PrepTalks: Dr. Sheri Fink “Healthcare Emergency Preparedness and Response”


[PrepTalks Theme Playing] Hello, it’s so great to be amongst people
who are dedicating their lives to this issue of preparedness and response. And
how we allocate the resources that we have in disasters, how we choose who gets
the resources that you work so hard to to organize and to deploy, of course that
is going to affect the outcome who gets those resources. And how you choose kind
of where you target them is a question that involves a lot of value judgments
and has sort of ethical dimensions. So in New Orleans for example in 2005 the
levee failures after Hurricane Katrina surrounded this hospital, Memorial
Medical Center. And the hospital had critical electrical equipment where? In
its basement, yes. And of course the city is below sea level and vulnerable to
flooding. So helicopters did start to arrive, but
these helicopters could take maybe one or two patients at a time. And this
hospital had about 250 patients, it had about 2,000 people inside of it doctors,
nurses, staff, and family members. So this question of where do those critical
resources go, in this case the helicopter, if you were in charge of making some of
the decisions. How would you begin to make that choice who gets on those
helicopters first? When you know that you’re a modern hospital that
could lose power at any moment. So do you choose for example, the babies there was
a neonatal intensive care unit? Maybe because babies are so vulnerable. So you
would want to help them out first or they rely on a lot of power which is the
resource that you’re about to lose in this hospital. Or maybe simply because
there could be an ethical argument that children haven’t lived as long as other
people and we all sort of deserve as many innings of life as as possible. Or would you perhaps look to help some of the older intensive care
unit patients? Maybe because they’ve given so much to society already or
there are people who depend on them. Also they too need a lot of resources which
will be in short supply if the situation gets worse. Would you perhaps want to
help people who could sit up like these people in these
wheelchairs? Who could perhaps move more quickly, get to your staging areas more
quickly, who perhaps would have a better life expectancy in the long run. So would
you want to prioritize some of them first. And then there are all the people
who are filling the hallways the visitors, the people who’ve come
from the neighborhood even seeking help. You had people boating up to this
hospital. You had also just the healthcare workers themselves who would
be a critical resource for the recovery. And we talked about how that’s the the
long tail of a disaster, some of them had chronic health issues, some of them were
very vulnerable. Of course it it was very, very hot in New Orleans in 2005 when
this happened in late August. And there are even healthy children. And the staff
members who brought them along to the hospital really wanted them to be
rescued, wanted them out of harm’s way, it was distracting them from their work to
be worrying about their kids. So how do you begin to make these decisions?
Obviously a great example of where there are so many ethical dimensions, so many
dimensions of values, that come into these choices. Even the question of who
gets to make that choice is one that has ethical dimensions as well. What happened
in this situation, was that some of the people who could move more quickly
were put on to boats that were coming up to the entrance of this hospital. The
water was rising that high. And then intensive care unit patients, including
both the babies and the adults, were sent out on some of those first helicopters
for some of the reasons that I mentioned. But there was also a very important
decision that was made early on, which was not only which patients would go
first, but that a category of patients would go last. And these were some of the sickest patients in fact, patients who
had so-called do not resuscitate orders. And so these
were the patients who were there when in fact the power did fail and each patient
was put through a hole in the machine room wall and had to be carried up
flights of steps to the helipad. And so as this was happening hours were passing
and ultimately the power failed inside of the hospital and that’s when the
situation became very dire as you can imagine. There were staff who were hand
pumping oxygen into the lungs of patients who relied on mechanical
ventilators, and time was ticking by. And the helicopters of course had a whole
city to triage and decide who to prioritize. Was it people who were waving
you know towels off their rooftops, who might not have water who might also have
chronic conditions at home? Or was it going to be this hospital, which
you know should be able to shelter in place for a while? But, is that realistic
when a hospital loses power? There were boats coming up and slowly the
hospital was beginning to get people out, but it was taking so long. And then there
were the patients who were just lying there on the the level of the parking
garage just below the helipad waiting and waiting for rescue. Some of these
very sick patients with the do not resuscitate orders and they were getting
sicker and sicker. And there were some staff members who concluded that some of them just really didn’t have a chance of survival at that point. And then the
second decision ended up coming into play. That some people raised this
question, could it be okay to hasten their deaths while they were assuming
that these patients just could not be rescued and everybody else had to start
getting out? And it was, as you can imagine, a very very controversial
question even in the moment. Obviously for us here we’re in a comfortable room.
