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Are you prepared to respond to bioterrorism?

Doctors will have to trigger the alarm-and make tough calls about patient care

From the December ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Treating anthrax: lessons learned from two front-line physicians

On a Friday in late September, infectious disease specialist Lawrence P. Martinelli, ACP-ASIM Member, spent the day playing a terrifying game.

He was part of a panel of physicians and public officials in his hometown of Lubbock, Texas, trying to think through the unthinkable: a fictitious bioterrorist attack being staged by the U.S. Department of Justice. Over eight hours, the local panel had to decide how to cope with the following scenario:

Pneumonic plague is released at a music festival in Lubbock's civic center. Within two days, patients with flu-like symptoms flood physicians' offices and emergency rooms; within three days, more than 200 are dead. By the time the epidemic is contained 10 days later, 4,300 people have been infected and 600 have died.

Dr. Martinelli and his colleagues were forced to answer questions they'd never faced before. What should they tell the media? Should—and can—the city be quarantined? Who should be considered too sick to treat and shunted to palliative care, and who should get the initial scarce supply of antibiotics?

"The most valuable aspect of the exercise was bringing the key players together," Dr. Martinelli said. "We now know who we'd have to talk to and what we'd have to think about if this were to happen."

As the ACP-ASIM launches a new bioterrorism task force, physicians across the country are rushing to learn the clinical presentations of biological agents. But experts say that doctors also need to look at the bigger picture when it comes to bioterrorist attacks.

Many hospitals, for example, can't handle the extra patient load during flu season, let alone mass casualties. Even worse, a recent survey in the Annals of Emergency Medicine found that only one-quarter of East Coast hospitals have procedures in place to meet biological or chemical incidents.

As a result, experts are urging physicians to talk to local public health and law enforcement officials now about how their community would respond to a bioterrorist attack, either in formal exercises like Lubbock's or in informal discussions. While no simple "cookbook" solution will fit every community, there are some specific things you can do to help respond to bioterrorism.

Spotting trouble

As part of their preparedness plan, public health officials in New York City comb through data on each day's ambulance runs, looking for unusual volume. Since mid-September, Philadelphia officials have crunched daily data from six sentinel hospitals to try to spot peculiar infectious disease patterns. And Tampa officials are tracking one school district's daily absenteeism to establish a baseline—particularly during flu season—that can be used to quickly detect unusual numbers.

While your community probably can't implement such high-tech surveillance systems, it can at least track emergency room admissions by patient age and condition. (The age group could tip you off to where an incident might have occurred.) Even if your town can't afford sophisticated indicators, every community must rely on a key surveillance system: your instincts as a physician.

"Be suspicious," said Larry M. Bush, FACP, the infectious disease specialist who diagnosed this fall's first case of inhalational anthrax in Florida. (See " Treating anthrax: lessons learned from two front-line physicians," below.) "Learn the symptoms of different conditions, question what you see and test your hunches."

Because treatment protocols for anthrax are being constantly updated, large practices like Dean Health System in Madison, Wis., are using e-mail and internal computer systems to update physicians and clinical staff. In smaller practices, experts say, physicians should regularly check Web sites of the CDC and state health agencies. (See "Clinical and disaster response resources," online at www.acponline.org/journals/news/dec01/bioterror.htm#resources.)

One critical surveillance question has preoccupied Dr. Martinelli since Lubbock's disaster exercise: What's the threshold number of cases that should trigger an alarm? One case of suspected smallpox would be enough, he said, but both anthrax and plague initially present with flu-like symptoms.

"How many cases of flu-like illness do you get before you sound the warning?" he asked. "You don't want to get so paranoid that you call the feds the first time you see five sick people in one day. But you don't want to delay your ability to access needed resources."

If you see suspicious cases, ask colleagues if they're seeing anything out of the ordinary. And check to see if your hospital's infection control and emergency departments are seeing unusual cases.

As part of any disaster response plan, make sure community physicians have the phone numbers to call if they suspect bioterrorism. Keep the number of your local public health agency handy. Also list the numbers of your state health department and the CDC, because many local agencies aren't open after 5 p.m. or on weekends.

Also think about how you'd communicate with staff in case of an emergency. In a major event, you'd probably be assigned to the hospital or some other treatment facility, so you won't be at your own practice. Keep a list of all staff phone, fax and pager numbers to activate a phone tree, or advise staff to call the answering service or their voice mail for a broadcast message.

