Serious tactical planning for bioterrorism and other acts of mass violence has been under way since the early 1990s. Health practitioners’ skills are being honed, but questions remain.

 The change that happened on September 11, 2001, caught most Americans by surprise. But not health care institutions. They saw the change coming at least 5 years before terrorists flew fuel-laden jet airliners into the Pentagon and Manhattan’s Twin Towers. Consequently, many of them were far along the path to equipping themselves to deal with those kinds of lethal attacks by the time Osama bin Laden and al-Qaida became names seared into the public consciousness.

Today, should it again happen that terrorists strike at the United States—not with planes but with deadly biological agents like anthrax, smallpox, or botulinum toxin—most major hospitals and quite a few smaller ones around the country will be ready to respond. And, thanks to that readiness, fatalities and permanent lasting injuries to innocent victims may be far fewer than the perpetrators hope to achieve.

Credit for thwarting those designs will be legitimately ascribed to many. Front and center among them will be respiratory therapists.

Resources for RTs

• The Occupational Safety and Health Administration Web site,, provides information on various aspects of preparedness, initiating teams, appropriate roles for each person on the team, risks, and other data.

• The American Society of Health-System Pharmacists’ bioterrorism resource manual includes information on antibiotic treatments and risks.

Disaster Medicine, published by Lippincott and Wilkins, discusses the role of the health practitioner in various types of disasters, with a focus mostly on natural disasters rather than bioterrorism.

Only a Drill
The process of preparing America’s hospitals for response to terrorist attack began in the mid 1990s, amid fears that foreign foes of the United States might smuggle into the country one or more biologic weapons of mass destruction. Congress sought to protect American lives from such a potentiality by passing the Nunn-Lugar Act in 1996. “Nunn-Lugar acknowledged our vulnerability to bioterrorism and called upon the states to make preparations for dealing with a bioterrorist event,” says Richard E. Hoffman, MD, MPH, a former official with the Colorado Department of Public Health and now a private consultant and medical epidemiologist in Denver.

Since 1996 and the advent of Nunn-Lugar, hospitals around the country have been busy developing, testing, and refining disaster-management plans. “The first priority for these hospitals has been to make sure they can protect their own staffs and patients,” says Hoffman. “They are doing this by arranging to provide the necessary personal protection and infection-control equipment, such as masks, gowns, gloves, and negative air-pressure rooms. They also have been stockpiling antibiotics and making sure their staffs are vaccinated. Further, they have been establishing communications networks whereby they can talk to other hospitals’ emergency managers and coordinate their response for the benefit of the affected community or region.”

An example of that sort of coordination can be found in New York City, where hospitals participate in an information collection program operated under the auspices of the local health department.

“We—along with other hospitals in the metro area—are linked by computer to the Department of Health so we can provide timely updates on the availability of beds, the number of saline bags in stock, and so forth,” says Victor Cohen, BS, PharmD, clinical pharmacy manager of the Department of Emergency Medicine and Pharmaceutical Services at Maimonides Medical Center in Brooklyn. “All of this information becomes part of a huge database that is intended to help with mobilization in the immediate aftermath of a disaster.”

Cohen, who also serves as director of the Hazardous Materials and Decontamination Team for Emergency Operations at Maimonides, notes that many hospitals have taken the added step of substantially fortifying their infection control groups as part of their bioterrorism response readiness efforts. And they are participating in periodic drills to test their readiness for the real thing.

Drills are called at least twice a year at the University of California, Irvine Medical Center in Orange, Calif, where Steven T. Martin, RRT, is assistant director of respiratory care services. “These drills take only a few hours on a designated morning and are intended to present us with different scenarios that could occur,” Martin says. “One of the drills last year tested the reliability of our decontamination systems.”

UCI Medical Center’s respiratory team is trained to mobilize quickly once a disaster is called. “We all assemble in a predetermined location,” says Martin. “The person in charge—whether it be the director of respiratory care or myself or a supervisor, depending on who is the highest-ranking member of the department on site at that moment—would report to our hospital’s disaster-response command center to obtain information and directives as to where to send our people. If they needed some of us in the emergency department, for instance, we would reallocate our staffing resources accordingly. It is a very simple process, actually.”

