The view from inside major medical centers
Participants in this panel, moderated by U.S. News Executive Editor Brian Kelly, included Dr. Thomas Burke, executive vice president and physician-in-chief at the University of Texas's M.D. Anderson Cancer Center; Dr. C. Ronald Kahn, president and director of the Joslin Diabetes Center; Dr. Edward D. Miller, dean of the medical faculty and CEO of Johns Hopkins Medicine; Dr. W. Frank Peacock IV, vice chief of research at the department of emergency medicine at the Cleveland Clinic; Vicki Running, administrative director of the Office of Service Continuity and Disaster Planning at Stanford University Medical Center; and Dr. Michael Salem, president and CEO of the National Jewish Medical and Research Center.
KELLY: We have assembled a collection of the leaders of some of the finest medical institutions in the country to try to pursue this topic. Secretary Leavitt, I think, got our attention with his remarks, particularly as it relates to the private sector, local institutions. And our thought was that if w could assemble some of the leaders of medical institutions who are on the front lines and get them to tell us very specifically their experience both in past disasters and where they are in terms of moving forward, this would be a valuable addition to the dialogue here.
I'll introduce briefly – I have to apologize; I have to get my specific bios. These are gentlemen and one lady who have biographies that would stun most of us in terms of the depth of their experience. Medical professionals, they have curriculum vitae, published works. Most of these are folks who have had great exposure in the specific clinical fields, but also have moved into management roles, so I think they all speak with tremendous authority. I could go on at great length about all of them, but let me just sort of quickly give you a sense.
Dr. Thomas Burke is executive vice president and physician-in-chief at the University of Texas M.D. Anderson Medical Center. He's responsible for oversight and strategic planning for patient care delivery through the hospital clinics and outreach programs. Next to Dr. Burke is Dr. Ronald Kahn. He is an internationally recognized diabetes researcher. He is president and director of the Joslin Diabetes Center and the Mary Iacocca Professor of Medicine at Harvard Medical School. He has served on many national commissions and advisory boards, including as chairman of the congressionally established diabetes research working group. Dr. Ed Miller is the chief executive officer of Johns Hopkins Medicine, which is consistently ranked one of the best medical institutions in the United States. He is also vice president of medicine at Johns Hopkins University. Dr. Frank Peacock is the chairman of emergency preparedness, as well as the vice chair for research at the Cleveland Clinic. He's also the medical director of event medicine at the clinic, which includes sports medicine for the Cleveland Browns, the Indians, and the Cavaliers, so that may be a disaster in the making if you're a Wizards fan. Vicki Running is the administrative director for general services and the administrative director for the office of service continuity and disaster planning at Stanford Medical Center. She has been with Stanford for more than 20 years, where she is responsible for disaster planning and environmental health and safety among other duties. And finally, Dr. Michael Salem. He is the president and CEO of the National Jewish Medical Center in Denver. He has two decades of experience in the healthcare industry as an academic researcher, surgeon, and healthcare entrepreneur, recently traveling on medical missions to Vietnam and Israel. If we can't answers from this group, I'm not sure where we will be able to get them.
What our procedure here is we're not going to have opening statements or prepared papers. We're going to try and do this on a less formal question and answer basis. I will throw out some questions to the panelists, but encourage people to respond and engage in a dialogue on this. I think, as I say, we have a great deal of expertise that we can take advantage of here.
What struck me is a line from the secretary's remarks, which I think I heard him say it once before, but it is kind of startling when you really dissect it, when he said that any community that is relying on the federal government to come to its aid in a pandemic, or more broadly I guess disasters, is making a tragic mistake. I guess that's a wonderfully candid admission from the government. It's good we know that. We're obviously dealing here with people who have the other end of that responsibility in some ways. So I'm going to put you all on the spot and ask you, is your community ready to deal with the sorts of things that the secretary was talking about? And I think maybe if we just start on the far end with Tom Burke and go all the way through.