It’s hard to put ourselves in that place. But even in that place and time there were some staff members who said absolutely not, this would violate
the the fundamental principles of medical ethics and nursing ethics. And
others who thought that it was the right thing to do at the time. A disturbing photograph but there were about two dozen patients who received a
drug combination of morphine and a fast-acting sedative called Versed. One,
or the other, or both in a very short time period. Just a little over a day
after the power failed. That’s how desperate the circumstances became. And
ultimately this became a wound in the city. In fact, two doctors explained to me
that they did in fact hasten the deaths of their patients intentionally. Another
doctor and two nurses were arrested and accused by the attorney general of
having hasten the deaths of patients like the one you just saw, Emmett Everett
who wasn’t even a terminally ill patient, but in fact was very heavy and the staff
told me they thought that he would be very hard to move. So ultimately there
was a press conference and the attorney general announced that he had arrested
three health care providers, health care professionals on second degree murder.
And ultimately a grand jury did not indict these health care providers who
maintained their innocence and that was the end of the legal case. However,
there’s been a long tail and many people in the preparedness world, many people in
the health care world know about this story, have grappled with its
implications, and certainly have thought a lot since then about how we should
think about preparedness. There have been numerous actions. Obviously the people
who are officially in charge of thinking about emergency response, like many of
you watching, are the ones who think about this on a day to day basis. But we
know that in fact it’s often regular people, who preparedness is not their
main job, who end up being on the front lines having to make some of these
decisions. So there’s been a lot of thinking about how to prepare them
better for making some of these tough choices about where resources should go in the midst of a crisis, when they’re limited like a
helicopter landing on a hospital rooftop. So it’s included everything from experts
at the what used to be the Institute of Medicine, now the National Academy of
Medicine, gathering looking at this case. Saying well we believe that DNR orders
end-of-life preferences the DNR is “Do Not Resuscitate” don’t you know restart
my heart if it stops, that that shouldn’t be used as a triage criterion. First,
because it doesn’t necessarily predict for somebody who will or won’t survive.
And second, because it’s hard enough to get people to focus on their end-of-life
preferences without them thinking that a DNR will be used as a “Do Not Rescue”.
So that was one conclusion. Another even in the midst of an emergency that it’s
never okay to cross that line as a health professional and hastened death.
That were two of the conclusions by an expert panel that came together at
the Institute of Medicine, about ten years ago to look at this. Other things
preparedness grants for healthcare have included, at some points have included,
the mandate that the localities prepare, think about triage and crisis standards
of care and how how would they sort of triage or the word nobody likes to
use ration resources. For example critical care resources or ventilators
in a flu pandemic when you have way more patients who need that resource than
could possibly have access to it. So recognizing that that is a question of
values as much as it is medicine or preparedness and planning. There have
been some efforts around the country to involve the larger public who actually
can grapple in quite sophisticated ways with these questions. And give feedback to officials so that they can make some decisions in advance
about how to think about these very very difficult and ethics laden triage issues.
These are just some of the things that have come out of and of course the the
federal government now instituting, requiring through the Centers for Medicare and Medicaid Services some basic minimum
standards in disaster preparedness in emergency management for all healthcare
provider subtypes. So these are some of the things that have come out since that
experience in Hurricane Katrina that was so searing for the nation in so many
ways, including this tragedy at this one hospital. But while this is incredibly
tough life and death kind of stuff, it’s very very hard to think about. In fact in
some ways thinking about how you marshal resources within a single institution is
easier than when you think about, what about having to do that across an entire
population. In fact, what if the people having medical emergencies were
scattered across a flooded county with a population of over 4.5 million
people. That is the situation that response officials faced when last year
in Harris County, Texas which contains Houston when Hurricane Harvey was coming and became tropical storm Harvey and just releasing over a trillion gallons
of water just in that one county. So you had the emergency operations center and
so this question of where our resource is going to go? This was a county that is
constantly being hit with flooding disasters. They had had two major
flooding disasters in the two years before hurricane Harvey, so they had
thought about this stuff. And one of the top emergency management officials said
to me, “Our resources our rescue resources in a flood situation are prioritized for
people who are in life-threatening situations.”That could mean fast rising
water or it could mean somebody who has a medical crisis in the midst of a mass
emergency, where a lot of people want to get out of their houses but a relatively
smaller proportion a much smaller proportion are actually in a
life-and-death situation. So that is a reasonable triage decision I think we
could all agree. Who needs the resources the most. Let’s try to marshal them and
get them there first, because you don’t automatically
have everything you need all at once and certainly they didn’t in this case. But
was the system set up to accomplish it. So if you are thinking as you should
about how will I marshal my resources, who do I want to make sure get those
resources? The second part of that is you have to think about, is my system set up
to accomplish that? And so let’s look at one person who was having a medical
emergency and kind of go through the steps and see what it would take to get
to get rescued in that situation. So this is Casey Daly, a 38 year old
mother who had surgery just a few days before Hurricane Harvey. She went home.
