Biological Emergencies

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Having watched the spread of SARS, the incidence of E.coli. in a number of communities, and the threat of terrorists releasing a biological agent such as smallpox or plague and the resulting immunization programs in the United States, health-care workers can no longer deny the possibility of a major infectious disease striking their facility in the near future.

While the incidence of biological emergencies is not new, the probability of such emergencies is increasing. So what is the overall impact of a biological emergency? How would your hospital be impacted if 10,000 people became ill as occurred in Kelowna B.C. in 1996? How would your medical community be impacted by a meningitis outbreak within the school population? How would Canada fair in a pandemic influenza situation? How would your hospital deal with an outbreak of SARS or a similar virus of unknown etiology? Hospital staff and administrators will be presented with new challenges under such conditions.

Unlike most hazards in which the impact is rapidly apparent, as injury and property damage are sudden, the appearance of a biological agent is often a sneak attack and detection and awareness of the problem is the most difficult aspect. And control of the spread and degree of impact largely lies in early detection. There will be no bomb blast, no explosion, no shots fired. Rather a community will experience an increase in the number of physician, clinic and hospital visits, for the same typically vague gastrointestinal and flu-like symptoms. There will be widespread increase in fever, malaise, and non-diagnosed illness. There often are several deaths before a pattern of illness is discovered.

In typical emergencies such as fires, floods, earthquakes or tornados, there are well-defined emergency responsibilities for those trained and equipped to immediately take charge of the event with hospitals playing an important but supportive role. In biological emergencies, the hospital may suddenly find itself in charge. The emergency response team changes from the tri-services of fire, police and emergency medical personnel to include hospital staff, public health, public works (if water contamination is an issue), family physicians, labs and clinics, veterinarians (diseases often occur first in animals), and the M.E. or coroner. New communication lines between these groups and the traditional responders need to be established. Reporting lines are critical and coordination of effort is essential.

There may be dramatic decreases in the number of available staff members or volunteers as they may be infected themselves or required to help at home with ill family members. There may be a large exodus of people including health-care staff, emergency services personnel, and volunteers, as many leave to escape contracting the illness or to protect family members.

The community itself may be quarantined. Supplies and people may be restricted in their movement preventing easy access for volunteers and equipment. The community may become quite isolated in its handling of the emergency.

Biological agents are things we cannot see, touch or feel. People can’t get to a safe place, or properly assess the hazard with their own eyes and ears. The only way many will know if they have been infected is to sit and wait for symptoms. This can easily cause panic and misuse of the system. There may be large increases in psychosomatic illness and trips to the already overtaxed emergency department because people have symptoms that may or may not be consistent with the outbreak.

Staff members themselves may feel episodes of panic as they treat the very people who could infect them. There may be concern as to whether or not the protective actions will work. This fear may be magnified, and in fact well founded, given the high incidence of SARS infection rates within health-care workers.

Vaccines are usually quite limited and can take upwards from 6 months to manufacture in appropriate supplies for mass immunization. There may become a need to set protocols as to who gets the vaccine or treatment. In many outbreaks intravenous antibiotics are most effective, but they may need to be rationed while oral doses are given instead. While resources such as antibiotics, lab testing equipment and vaccines may initially be limited; the situation may get worse instead of better as the emergency continues. Not realizing the initial problem or magnitude of the spread, supplies may not be rationed initially and therefore quickly depleted.

The bad news is that there is a good chance you are likely to experience a biological emergency within your career and it has the potential to be quite devastating and challenging to manage. The good news is that there are some solutions and ways to prepare. Most of the solutions line within four parameters: accept the reality, train, expand your resources, and practice.

There are a lot of priorities in health care and a lot of demands for training and planning. It is easy to become so overwhelmed by the thought of a biological emergency that it is easier to ignore the possibility and become convinced it “couldn’t happen here”. Yet experts agree biological emergencies have been and will continue to increase in frequency. Accepting the possibility that it can and will happen is the first hurdle to action.

If you can accept the reality you understand the need to have training. Hospital staff need to understand what their roles and responsibilities will be, what procedures and protocols should be followed, what resources will be available from where, and how they can work to prevent the spread of disease and protect themselves. Hospital administrators and unit managers need to know how to inform the public, staff, and volunteers of a health crisis without panicking them into flight but empowering them into appropriate action. Training within an expanded team environment is also essential.

Most hospitals and communities have emergency plans that include contact lists to acquire necessary resources such as generators, blankets, food supplies, shelter and other common emergency supplies. They may not include extra antibiotics, personal protective gear, and links to vaccines or alternative community water supplies. It is crucial managers know what types of resources are available locally and nationally to combat a health crisis.

Once hospital staff has accepted the reality, trained for the possibility, and built up some resources, it is essential to practice for a crisis to ensure theoretical knowledge and plans can work in the real world. Emergency services commonly practice for large-scale emergencies. Such training events should involve the hospital as a pivotal player as may be the case during a biological emergency. Exercises, which involve the setting up of facilities outside the hospital to treat patients of an outbreak, and immunization center set-up, should become part of exercise simulations. Such events allow the expanded team to work together in a safe environment prior to an actual event.

Biological events are a hazard that all communities must face. Due to the huge impact of these events, diligent planning and preparation are required to enhance the response. Health care workers need to be part of the solution and therefore must accept the reality, be trained to respond, have the necessary resources, and a chance to practice these new skills prior to an actual event. Ignoring the possibility of a biological emergency is done at our own peril.