BURKE: I think the secretary was exactly right, and with our recent experience in Houston with both the aftermath of Katrina and then the subsequent onset of Hurricane Rita, we had very good – it's about as good a live drill as you could put together. But I think the success of the medical community there was largely based on local planning and local efforts. The refugee or evacuee areas that were set up for medical evacuees from the Gulf Coast were all manned by local physicians at the local evacuation centers. All of the health care was provided by local entities. In fact, the supporting services for housing and food and shelter and clothing were all based in the community. And it's that initial effort that really has to come from the local community, sort of people helping each other in a local way. It was in our community very well orchestrated by the county judge and by the mayor of the city, but really all of the areas in our part of Texas had local response teams that came out to meet the needs both of people evacuating from Louisiana and for subsequently people in the Texas area. After that, state and other kind of agencies that bring in better resources, more forceful kinds of services helped us through that period, but the initial time really depends on local preparation and local willingness to contribute to the effort.
KELLY: Okay, if you could –
KAHN: ÃÂÂ The Joslin Diabetes Center [is] in the middle of the Harvard medical campus, obviously a place surrounded by a lot of world-class hospitals, a very strong public health system, and there is no doubt that the city and the local medical area is very well versed in emergency medical care. But I would like to make a comment that kind of balance what was said about Houston, and say that I do think that one of the areas where I see us being less prepared is to think about what happens if the disaster involves the hospitals themselves.
This is – it is certainly great that many of the academic hospitals and leading medical centers can participate in helping an emergency preparedness – can help in planning for emergency preparedness, and even can participate in going to send out teams to sites that need help. But I do see that we also have a little bit of a blind eye to the kinds of problems that would occur if we are part of the problem, where a natural disaster could destroy our physical facilities, where a pandemic or a toxic substance being released could limit the number of people who could either get to work or participate in work.
And so I think that we have a ways to go as even leading medical institutions to really address not only how we can participate in helping if we're a in a viable and vibrant state, but also what happens when we are compromised by the problems. And I would say that this becomes also a problem for the people as patients in the hospitals. We know that of the people who were left behind in New Orleans after Katrina, 150,000 to 170,000 people were left behind because they were the sickest people. They were too sick to evacuate or too difficult to evacuate. And so we need to think about this as another dimension of emergency preparedness, that I think perhaps we haven't given as much attention to as we need to.
KELLY: Great, thanks – (inaudible). Ed Miller, can you –
MILLER: Well, I think after 9/11 Hopkins because of its proximity to Washington and the fact that we thought we were probably going to be involved in some of the casualties after 9/11, we put in place across the entire university, including the applied physics lab an office of critical preparedness called CEPAR. And I think of all – I think our institution is well prepared. We have had a variety of drills. One of the things we have done is we have decided not to look at just the pandemic or a biological, but any kind of a disaster. So we use all of the events.
The other thing that we have done has been to very critically look at various scenarios about where – the questions you raised, what would we do and how would we pull it together. The things that we have not dealt with I think are the ethical issues, which I think are going to be very severe. In the pandemic, a good example – who is going to get the ventilators? It's nice for the secretary to say that we should stockpile ventilators, but I think we all know most of us don't have the resources to buy another two, three, four hundred ventilators, nor where we are going to use those.
So some of the ethical questions we have not dealt with – and the other thing that I think concerns us is the interaction between the state and the city and an institution the size of Hopkins, that will only be tested in real time.
KELLY: We are going to get back to some of that. I think that raises a really interesting topic. Frank, can you talk about your experience at Cleveland?
PEACOCK: Sure, the issues I see with all of this become one of surge, and the secretary talked about that, and that becomes a critical issue. And we have a drill every year in this country; it's called February. And in February we have our normal flu season, and you can go to any city in the United States and see ambulances diverted from hospitals because our margins are so skinny. We live on a just-in-time, deliver-it-now – we look like a car company. That is the American hospital system that we use.