Shaky drug supply

In any major event, federal drug supplies and other resources are typically available within 24 hours. Initially, however, your community will have to depend on the resources already on hand.

Unfortunately, experts point out, most health care systems have been steadily downsized due to cost-cutting measures and falling reimbursements. As a result, they can't handle a surge of patients.

"Communities have absolutely no surge capacity now," said Tara J. O'Toole, MD, director of the Center for Civilian Biodefense Studies at Johns Hopkins School of Medicine and Public Health. "Just-in-time supply models are being used not only to stock drugs, but to purchase ventilators, staff nurses and manufacture pharmaceuticals. All along the line, there is no excess capacity." (For more on this trend, see "Drug shortages raise new fears about patient care," page 1.)

Check your community's inventory of masks, gloves, IV fluids, ventilators and medications. A ballpark estimate of how much—or how little—you have on hand will help you judge what to ask for in an emergency. It will also help you make tough decisions if an incident takes place.

During the exercise in Lubbock, for example, Dr. Martinelli and his colleagues had to decide who should get the community's limited supply of antibiotics before federal supplies arrived. "We decided to give it to the first responders—the EMS people, nurses and docs—rather than patients," he said. "That shocked a few people and it sounds self-serving, but in an epidemic without enough drugs, you have to decide where they'll do the most good."

Some communities are stockpiling antibiotics, a solution that may be beyond your community's means. And some hospitals have decided to keep several days of drugs on hand for hospital staff and their families.

"That's an expensive policy," Dr. O'Toole acknowledged, "but people are not going to risk bringing a deadly disease home. If you can't give drugs to medical staff and their families, they simply won't come to work."

Another crucial capacity question: How many beds would be available for attack victims? In a major event, patient volume would overwhelm local hospitals almost immediately, so you need to identify other community facilities that could be pressed into service, particularly if patients need to be quarantined.

In Lubbock, panel members used six schools around the city as triage and treatment centers. Experts also recommend that you consider hotels, civic centers, nursing homes and fairgrounds—places with phone banks that can be secured.

Deploying physicians

Medical staff is another scarce resource you'll need to utilize. Who, for instance, would care for the chronically ill and patients who need dialysis or coronary care that is unrelated to the bioterrorist incident?

"You could use retired physicians and nurses to handle normal emergencies and chronic care," said Paul P. Rega, MD, an emergency physician at the Toledo Hospital in Toledo, Ohio, who has authored a physicians' guide to bioterrorism. "That would leave the youngbloods to handle the onslaught."

While FBI agents would technically be in charge of any major event, they would need to work closely with local physicians and hospitals. As part of your response plan, put together an emergency call roster of community nurses and physicians.

It's also critical to identify who will assign responsibilities to physicians during an emergency. Otherwise, "physicians will start self-tasking or freelancing" in a disaster, Dr. Rega said, "which can hurt the whole response system."

How you'll deploy medical personnel depends on how many and what kind of physicians are in your community. If you have a diverse physician specialty population, you could give physicians tasks according to discipline.

"Triage becomes critical during any disaster," said Mark G. Kortepeter, ACP-ASIM Member, chief of the medical division of the U.S. Army Medical Research Institute of Infectious Diseases. "The people who probably have the most triage experience are emergency physicians and trauma surgeons."

Infectious disease specialists would be needed to provide treatment information, while other disciplines might be assigned to patients according to illness severity. Hospitalists, critical care physicians and internists might care for the very ill, while family practitioners and pediatricians could manage the less sick or the worried well.

With noncontagious agents like anthrax, you might set up physicians in neighborhood triage and prophylactic centers. When planning for infectious conditions, however, consider strategies that would keep large groups from congregating. Some communities are planning to have antibiotics delivered door to door by mail carriers, while others may use "drive-through" prophylactic centers set up in large parking lots around the community.

You should also discuss how you'd use the disaster medical assistance teams that would arrive in a major event. In Lubbock, Dr. Martinelli and his colleagues decided to keep local physicians and nurses working together in the hospitals and the overflow areas immediately around them. The Lubbock panel reasoned that locals would be most effective working in already established teams, so they sent arriving teams to the outlying triage and treatment centers.

Frances Edwards-Winslow, PhD, the director of emergency preparedness for San Jose, Calif., said that some communities might instead use disaster teams to replace local personnel. "These teams could go to the hospitals and replace ER staff or internists for a rotation," she said. "That way, your staff can rest or spend some time with their families."