Her home was well prepared the electricals had been moved up. They lived
in a trailer park, but they had done a lot of preparations.They are used to
flooding there and so they had stocks of water and the county official, the city
official for Houston, and the county official for Harris County had urged the
population to stay in place so they followed what they were told and advised
to do. But Casey had been discharged without a critical medicine. She had a
hormone producing tumor removed from her adrenal gland produced the hormone
cortisol, but she was discharged after the tumor was removed without that drug.
And so as the floodwaters began to rise she began to get sick.
And this is Casey, mother of two children, so kids are in the trailer, she’s
there she’s getting sick. Floodwaters are rising and after about a day her husband
says, “I better call 9-1-1.” So that’s that first step, identifying where somebody needs help. So his phone had to work.
Fortunately most of the cell towers did work, because by the time Harvey hit
Harris County the winds were not so high. And so that phone had to work and
it did. It went to two call centers. First the sheriff’s call center which had
flooded so they were displaced. And because they were on an analogue system,
which we still are and most of systems, they couldn’t just flip a switch
and have the call go to an unaffected area they actually had one physical
backup location. So that’s where the call went first and so let’s hear just a bit
of that call. [Call-Taker 1] “Okay do you need medical or is this for a water rescue?” [Wayne Dailey] “This is for a water rescue. My wife recently had surgery last Wednesday. She had a tumor removed from her left kidney and she has been very sick even vomiting for the past day and
a half approximately, and she is in severe pain and I don’t want her to get
in this water in her sutures. She needs to be airlifted to a hospital.” [Call-Taker 1] “Okay.” [Wayne Dailey] “I do know, I do know that Coast Guard is out doing air rescues right here in my neighborhood.” [Call-Taker 1] “Right, I probably have to get you over to the EMS and order to
get that, let’s talk to South Lake Houston EMS and let them know what’s going on. Okay?” [Dr. Fink] So it’s going to a secondary call center now that dispatches for fire and EMS. This is a common system with 9-1-1. [Call-Taker 2] Inaudible. [Call-Taker 1] “Transfer referral for medical and water rescue.” [Call-Taker 2] “Okay, for a water rescue?” [Wayne Dailey] “Yes, my wife recently had surgery last Wednesday she had a tumor removed from her left
adrenal gland on her left kidney and she’s been vomiting for the past day and
a half. [Call-Taker 2] “Okay, how many people are in the house?” [Wayne Dailey] “I have two boys and me and my wife.” [Call-Taker 2] “And how old is your wife?” [Wayne Dailey] “She is 38.” [Call-Taker 2] “Okay, we do have over a thousand calls for service in this area for citizens with evacuation. As soon as the fire department is able to make it to this area then you will be evacuated, okay?” [Wayne Dailey] “Okay, thank you very much.”