The problem is, is we are just good enough for what happens now, and the idea of doubling our infrastructure, which will take a tremendous amount of revenue isn't going to happen because if you just look at hospital numbers over the last decade, we close hospitals all of the time. I have been in Cleveland for a decade; we have closed three hospitals since I got there. They are not closing because they have bails of money laying around; they are closing because we're – we have turned it into a business and we have squeezed it to the tightest margin we can, and now we are going to double our infrastructure for nothing because we can't get money from a moth-balled hospital, but when we talk about pandemic flu, we need to double our beds. We have trouble now managing flu in February across the country.
So, you know, I really do appreciate that all things are local, that if we have a pandemic you are going to take care of it on a local business. All emergency medicine is local; I don't care where your hospital is. But we need to have a comprehensive plan across the nation for improving infrastructure. This is – otherwise we can't go anywhere.
The other piece of this that is important is the safety. And there was the article, Vicki, you showed me today, in the paper, which shows that people won't show up, and that is absolutely critical. And if you don't have the hospital as regarded as a safe oasis, people don't come to work. And that is something we have worked hard at doing, is establishing the fact that if you – if there is a flu epidemic, the best place to go is the hospital, that you have got the respirators, and you have got the masks and the things that you need so people show up at work because otherwise you may have a good building but nobody is in it.
KELLY: Thanks, Frank. Vicki?
RUNNING: Mainly at Stanford, we focus on the practical and try to focus on what is concrete and what we can do. We understand, being in an earthquake area, that there are often events that impact our facility. And a pandemic is actually quite different than those types of events. In a pandemic situation, you have staffing issues. While we may have 30 or 40 or 50 – maybe 80 or 100 ventilators available in the county, we may not have the staff to be able to manage those ventilators effectively and provide the quality of care that we would like to provide anytime there is someone that is ill.
So staffing becomes the No. 1 concern. And as we focus on staffing, we not only have to focus on healthcare professionals like physicians, nurses, respiratory care provides, and other clinicians; we need to think about the infrastructure itself, those people who provide the laundry service, the people that provide the housekeeping, the people that provide the food, the people that provide the facility lights that maintain our critical building systems. These people need to be empowered to feel comfortable and protected and anxious to come to work to assist us anytime there is a critical event that impacts our building or our business.
So at Stanford, we are trying to focus on staffing; we are trying to focus on the concrete, meaning disaster action guides and plans, training, which is essential for each person to know exactly how to respond and what to do, and then reach out into the community and partner with the media, and partner with our local and civic officials, as well as the state and the federal government, to try to lay down an infrastructure that would be effective during that type of crisis. Thank you.
KELLY: Thanks, Vicki, and finally, Dr. Salem.
SALEM: We at National Jewish focused, similar to Dr. Miller after 9/11, on disaster planning, and from a broad range of potential disasters. However, we simply don't, you know, have the surge capacity or multi-hundred ventilators that others have, and we do agree that certainly the largest potential cause of death is respiratory in nature.
You know, I certainly agree that all politics and disaster preparedness starts local. And Houston in the recent Katrina disaster did a marvelous job I wonder in part because, number one, they didn't take the primary hit, but they had a short period of time to get ready; and then secondly, they had done a marvelous job in terms of preparing down to the local level, to the church level, to who is going to call who, who is going to do what, and either drill after drill, or really being prepared in that kinds of state and situation. And I think that that was one reason that they were most successful. Now, can that be emulated at other centers? Are we ready for that in Colorado? I'm not sure because we probably haven't been – had the experience or had been hit yet.
One of the things that we have tried to focus on in National Jewish are our strengths, and how can we prepare for this. I do believe that in any disaster, albeit bio-terrorism-related, or pandemic, which seems to be the topic of discussion potentially today, that there will be a surge of people coming to whatever institutions that there are, and therefore, you know, local issues and workers that are able to staff and provide that care in terms of doses and so forth, and treatments are going to be enormously important, and frankly I'm not sure that the institutions around the country are ready for that.