After a drill at UCI Medical Center, the heads of each department sit through a debriefing. “The debriefing is our opportunity to give and to receive feedback about the way things were handled, to suggest things that could be improved based on what we experienced,” says Martin.

Who First?
In various states, the disaster plan hospitals follow is based on guidelines and regulations supplied by the government. Colorado, for example, seeking to fulfill the mandate of the Nunn-Lugar Act, initially moved to develop a statewide preparedness master plan for health care enterprises in 1999.

“The state at that time did have a few rudimentary preparedness plans in place, but these were designed only for responding to single-point events, such as toxic chemical spills, that would, in essence, affect just a small, easily contained area,” says Hoffman, explaining that these predecessor plans provided a foundation for the development of the much broader bioterrorism plan now in effect. “The difficulty in preparing to deal with a bioterrorism attack is that there is usually no single point where you can send all your first responders. With a chemical spill, the toxic material is released and people in proximity immediately are affected. But with a bioterrorism attack, the agent is released and then there is an incubation period of maybe a week before people are affected. By the time that happens, the resultant infection can have spread across a wide enough geographic area that you don’t know where to send your first responders or marshal your resources.”

Colorado’s law was introduced in the legislature in early 2000 and approved soon afterward. Two months later, the state participated in a federally organized drill to test the emergency medical system’s ability to deal with a bioterrorism event. The lessons learned in the course of that nearly 4-day exercise helped Hoffman and his colleagues craft the regulations that hospitals, local health departments, and trauma care consortia would subsequently use as guidelines in developing their individual preparedness plans. “The rules were adopted in spring 2001, and plans from all the hospitals were submitted to the state Department of Public Health in December 2001.”

Part-and-parcel to this process, a special committee of advisors was assembled to provide Colorado’s governor with the technical expertise necessary to make the hard decisions about, for example, who among the citizenry would be designated as first in line to receive medications that might be available only in severely limited quantity.

“Because these decisions carried the potential for very unpleasant ramifications, the legislature gave members of the committee immunity from lawsuits by people who, in the aftermath of a bioterrorist attack, might be somehow harmed as a result of the guidelines,” Hoffman says. “That immunity was necessary so that committee members could make the tough decisions unencumbered by fear of legal retribution. Our law also has a provision to grant immunity to hospitals and doctors who comply with board of health regulations and executive orders from the governor following a bioterrorism event.”

Hoffman contends that the Colorado plan is a good one, while conceding there are several important issues it does not address. “One problem is personnel,” he says. “To mount an adequate response to any given event is going to require a certain number of people to operate the various systems and provide the requisite services. The plan does not specify what that appropriate number is. So the question is, can we adequately and quickly enough mobilize following an incident?”

The state, he says, has sought by drafting the governor’s order to ensure sufficient manpower to permit emergency recruitment of out-of-state doctors, nurses, and respiratory care practitioners to work in Colorado during an emergency epidemic. “While they are here, they can care for bioterrorism victims as long as they do so under the supervision of a Colorado-licensed practitioner,” Hoffman says. “The law also permits the state to open its doors to retired RCPs and those in the military should even more manpower prove necessary.

“There’s no provision for conscripting the needed personnel, though. The law instead tries to encourage volunteerism by removing some of the obstacles to that—for instance, by providing immunity from lawsuits and eliminating the red tape that would otherwise hamstring efforts to instate them as practitioners able to work in Colorado. Also, volunteers injured in the performance of their job during a disaster would be eligible for workers’ compensation benefits.”

Similar to the concerns about manpower shortages in a time of crisis is the possibility that there will not be enough equipment to go around to provide for all casualties.

“If we run out of ventilators, we would have to scramble to get additional ones,” Hoffman says. “The law does allow authorities acting on orders from the governor to commandeer materials that would be needed to abet the response effort.”

And then there is the matter of organization. A problem for hospitals is that many hours or even days might lapse from the moment a biological terror attack takes place until the time officials determine that the people showing up sick at the hospital are casualties of it, says Cohen.

