Our nation's terrorism threat level until last week stood at code orange, but in our nation's emergency rooms the threat level is code red. While huge sums are being spent to strengthen America's capacity to identify and respond to acts of bioterrorism, little is being done to help our emergency medical services meet a far more plausible threat: terrorism with explosives.
It is worth remembering that the tragedies of Sept. 11, 2001, involved the coordinated use of flying bombs-fuel-laden airliners purposefully flown into heavily populated buildings of high symbolic value.
Worldwide, few acts of terrorism have involved the use of chemical or biological agents. In contrast, explosives and/or firearms have been used in countless acts of terrorism in countries such as Argentina, Bali, Colombia, Egypt, Israel, Kenya, the Philippines, the United Kingdom, the U.S. and Yemen. In recent weeks, a car bomb claimed 21 lives in the southern Philippines and a suicide bomber killed 15 people and injured dozens more in Israel. The frequency of these acts and the severity of their consequences suggest that terrorists are much more adept at using explosives than they are at harnessing the destructive power of nuclear, chemical or biological agents.
Remarkably, in the face of this clear and growing threat, our ability to handle mass casualties from a terrorist strike is deteriorating at an alarming rate. An April 2002 survey conducted by the Lewin Group for the American Hospital Association revealed that 90% of the country's Level I trauma centers and 90% of the nation's large hospitals are operating at or above their capacity for treating patients.
When a hospital is full, seriously ill and injured ER patients cannot be moved to inpatient units because of a lack of beds. When the hospital's ER becomes too jammed with admitted and newly arrived ER patients to safely accommodate more, inbound ambulances may be diverted to other facilities. When multiple hospitals in a community attempt to divert ambulances simultaneously, it can produce the healthcare equivalent of a rolling blackout.
This is not an isolated phenomenon. According to a newly released report by Congress' General Accounting Office, two-thirds of all U.S. emergency rooms diverted ambulances to other hospitals in fiscal 2001. Hospitals that reported the most problems with crowding were in the largest metro areas, precisely the communities most likely to be targeted for a terrorist attack.
In light of the tragic events of Sept. 11, one might assume the federal government is doing everything possible to strengthen our nation's beleaguered trauma and emergency-care system. Instead, it is ignoring the problem. In its 2003 and 2004 budgets, the Bush administration zeroed out funding for the Health Resources Services Administration's Division of Trauma and Emergency Medical Services. This federal program was established to help states increase the number and quality of emergency- and trauma-care systems.
This begs the question: If our nation's ERs and trauma centers are struggling to handle their daily load of 911 calls, how can we expect them to manage a huge influx of casualties from a terrorist act?
Intelligence reports warn of further attacks by Al Qaeda. Instead of strengthening our capacity to handle large numbers of seriously injured people, we are spending vast sums of money on "sniffer stations," a smallpox-vaccination program and other measures to defend against bioterrorism. Meanwhile, our emergency-care system continues to decline.
Three steps must be taken to counter this alarming trend:
* The Bush administration should immediately convene a meeting of key stakeholders to discuss the problem and identify promising solutions. The participants should include senior officials of HHS, the new Department of Homeland Security, major hospital and physician groups and patient advocacy groups. Congress should hold hearings to coincide with this meeting.
* In its new report, the GAO notes that the current imbalance in reimbursement rates between scheduled and emergency admissions gives hospitals a powerful financial incentive to favor elective admissions over emergency cases. When the ER becomes crowded, hospitals are more likely to divert incoming ambulances than to cancel elective admissions or postpone surgeries, the GAO found. Unless something is done to address this, as well as reimburse hospitals and doctors for complying with the mandates of the Emergency Medicine Treatment and Active Labor Act, these practices will continue.
* Widespread adoption of emerging technologies and innovative clinical practices could make ambulances, ERs and trauma centers more efficient, cost-effective and safer. Promising ideas include: routing nonemergency 911 calls to nurse advice lines; incorporating chronic-disease care and injury prevention into emergency medical services activities; targeting investment in computer information systems to improve triage, enhance patient monitoring and reduce medical errors; and offering regulatory relief to promote point-of-care laboratory tests and bedside portable ultrasound exams, and expanded use of ER-based "clinical decision units" to reduce the demand for costly and scarce inpatient beds.
It may be wise to prepare for low probability but catastrophic threats such as bioterrorism, but it is downright foolish to ignore the far more likely threat of terrorist bombs. The best way to prepare for all forms of terrorism is to strengthen our nation's emergency-care system.
Arthur Kellerman is chairman of the Department of Emergency Medicine, Emory University School of Medicine, Atlanta.