Nor is there – I'm sure in Secretary Leavitt's 43 of 50 states that he has been to – he must have heard before the issue of, yes, ventilators can't be provided to all local facilities, but how can local facilities, as my colleague from The Cleveland Clinic said, decide to take on an institution and fill it with ventilators that aren't going to be used. That is simply too challenging I think in this day and age, and a very important thing to consider as part of the push supplies that are supposed to come from the federal government in the first 12 hours.
So what we have tried to focus on at National Jewish is our areas of expertise, which relates to both pulmonary medicine and immunology so that we have developed and are utilizing some of our most senior professors, as well of a substantial part of research capacity for a respiratory bio-defense initiative, where we could serve as a local and potential national research for the issue of respiratory bio-defense because obviously the lungs are a primary entry point for any particular noxious event. And so we have been focusing our respiratory bio-defense initiative on potential treatments for radiologic entry, new molecules for the treatment of chemical attack. The issue has been focused in our immunology department in making innate or your own immunity in the lungs more enhanced, whether it be safer vaccines, more effective vaccines about both viral agents as well as anthrax and other bacterial agents. So that is what we have been focusing on recently.
KELLY: Picking up on that point – I'm going to move this around a little bit. And please, any other members of the panel, just jump in. But picking up your point, Michael and Frank, is an unfair burden being put on private-sector hospitals? I mean, is the expectation now really out of whack with reality in terms of what you're dealing with at Cleveland, for one example?
PEACOCK: You know, we have spent the last three years working hard stockpiling ventilators and doing all of that sort of thing. I think we are as prepared as anybody in the nation, but we don't have beds, and that is really what it comes down to. And to ask any industry to double it's productive capability with no funding is really a hard row, even if you were a wealthy industry, and the hospital industry is not wealthy. I mean, that is the mis-stereotype here. Hospitals are closing for real reasons. And to say, well, you have to double your infrastructure and all of these capital expenses and just tough it out won't do well, and nothing gets done in that situation. If the federal government doesn't help run this, it's really a lot to ask for the local people.
KELLY: Ed Miller, you I think have the biggest budget here so let me ask you – [laughter]. Who pays for all of this?
MILLER: Well, we have gotten – over the last three years, we have gotten about a million dollars from the federal government for it. But we put about 10 million in ourselves. And it comes out of other programs that we're not funding. So there is no question that we have shifted our priorities and done that. But this is not a sustainable business plan.
PEACOCK: Can I put a million dollars in the context for the disaster world? We put in decontamination showers last year. We decontaminated about 300 people an hour we are guessing. That costs a million dollars, showers; that is no beds.
KELLY: Yeah, please.
SALEM: The fact of the matter is that even though it is an unfair burden on the public-private issue, that is the way it is. And we just heard from Secretary Leavitt and that is where people are going to show up.
So the question is, as part of this, whether it – $4 billion initiative for the federal government, where are the true partnerships with local medical centers and at the local level? I mean, a lot people say those words, but the question is as part of – you heard the difficulties in terms of even distributing Tamiflu around the country. But the issue is can we tackle these particular larger issues, partner with the federal government, and make these changes that are necessary in order to be prepared?
KELLY: Yeah, Ron.
KAHN: Yeah, I would just like to make a comment in relationship to this, as I did to Secretary Leavitt, which is I think that one party that is missing a bit from this discussion are the health insurance companies. And most medical institutions depend on funding from the federal government, from patients themselves, but of course a large part of this comes through health insurance. And while it's true that in an acute medical disaster, maybe for those first few days that people will waive a lot of considerations about health coverage as something protracted takes place, we look to has insurance, who doesn't – does the insurance cover this or does it not?