[Call-Taker 2] “Alright.” So the second call taker is at a call center that is just slammed with calls. They’ve staffed up usually four call takers, now there are eight
call takers. I think at this point we are five times, four or five time,
their normal call volume. Somebody had come out, one of the leaders had come out
to the call floor, and told the the 9-1-1 call takers to stop doing triage, to stop
interrogating each caller, to sort of go through the the calls and prioritize that as a medical emergency or not. So anybody in a
flood area was basically categorized as a water rescue. So she didn’t get that
crucial information about the gravity of the healthcare situation and dispatched
this to the fire department the local fire department. Under the County’s plans
that fire department was in charge of water rescues, but that small fire
department had no boats so they didn’t really have the resources. Also because
they were getting so many calls for rescue and there were about five
fire personnel they basically had all those calls going into their computer
dispatch and they would have to click open each one to even read it to even
know what the details were, like that there was a lady who was sick. And they
were basically focusing on one or another area they had about a 70 square
mile area, most of it was flooded. So you can imagine that this call did not get
prioritized and that was a situation for about a day. What did he do? What is people’s technology of choice now? Social media, so he went on social media
raised the alarm, his family raised the alarm, got on all these sort of Cajun
Navy and other priority lists for boat rescuers. Our systems could not sort of
take in disaster calls for rescue off of social media. So that was another thing
this ability to identify who the people are, who need the help the most. Can you
actually do it? Can your systems do it? So, it was about a full day later by the
time that he got through to 9-1-1. After four calls finally it was classified as
a medical emergency. It was dispatched to the local EMS
station it had two stations one was flooded the other
looked like this. And they basically, medical was ESF-8 was separate
from rescue ESF-9. So that had its own system and who could they call on well
the local coalition, except they didn’t have boats or helicopters, they mostly
were moving patients in and out of flooded nursing homes and whatnot.
So they had rely on the fire department with which
they had a very sort of an old rivalry as is true in many fire versus EMS
departments. They did not set up a joint command and they would have had to call
that fire department, the fire department would have to call the fire desk at the county
emergency operations center and then ask them for some resources try to get
some state or federal resources. So any bit of that chain fails, there’s no
helicopter for this family. And that’s the EMS and this is sort of the
situation that they they faced in their area. So what did he do? He was looking
out the door, he heard a helicopter. This is his neighbor and there was a helicopter that came for his neighbor.
And so he ran up to the rooftop and tried to flag down this helicopter to
say, “My wife needs help!” And that helicopter actually sort of seemed to
hover above his house, his trailer, and then kept going. And he only found out
later, how did this lady who needed dialysis how did she get the helicopter?
She actually had her husband, the owner of the trailer, he knew somebody
who had a good relationship with a U.S. congressman and called the congressman.
And an intern in the congressman’s office had a federal officials phone
number arranged for this helicopter rescue. So that was the unofficial system
working in a more efficient way for somebody who needed rescue then the
official system, that was in place to try to prioritize people who had medical
problems. So long story short what happened was that the unofficial system
was what helped. The local EMS called said, “We got you on our list, we have no
way to get to you. Look out for any boat.” And the the husband of this lady he saw
a boat trolling past, he burst out the door, called for help. Three boats, this is
one of them, got them onto a channel onto a flooded bayou to a place where they knew that they had launched that morning where some state Texas Department of
Transportation dump trucks, that have been just-in-time trained to go through
high water, had been waiting for hours for somebody to help. By that day the
waters had started going down and in fact very few people wanted rescue
anymore. But communications, their radios only worked with in their
small team. They tried to find a hospital they couldn’t find their way there.
Finally, they themselves called 9-1-1 got an ambulance. By that point
Casey’s heart had stopped and they couldn’t bring her back. And she did get
to the hospital, but they after several minutes of performing CPR they realized
that she wouldn’t make it, and she died. By not probably, ultimately because
she lacked this critical medicine. So what can we take away from from both of
these tragic stories. I think it’s just this realization to think very
realistically about where you want to target your resources when you don’t
have enough and you’re gonna be fighting to get more. That’s so crucial, but in
those early moments how are you going to make sure that those resources have a
good chance of getting to the people who need it the most? How are you gonna think outside the box and think about the technologies that
people used spontaneously? Social media and people getting online and creating
google maps showing where people needed help Are there ways that we can advance
this in our own work? That each of you can think about in your realms, how to
target those critical resources to the people who need them the most? So that we don’t have a father without a wife, a son without a mother for the next emergency
Thank you. [Applause] When we think about medical operations
and sheltering and there’s been some effort to make sure that drugstores can come and be a part of that and certainly that was the case at
the George R. Brown Convention Centers one of the chain drugstores showed up. But if you, and there was a you know federal efforts to make sure that
there would be reimbursements for those meds and so that they could be
given out, a supply could be given, I think a 30-day supply if I’m remembering
correctly. But there are issues they only perhaps had a limited pharmacy and
I’m not sure if they had all of the drugs that they needed. And we’re also
dealing very much with drug shortages and that’s a whole other issue that
involves triage and prioritization. But I think you’re absolutely right,
certainly in those shelters people would show up. People who either have chronic
mental illness who didn’t have their meds with them and needed them or people who had exacerbation of mental health issues because of the stressful
situation. So this is definitely you know in my experience as somebody reporting
on these disasters, is a critical issue that there’s only now starting to be
more awareness about. So thank you for raising it. The decision to hasten death, when that
moves into a legal realm, I think there’s the issue of medical ethics and what
medical ethics says about it which is no generally post-Hippocrates.
