering their time to role-play for the scenario. Then, suddenly, the 'real' part of the drill was cut off. That was disappointing. I wanted to see it though to a natural conclusion."
The take-home lesson for Prechtel was "that we can do our best to be prepared, but when it happens you'll find out there is really nothing you can really do to avert a crisis. In a real emergency, our resources would be overwhelmed. It definitely put to rest any false sense of bravado we had."
The experience further whetted the resident's appetite for emergency planning, however. "It was an educational exercise because I was able to sit in on preparation meetings on how all the components should and shouldn't work - we learned we needed a color-coded triage system, a minor treatment area and an urgent care area for the sick but not dying. We were able to expand and reallocate some of our spaces and set up a system where elective procedures would stop and we in the ER could take over."
When he moves to Orlando to begin his ER career at the Adventist Health System's Florida Hospitals this summer, Prechtel is hoping to become involved in an emergency-planning role there. "I really enjoy the work of the public-health investigator," he says. "It's interesting to uncover a possible epidemic through analyzing the common threads in my patients."
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