And it seems to me that they should be at this table too, not necessarily at this table at this second, but at the table as we discuss this issue because they have responsibility here which I think they need to recognize is partly theirs. It has to do with both health information, that they are accessible to that frequently hospitals don't have when patients come from out of state or out of town or from another area. It comes to the resources, the financial resources to provide for care. And I think that we need to engage them in a serious way part – have part ownership for this initiative because we won't be able to do it with any one piece alone, the federal government, the hospitals; we need them to participate as well.
KELLY: Tom, maybe if I can ask you to extend that a little bit. Who should pay in this instance?
BURKE: Well, I think the – if you looked at the entire price tag, I don't think anybody is capable of paying the full price tag, and that is kind of the issue that we are dealing with. And I think the comment of being practical is the most realistic approach we can take. We invest part of our resources like the others at the table do to provide first-response kind of activities. We have also taken the tack of trying to build on our strength. We are a cancer center. We are used to dealing immune-compromised people. We feel like we bring special expertise to our community should there be a nuclear event or some other kind of event that leaves people neutropenic or immune compromised. And so we have sort of taken that role in our community to kind of work from an area of strength.
I think the other thing is that we need to recognize that at least in the initial phases of any event, we are really talking about pretty basic medical kinds of services. And so you really need a partnership between academic centers like ours that have unique expertise but you also need the community connection. I think a lot of the success initially in Houston during the hurricane events was based on the county medical society mobilizing local doctors and nurses and other professional people to the areas that we needed those resources. And so that also helps to spread in ways of cost, but also volunteer efforts and other things into the community.
There are none of us that can afford to absorb the kinds of costs that would be required to – as an institution or a group of institutions meet the needs.
KELLY: Vicki, do you have a thought on that?
RUNNING: Well, again, I think it goes back to partnerships with community and other medical providers within the region that you're in, as well as reaching out to the broader base of the nation. As we saw with Katrina, we were able to mobilize a volunteer force very quickly to respond within a week or to and go down to that region to assist in some of the MASH-type care that was being conducted there. But what we found was that there was a period of chaos and a period of uncertainty, and I believe that our planning efforts right now need to be focused on reducing that amount of time so that we can mobilize more quickly. And that starts at the grassroots level.
If our organizations are prepared and our staff knows what to do, then that has a ripple effect and goes out into the community. As we know, medical centers are magnets for people when either they are frightened or they are uncertain or they are hurt or their family members are injured, and we can't forget that during any crisis, we also have normal medical care that has to continue. Not only would we have people injured, for example, in a pandemic by the flu, but we would have injury by people, who were not able to get their medications. We might have other injuries from a situation where some child falls down, someone gets hurt because they are not supervised as well as they might be when family members are ill. We have pediatric needs that are very different from adult needs in any type of pandemic situation or any normal disease. So those are issues that I think we have to begin to deal with very carefully in our own organizations before we can go out and assist the larger community as a whole.
KELLY: Yeah, Michael.
SALEM: I would just add two things. First of all, I do think that relative to partnerships, the partnerships with the military, whether it be first responders and civilian support groups I think is one where a lot of effort is being made, and I think at least in our area is going well. And then just to extend my colleague's point, what if we – you know, our efforts relative to this pandemic are being made to keep the spike of the pandemic curve that the secretary talked about from being as high. Once you flatten that curve out – and we will potentially be successful there, that is when the issues of health insurance and care over time where you will have an enormous number of folks still in the system, and then what do you do after that. That has to be looked at as well.
KELLY: Now that the secretary is gone, let me ask you a question. I'll throw this out to the panel. How are the feds doing? Are they meeting their end of the bargain on this in terms of coordination, in terms of – well, we know about money – what are they not doing – rate them and then what do they need to be doing next if you were running Mr. Leavitt's department?
MILLER: Well, let me tackle that. First, we and about 18 other institutions, academic healthcare centers across the country are – have an $18-million grant to try to set up the lines of communication across all of the centers from the north to the south, the east to the west, trying to get best practices. And so there are federal dollars that are starting to flow into institutions to help put in the infrastructure for communication, just the communication piece. And so I would say we are about 50 percent of the way there. We are getting support from Michael Chertoff and his department in this area. But some of the other issues, the ones that we have talked about already, have not been addressed at all.