But also there’s the legal aspect. So of course the prosecutors were
uncomfortable because they were applying law to a very extreme situation and they
had prosecutorial discretion. They can always decide whether or not to bring
charges in a case like that and certainly the grand jury seemed to have
a lot of sympathy for the health professionals. But also you know there
are laws, there are actual laws about that. When it comes to triage, and
prioritization, and crisis standards of care it’s generally thought that you can
and there have been some efforts legally to build in some legislation that will support health providers who do follow a standard that the medical profession has created. And so there have been a number of, I could
point you to, some sort of legislative efforts in various states. But you’re
absolutely right that there are health professionals who say, “I’m not going to
really change my standards so much because I’m afraid that I could be you
know brought up on on some charges.” So that there is a fear there. And I
generally think that it’s important for us all, when we think about disasters and
changing the way that we may have to practice medicine and in this example
but other really important standards that we adhere to, to always aim for the
highest achievable standard of care rather than you know immediately
galloping to the lower standard of care. Because often you can be creative and
find ways around some of the problems. This is not only about communications,
it’s about a lot of things, but it still is about prioritization because if you
are a top county official who says, that my systems are in place to prioritize
people who need care in a life-threatening situation, you have to
look at whether the system in place will actually do that. In this system of so
many steps to get to that resource doesn’t quite make sense, there must be a better way to orient the system. around getting those resources to people who need the help. it is critical. It is that link and I
mean it’s interesting at some point realizing how overwhelmed 9-1-1 was the Coast Guard released their phone numbers to their local command, to do
their own triage. They started paper and pencil at first writing down the names
of people who were calling them directly for helicopters. So 9-1-1 was siloed. They told me at that call center that they couldn’t dispatch a helicopter,
they had no communications with the federal officials. They were even afraid
to call the county EOC. They sent me a recording where they gingerly called the
local fire department saying, “Hey, we just got a call somebody’s on the top of a
car and we know you’re nowhere near there. Do you mind if we call the county
fire desk to see if they could maybe send somebody?” They were afraid to even
do that. So yes, better communications, 9-1-1 it’s so localized, there’s federal guidance but, not a lot of regulatory authority
on that. It’s very localized. So bringing up 9-1-1 making those connections. Look
up FIRSTNET, that’s sort of the communications link from sort of 9-1-1
to the responders. That dedicated broadband, part of the broadband spectrum, that should allow better communications. And then upgrading 9-1-1 systems to
something called “Next-Gen” which will be internet protocol based and be able to be more flexible in terms of forwarding calls, and accepting multimedia, and then
forwarding that on to the responders at various levels. But there’s so much
work still to do it’s crucial. Harvey really has taught me that you know
wanting to target people who really need help, we need to invest more in these
public safety systems and making them work I think it’s a discussion we all have a
stake in, right? Any of us could need healthcare and a disaster and so the
broader the conversations around this the better. And what we’ve learned in the
last decade is that the public can handle it and in fact we need, I would
argue, of course I’m biased being in journalism and writing I want to say we
should be as transparent as possible because you need the public as your
partner in one of these situations. They need to understand what the likely
scenarios will be. And people can wrap their heads around that and they can
make some really good very sort of ethically sophisticated choices and we
need to listen to them. You know those of us who are in this room
probably have a certain set of ways of looking at the world that may be very
different from broader segments of the communities where we come from. And you find yourself being surprised I’ve gone to a number of these workshops that
brought in the public. And the people who organized these when they have open
minds they always learn something they always think, “Oh my god I never thought
about that,” or this equity issue that will magnify itself if we do triage our
resources in a certain way we’re going to be biased against this whole group of
people we never even imagined.So this is really important to have these broad
conversations and I urge you to have them in your communities. [Music Playing]

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