Prepare yourself

Finally, experts say, be prepared yourself. In the hours and days after the World Trade Center attacks, many physicians from other states jumped in their cars and drove to Manhattan. In case you do respond to an emergency, keep a sleeping bag, as well as food and water, in your car.

And if you think you're likely to volunteer for an emergency outside your own practice area, consider joining a disaster medical assistance team at the local, state or federal level now. Medical volunteers need to have their license and insurance checked out before they can be assigned during disasters.

"As part of a team, your credentials and insurance are already in place, and you train with the people you'd work with," said San Jose's Dr. Edwards-Winslow. "Otherwise, it's likely that someone with high-level medical skills will show up at a facility sincerely wanting to help, but because of credentialing issues may be either sent away or given only menial tasks."


Treating anthrax: lessons learned from two front-line physicians

Larry M. Bush, FACP, an infectious disease specialist in Atlantis, Fla., started thinking about the possibility of biological attacks immediately after Sept. 11. He was planning a CME course on bioterrorism for the hospitals in surrounding Palm Beach County when he was called for an emergency consult on Oct. 2 at JFK Medical Center, where he is chief of staff.

A patient admitted in the middle of the night was extremely ill and on a ventilator. Emergency physicians, who suspected bacterial meningitis, drew spinal fluid that was stained in the lab. When Dr. Bush looked through the microscope, he saw "big blue boxcars," he said. "As soon as I saw the gram stain, I turned to a technician and said 'That's a bacillus, and it could well be anthrax.' "

Among the 50 different kinds of bacilli, Dr. Bush knew that only Bacillus anthracis and B. cereus could make a patient that sick. "But with B. cereus, there is usually a preceding event or underlying disease, like immuno-incompetence or trauma," he said. "The patient had nothing to suggest that."

Over the next several hours, he and a technician kept testing the organism, and all the results supported his original diagnosis. The bacillus was non-motile, growing aerobically, non-hemolytic and penicillin-sensitive—all hallmarks of anthrax.

That afternoon, as rumors raced through the hospital corridors, Dr. Bush called the county health department and shipped samples to a state lab in Jacksonville. The next night, state health department officials pored over the patient's chart, and the day after that, Dr. Bush sat down with CDC and FBI officials. He had become the first physician to diagnose a case of inhalational anthrax in the United States since 1978. Three days after the diagnosis, his patient would become the nation's first bioterrorism fatality.

Dr. Bush said he learned some valuable lessons in the days and weeks that followed. For one, he realized the importance of getting out accurate, scientifically based information-an opportunity he said he believes has largely been fumbled.

First, his patient was called an isolated case, which turned out to be false. "You don't want spokespeople speculating-that's how to lose credibility," he said. "You need people out front who will admit they don't really know what's happening." Then, Dr. Bush said, officials waited for weeks to announce alternate therapies for anthrax besides ciprofloxacin.

He also said that officials should be more forthcoming about the fact that there is no vaccine available for smallpox, for example, and that the only company producing anthrax vaccine was closed down last year for quality control problems.

Another key lesson, according to Dr. Bush: "You have to think outside the box. The FBI kept suggesting that this patient got infected while fishing or gardening. I looked at them and said, 'You can't honestly believe that.' It took several days before they checked the patient's workplace and decided to close it down."

Keeping an open mind was also crucial for Richard P. Fried, ACP-ASIM Member, an infectious disease specialist in Manhattan. When he saw a patient on Oct. 1 with an unusual chest lesion, he suspected cutaneous anthrax even though the lesion did not have the classic textbook presentation.

"It wasn't blistery or ulcerative, and there was no black eschar yet," Dr. Fried recalled. The lesion was, however, "intensely inflamed and covered a good part of her upper chest." When the patient explained that she had recently opened a letter that spilled powder on her chest while working at NBC, he decided to act.

Dr. Fried started the patient on antibiotics and called the New York City Department of Health that afternoon, becoming the first physician in the country this fall to notify public health officials about a possible anthrax case.

Like Dr. Bush, Dr. Fried ran up against a lack of coordinated communication between different agencies. "When I called the health department, they had absolutely no knowledge of a letter having been sent to NBC, even though the FBI had been notified several days before and had begun investigating," he said.

One of the most glaring lessons he learned? The criminal and epidemiological arms of a bioterrorist investigation need to stay in constant communication.