BURKE: I would say we've also been the beneficiaries of federal dollars related to flood-mitigation projects. We now have hardened our infrastructure to try to support it through mostly storm scenarios but also it applies to other emergency situations. We've also received some state support for bio-terrorism preparation and other equipment and facilities needs that we've had to put forward.
What wasn't mentioned was the amount of revenue lost that you sustained during one of these events that I'd point out for our own institution. We estimate that we had a revenue loss of about $20 million during the Hurricane Rita scenario in which the storm didn't even strike our city; that we shut down our operations for four days. We lost the revenues associated with those four days of operations, and we paid overtime to all of our employee ride-out team member who stayed through that period. So we started out with that revenue loss just preparing for the scenario and it's difficult to sustain that for an extended period of time.
KELLY: Yeah, well –
KAHN: Maybe one brief comment from my perspective about this issue is that I think it's very important that we look at all the types of emergency preparedness that need to be considered at the same time. It isn't just the pandemic, it isn't just a natural disaster like an earthquake or a hurricane; it could be a manmade accident – either intentional or unintentional. It could be a variety of different factors and, I think, as we evaluate how we're doing as a medical society and as a government and as other agencies, we have to say – we have to separate how prepared are we for individual types of events versus those things which cut across all events, which certainly should be our first level of preparedness. We want to try to be sure we cover those basic needs that will occur no matter what the problem is, and then add on top of that, those things that are special to the kind of events that might be epidemic related or pandemic related versus those that might be natural disaster related, which would be quite different.
SALEM: One other piece that really comes to into play when you talk about big federal dollars in that is the pharmaceutical aspect relative – you know, we – academic medical centers, aren't purchasing from Rouche the doses of Tamiflu, nor are we funding the large paramedical production of the vaccine relative to H5N1 bird flu. And that's where a huge amount of dollars are going.
KELLY: Yes, Frank.
PEACOCK: I have sort of a carrot and a stick and the good news, I think, is that the surveillance system seems to be getting put in place and that seems to actually work, where at the local level we have labs that are testing for flu and when have they have a positive they report it up the chain on command to the Ohio Department of Health. We have doctors scattered throughout the community that when they see someone with an influenza-like illness, they report that. And then we have autopsy reports. All that stuff then is reported up to the Ohio Department of Health; that then in turn is reported regional, which is then reported nationally.
Now I know the Ohio system well, I don't know all states, but I'm making the assumption that works across the nation because the CDC ultimately ends up with that data. That's good. That way we can track the flu – we know when we have to do something.
I think the other difficult part of this is, and you'll – a little bit with the military, is what I call the transportation issue. Now, you wouldn't transport people around for a pandemic but for a disaster, you know, during Katrina I got all these phone calls even single day, let's go down there, let's set up a hospital down there, and my response is, they're under 10 feet of water. Why do I want to go try to put a hospital in 10 feet of water? I've got a perfectly, functioning, dry hospital right here – bring them to me. That system doesn't really seem to work. And if San Francisco gets hit or if, you know, there's a disaster in Chicago where they are locally overwhelmed, Cleveland's going to be fine – bring me those people. And we have the NDMS – the Natural Disaster Management System – but I'm not convinced that we have a way to get 2,000 people from Chicago to Cleveland but I got the beds for them. We cancelled – in September 11th we cancelled elective surgeries in two days. We got a whole hospital that can take people but somehow we have to have interstate transfer of sick people when the local area is overwhelmed.
KELLY: Vicki, in your experience, I mean, do you know who to coordinate with in the federal government? Do you feel confident that the right people are going to be there when you need them?