“You need to see a cluster of cases come through the door before anyone is going to declare a disaster and initiate the response plan,” he says. “The classic number of cases you would have to first see is five. But here in this urban area where we are located, we have four hospitals in proximity to one another, so it could happen that the cluster of five cases that would give you the requisite high index of suspicion ends up dispersed. The only way such a dispersed cluster might be identified in this kind of situation would be through surveillance by the emergency medical system.”

Important Roles for RTs
Among the best-positioned spotters for these indices of suspicion of which Cohen speaks are respiratory therapists. “The respiratory therapist is the one seeing the patients,” he says. “The respiratory therapist therefore has the ability to identify the high-risk patients with epidemiological clues. Let’s say he just got done intubating or mechanically ventilating a cluster of six or seven patients who are younger than you would expect to find at this level of respiratory failure. He is now looking at an index of suspicion. Realizing such, he would then notify the physician and can pose the question, could this be anthrax, could this be influenza?”

However, as Cohen attests, the role of RTs in disaster management extends beyond serving as mere front-line eyes and ears. “One of the most important things respiratory therapists can help with is in ensuring that the hospital is obtaining the optimal protection for staff, employees, and patients,” he says.

That very situation currently is occurring at UCI Medical Center, where Martin’s team is fit-testing respirator masks for all health care providers who would need to wear that type of protection in carrying out their roles in responding to a disaster.

“We’ve now identified everyone who would need to wear a mask, and are in the process of making sure each of them knows how to wear it properly,” Martin says. “We’re also informing them that they must undergo fit-testing again in the future in the event they do anything that ends up altering the shape of their faces, such as losing a significant amount of weight, having cosmetic facial surgery performed, or growing a beard.”

Cohen suggests there is also a role for RTs as contributors of valuable input at meetings of their hospitals’ disaster-management planners. “RTs can volunteer to be responsible for identifying the respiratory protection mechanisms that deliver the biggest bang for the buck,” he says. “There are institutions buying $2,000 masks versus the $1.99 N95s versus surgical masks. Respiratory therapists’ expertise could be put to use determining the differences between each type of mask, showing the decision-makers which one is most cost-effective for each type and level of risk that will be encountered.”

Money is, of course, an issue in disaster planning, even though there are significant dollars being made available from the government to hospitals for this purpose. Shortly after 9/11, Congress authorized a distribution in excess of $1 billion to the states to help them implement disaster-preparedness plans. In fiscal year 2003, that figure rose to $4.4 billion, according to the federal Department of Health and Human Services, which awards disaster-planning grants to the states and individual institutions.

But is that going to be enough money? Unfortunately, there is no way to calculate the actual costs of preparing and responding to an attack, Hoffman concludes. “These costs can’t really be predicted because you can’t know how widespread the event will be and how long it is going to last,” he says.

Hoffman is reasonably certain, though, that the costs would be enormous. He cites the example of the 2001 anthrax attacks in which 22 people died or became seriously ill after receiving mail deliberately contaminated with the bacterium: “The letters showed up only in several East Coast states, but, because the US mails were involved, it impacted the entire nation. The amount of money that had to be spent to deal with the problem on the level has never been disclosed, but it must have been huge, even though it involved fewer than two dozen cases. Imagine, then, how much more it would cost if there were an event or epidemic affecting the lives of many thousands.”

Works in Progress
Despite the cost concerns, hospitals generally are confident they have in place good plans and are making effective preparations for dealing with bioterrorist incidents. Nonetheless, as Cohen notes, these plans are not cast in stone.

“Even a good plan is very much a work in progress,” he says. “Part of what makes a good plan good is the fact that it’s always evolving through continuous reevaluation and continuous improvement.”

Here again, there is opportunity for respiratory therapists to function as important players. Doing so will require, though, that RTs first become very knowledgeable about disaster preparedness planning. Cohen recommends interested practitioners first acquaint themselves with several helpful resources (see “Resources for RTs,” page 42).

What most intrigues UCI’s Martin is that, when you get right down to it, RTs probably are already well prepared to step up to the plate with disaster planning and disaster response.”The role of the respiratory care practitioner during a bioterrorist attack is not going to be much different from our ordinary, day-to-day role,” he says. “We are asked simply to provide high-quality care of patients who are respiratory-compromised. That is our mission; it is what we do best.”

In other words, RTs: let’s roll.

Rich Smith is a contributing writer for RT.