The staff at NYU Downtown Hospital was put to the ultimate test when the World Trade Center, just four blocks away, was attacked on Sept. 11, 2001.
Cut off from outside power, telephones and even cell phone networks, the hospital treated hundreds of the injured in the first few days after the attack.
Howard Beaton, M.D., a senior vice president at the hospital, says staffers knew their roles well because they had participated in a disaster drill just six weeks earlier. Now, he says, the hospital is in the process of revising its disaster plan, based on problems uncovered on Sept. 11.
One obvious change: Staffers are switching to satellite-based mobile phones from cell phones that depend upon transmitters on tall buildings like the World Trade Center.
"We have realized that here in lower Manhattan we are very vulnerable," Beaton says.
Physician executives across the country came to the same conclusion after raising and answering a plethora of questions in the wake of the Sept. 11 attacks and the deadly dispersion of anthrax-laced letters that followed.
They asked: What would we do as a group or hospital, city, county or state if a plane hits a building here? Can we handle an outbreak of anthrax, smallpox or botulism? What happens if a bomb goes off, the power grid goes down or the phone or computer systems go dead? How will we communicate, coordinate, cooperate, transport, triage or quarantine?
In working through a multitude of disaster scenarios, physician leaders found answers to these and countless other questions. These leaders agree that, while much work lies ahead, the U.S. medical community has made great strides and is much better equipped to face the unthinkable than it was a year ago.
"We are far, far better prepared than we were before," says former Army Surgeon General Ronald Blanck, D.O. Blanck is chairman of the Texas Medical Association task force on bioterrorism. He is helping draft courses on bioterrorism for medical students on a task force for the Association of American Medical Colleges.
Unprepared for anthrax
The terrorist attacks exposed many gaps in preparedness plans, and officials at the local, state and federal levels have started to fill them in, tapping into billions of dollars in new federal funding.
For example, after a hijacked jetliner hit the Pentagon, Washington-area authorities report that, while government workers were alerted, the emergency alert system was not activated for the rest of the population. And when anthrax spores were found in a Washington, D.C., postal facility, officials at one suburban Maryland hospital say they were not notified in time to diagnose a victim who later died at the hospital.
"The D.C. hospitals were told, but our doctors did not know that anthrax had been found," says Dave DeClark, spokesman for Southern Maryland Medical Center in Clinton, Md. "That alert might have helped them with their diagnosis."
In response to these gaps, the governors of Maryland and Virginia and D.C. Mayor Anthony Williams in early August signed an eight-point agreement to coordinate and improve emergency plans in the greater Washington, D.C. area. In addition, the District of Columbia Hospital Association is building a coordinated regional response system and improving communications and surveillance systems.
"As long as complex jurisdictions and competing interests can be juggled, we'll move along just fine," says Jeffrey Elting, M.D., medical director for bioterrorism coordination for the DCHA system. He says he intends to align bio-defense strategies in D.C. with those being developed in Maryland and Virginia
Larry Bush, M.D., who diagnosed the first anthrax case last Oct. 2, criticizes the response of federal officials in that case.
Bush, an infectious disease specialist in Atlantis, Fla., says he had enough lab evidence to strongly suspect an intentional act of bioterrorism, but "the U.S. government's reaction was that this is an isolated case," and it did not alert the public for days. Because the public needs to know if there is a credible threat, "You should call it bioterrorism until proven otherwise," Bush says.
But since then, he says, federal health authorities have reconsidered their policies and are taking a more proactive approach to bioterrorism, such as stockpiling anthrax and smallpox medications and creating plans to prevent the spread of these biological agents.
He adds that the FDA has ordered the only factory making the anthrax-fighting vaccine to reopen. The FDA had ordered the Michigan facility to close in 2000, citing quality problems.
Bush says even toxicology experts were unprepared for the level of potency of the anthrax in the October letters. He says it was hard for them to believe that a Connecticut woman died of anthrax because the letter sent to her had merely brushed against an anthrax-laced letter in a postal sorting machine, as is now believed.
Since anthrax reports began, Bernd Wollschlaeger, M.D., who was trained in the Israeli army to deal with biological and chemical warfare, has given dozens of educational sessions on bioterrorism for Florida physicians.
"The presumption is that the physician is the front line of defense," the North Miami Beach, Fla., family physician says. Last fall, he says, hundreds of doctors packed into his lectures. Audiences are now smaller, perhaps because those who wanted to attend have already done so.
Authorities also are cracking down on the security of pathogens held at research labs. Under new federal regulations signed by President Bush on June 12, some 190,000 labs in the nation must report by Sept. 10 whether they hold any of 36 types of pathogens.
Blanck says doctors will be aided by systems that pinpoint bioterrorism by evaluating electronic medical records being developed in military hospitals.
"Syndromic surveillance" software surveys data for unusual clusters of cases, he says.
Authorities also are trying to improve coordination of healthcare providers' response to any kind of terrorism and are creating a larger role for hospitals, according to Mark Smith, M.D., emergency medicine chair at Washington Hospital Center, the largest hospital in the capital city.
In August, HHS gave the center $2.5 million to enhance immediate preparedness.
Smith says the money will establish a "ready room" next to the ER with a separate ventilation system for isolation purposes. It is part of a strategy to increase modularity and flexibility, allowing better management of an emergency surge in the number and severity of cases.
Some contend disproportionate federal funding makes it difficult for certain facilities to be full partners in a coordinated response. Officials at Virginia Hospital Center say they have not received any HHS allocations. The Arlington hospital is just minutes from the Pentagon.
"The fact that one or two institutions are designated as those that would see mass casualties is poor planning," says the hospital's chairman of emergency medicine, Yorke Allen III, M.D. "It doesn't do any good for one hospital to be more ready than others."
Smith concurs that preparedness involves a coordinated response, but he says it will take time for dollars to flow in every needed direction.
MMRS expands quickly
In the St. Louis area, officials last November tapped Jeffrey Lowell, M.D., to be co-leader of the St. Louis Metropolitan Medical Response System.
With the help of an $80,000 HHS grant, The Miller Group, a Kirkwood, Mo., technology firm, developed the Mass Casualty Incident Responder, a high-tech system to manage medical assets and keep tabs on emergency patients during a regional disaster. "It can track all mass-casualty victims in the bi-state metro area," Lowell says.
With the technology, medics at a disaster scene place a bar-coded wristband on each victim and assign a color-coded injury level to the patient. Medics scan the wristbands with handheld computers and transmit the information to a central command post, which checks service availability at 25 area hospitals and relays transportation instructions to the on-scene team.
Since 1997, the federal government has been helping regional authorities set up MMRSs like the 3-year-old St. Louis effort. Sept. 11 accelerated federal funding for the creation of 25 of those entities, which now cover 122 cities.
"The MMRS is a planning process by which we are able to link people that don't normally work well together," explains U.S. Public Health Service Commander Jim Sabatinos, national MMRS program manager.
"We now go and train all medical personnel for disasters, and not just ER personnel, as we used to do," Blanck says. "We have better education on biologic agents. We have better surveillance. We are stockpiling antibiotics. And we are learning to deal not just with disasters, but also with hidden threats, the biologics."
Reporter Neil Versel also is an author of this story.