RUNNING: Yes and no to that answer. I do believe that the federal government is trying their best to help the healthcare industry to mitigate a potential disaster that hasn't happened yet. And because it hasn't happened yet, unlike Katrina, we don't know exactly the nature of that disaster, so our planning has to be on a broad basis even though we realize there are two different types of events, one that impacts infrastructure like Katrina and other events that are disease related.
There are some similarities but there are very big differences as well. I think the federal government is good at doing what they do best, which is to legislate and to provide funding. I think where the breakdown occurs is when those funds compete for attention. For example, in the county, funds flow down from the government to the county and from the county, it's distributed through the systems within the county to provide those emergency medical services.
We, as a hospital system, and other hospital-type of responders, compete for those dollars with the fire departments, with the ambulance companies, with the police departments – for equipment and training and supplies. In that competition then, the dollars get diluted and actually, the money that ends up in the healthcare industry itself, are probably are not as much as we would like to see – I know they're not – to help us to get ready. So the actual process then, falls more to the organizations themselves, and as private industry, it presents real issues for us because within private industry, which is healthcare for the most part, we also have competition for dollars. We have to maintain our own infrastructure. We have to maintain our own practice, and again, we have to provide normal hospital and emergency care for the normal population in a normal environment.
And at this point, we're running at capacity in this nation. So to try to surge upward at the same time when staffing is being impacted and people are in a pandemic and ill, means that there's a shift in balance and we go out of balance to the negative. And that's what we have to try to mitigate and that's were our planning efforts have to be focused. So again, education and personal preparedness, as Secretary Leavitt said, are truly the only ways we can prepare well enough that we can lessen our concern.
KELLY: Thanks. Let me ask a quick question. Maybe – really a question of are we over – does anyone here think we're overreacting to this? Does anyone think, that despite this conversation, we really don't need to be doing anything extraordinary?
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MILLER: I certainly think we have to do this. As the secretary pointed out, as Katrina pointed out, as 9/11 pointed out – we were not really prepared and we have to take those steps. We know how to put scenarios together; we know how to get our workforce motivated and put things in place so that we can move forward. We know how to put teams together. We should have been able to take these various disasters that we've had and put together a coherent plan and I think we, as leaders need to do that.
KELLY: Yup, Frank.
PEACOCK: I think we have to be rational about this when we start talking about disaster planning. I don't care how much money you have, I can spend every dime of it and I can spend all your children's money, too – (laughter). We can spend endlessly – it's like insurance and everybody in house has to go through this, every person, every family. How much money do you put on your own insurance? I mean your own health insurance, your house insurance, what's it worth and how much of your household budget goes to it? It's the same thing for the country. How much budget do we put for – because this is our insurance policy. And the danger is we get all emotional, and policy by emotion is just misguided; we will get ourselves in trouble. But we do need to have more rational planning than we have currently.
BURKE: So the key is to find the similarities in preparation for each of the scenarios and focus on those and expend our resources there.
KELLY: We want to leave some time for questions here. I'm going to ask one last question of everyone. Short answer – I wrote down what wakes you up at 5:00 in the morning? And I realize you're all doctors; you're already up at 5:00 in the morning. I'm not, but so what wakes you up at 3:00 in the morning – one thing that you sit and, say, bolt upright in a sweat and say, boy we're not ready to do this or boy if this ever happened. What's the one thing? Tom.
BURKE: I think to sustain my staff for an extended period.
KELLY: Ron.
KAHN: I guess my major concern, coming from a diabetes center is that people with chronic diseases like diabetes, hypertension, heart disease, asthma, severe arthritis, represent a lot of this country. They represent 90 million people now. They'll represent 150 million people in the year 2020. And they all are at special risk when we have a disaster, whether it be an emergency of Katrina's nature or a pandemic, some other type of medical problem or exposure to toxic waste. These are the people who are going to be most vulnerable to have the worst consequences. And I think that we have a healthcare system that doesn't really give enough attention to how we deal with them first, or at least with special attention that they need because they are going to be the most vulnerable people. They often include women and minorities, the underinsured. So that's the thing that keeps me up at night.