Dr. Fried also said he was frustrated by a lack of faster diagnostic tools. He had taken both a smear and a culture—"there wasn't much material to sample"—and both came back negative. As a result, the city health department decided not to notify the CDC. His diagnosis wasn't actually confirmed until more than a week later, when a biopsy taken by a dermatologist tested positive at the CDC. (The same biopsy tested negative, Dr. Fried said, at a specialty lab.)

In Florida, Dr. Bush said he has learned how crucial it is to reverse emerging antibiotic resistance. And he said he draws a more basic lesson from this fall's events.

"Many things have changed since Sept. 11, and I think one of those is the practice of medicine," Dr. Bush said. "You can't practice over the phone or online. You have to see patients, make a differential diagnosis, follow up with tests and use your instincts. That's what worked, and internists should take comfort in that."

Clinical and disaster response resources

  • ACP-ASIM's Bioterrorism Resource Center has therapeutic recommendations and breaking news.


  • The CDC's bioterrorism site has extensive sections on epidemiology and surveillance, as well as information on the National Pharmaceutical Stockpile Program and laboratory response.

    The CDC also offers the 34-page booklet, "Bioterrorism Readiness Plan: A Template for Healthcare Facilities," that includes descriptions of biological agents and syndromes, as well as an appendix of FBI field offices.


  • The HHS Office of Emergency Preparedness maintains a national disaster medical system. Information includes steps to take to help form a disaster medical assistance team.


  • The U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) sells a 12-hour video set or CD-ROM, "Biological Warfare and Terrorism: The Military and Public Health Response." CME credits are available.

    The Institute also makes available the "Medical Management of Biological Casualties Handbook," also known as the Bluebook. A free download of the handbook in PDF or Word format is available.

    USAMRIID also offers in-house and satellite courses on bioterrorist medical and response issues.


  • The Web site of the Center for Civilian Biodefense Studies at Johns Hopkins University School of Medicine and Public Health includes a section on diagnostic criteria and treatment of different biological agents. It also has links to consensus statements published in the Journal of the American Medical Association on anthrax, botulinum toxin, plague, smallpox and tularemia.


  • Emedicine.com, an Internet-based peer-reviewed medical reference source, is offering free PDA downloads of its "Disaster and Trauma eBook." The publication contains nearly 2,000 pages of information on terrorism and biochemical and radiologic warfare.


  • The Texas Engineering Extension Service, a division of the Texas A&M University System, offers courses around the country on preparing a medical response to bioterrorist and chemical attacks.


  • The Federal Emergency Management Agency (FEMA) maintains state offices, most of which have their own Web sites. Those state sites contain the phone numbers of county and city emergency managers and sheriffs within each state.


  • The Annals of Emergency Medicine Web site offers full text of several articles related to disaster medicine and emergency preparedness.


  • The AMA has a disaster preparedness and medical response Web site.


  • Stanford University is offering its SKOLAR MD biological and chemical terrorism database of articles and information available to subscribers and to nonsubscribers for a 10-day free trial.


  • A physicians' guide to treating bioterrorist attacks, "Biological Terrorism Response Manual: A Stat Manual to Identify and Treat Diseases of Biological Terrorism," written by emergency physician Paul Rega, MD, is available for $74.95.


  • COLA, the national laboratory accreditation organization, is providing laboratory-specific information on chemical and bioterrorism.


  • "Preparing Your Business for the Unthinkable" from the Red Cross is geared more toward natural disasters like hurricanes or flood, but it offers good tips on how to take care of office space and staff during emergencies.


  • The Small Business Administration (SBA) has a disaster preparedness Web site. The SBA also offers a disaster loan program to help businesses rebuild after a disaster and offset financial losses that may result from physicians being called up for reserve or national guard duty. (For more on the Uniformed Services Employment and Reemployment Rights Act, click here.


  • Several articles in the Aug. 6, 1997, issue of the Journal of the American Medical Association discuss bioterrorism.


  • The July/August 1999 issue of the CDC journal Emerging Infectious Diseases covers a bioterrorism symposium sponsored by the Center for Civilian Biodefense Studies at Johns Hopkins University School of Medicine and Public Health.


  • "Weapons of Mass Destruction Events With Contaminated Casualties: Effective Planning for Health Care Facilities" was a special communications featured in the Jan. 12, 2000, issue of the Journal of the American Medical Association.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of the ACP-ASIM.

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