KELLY: Ed?
MILLER: No surge capacity whatsoever. Hospitals are filled, can't empty them fast enough, and then some very important ethical issues about who you will treat and who you will not.
KELLY: Yeah, Tom?
PEACOCK: Yeah, after my daughter woke me up at 3 with a cough, that was the issue. No, the surge capacity is clearly it. Having that been said, I'll say smallpox, because if that ever got out, we would be screwed.
KELLY: Vicki, any more good news?
RUNNING: Well, I think for me it would be the long-term effects of a disaster. I think we drill and we practice to the short term. When we drill and when we practice, we do it for four hours or eight hours. It's the long haul. These events are not short term. As we've seen with Katrina, they go on and on and on, and it's years before you can mitigate and get back to business as usual. So what keeps me up at night and in the morning is thinking about how we can better ensure that we can go on.
SALEM: I guess waking up at 5 and the E-mail not working, had there been an electric disaster of some sort would wake me up a little faster than normal. But I would say that from the sounds of this panel, we're just not ready yet – very straightforward.
KELLY: We've got time for some questions. I see a few. Jim, you can – if you would identify yourself –
Q: Mike Anderson, Homeland Security. I'd like to ask the panel if any of your organizations have considered altered standards of care in your plans?
PEACOCK: Yeah, I would say that we have that in our policy actually that if we are overwhelmed by a disaster, the moribund patient – the person who is going to take a tremendous amount of resources to save and you don't have the hands or the time – you have to have the contingency, which is those patients are going to get some morphine and get set in the corner. And when you're done treating the 30 patients you have over here and they're okay, you go back to them, but the probability is they will not survive. And that's the definition of disaster is need exceeds resources, and you make those decisions. And as the gentleman to my right was talking, the ethics had come in. That's a very difficult situation.
RUNNING: Brian?
KELLY: Yeah, Alex.
Q: Hi, I'm Jane Birnbaum. I'd like to follow up on the remarks of Cleveland's Dr. Peacock, who I think has hit a number of nails on the head. If what we have here is a money problem, an infrastructure problem today when we're in an era of for-profit healthcare delivery, are medical directors such as yourselves prepared to go to Washington and lobby members of Congress and say, well, we have tax cuts for millionaires but we need more money from Washington?
PEACOCK: Well, what I would like to see is we should mothball battleships – I think we should mothball buildings that are set up for a hospital. Every major city could take an old warehouse and stock it, not with perishables, but with a bed and with oxygen and that sort of thing so that you would have an option. It would not be high cost, but you know, there is no private industry going to do that unless there is funding source. And so, I sort of perceive this as lobbying Washington, but you had a more specific question.
SALEM: I think that I've recently interfaced with a number of senators and congressmen at least from our state and they have an acute awareness of these issues. And they have, of course, appropriated a substantive expenditure at least as it deals with avian influenza, and so I think that they want to solve the problem, but the issue of this kind of insurance and preparedness and buying buildings and providing surge capacity – I'm not sure has been addressed.
Q: ÃÂÂ I'm a psychiatrist, chairman of a large mental health company. During Katrina, there was serious mental issues as to what to do with the mentally ill, particularly the seriously mentally ill. Have you had any thoughts of how to deal with that population during such a crisis?
BURKE: Well, I think during the Katrina event, we had a special mental health team at both the Astrodome and the George R. Brown Convention Center, which were the two evacuee sites. And they were there specifically to meet the mental health needs of patients who were evacuated. That was a team that was separate from the regular medical team that was triaging for medical issues. And we had separate areas set up for those patients as they came in. That's an acute issue, not a long-term one, obviously.
KELLY: Yeah, Ron.
KAHN: Could I make a comment because I think that this mental health also falls into the chronic diseases that are often requiring medication. So you have a large percentage of people on chronic medication, and I do think this is an area where again we need to give thought to the issue of how we make sure that during emergency preparedness and all of these other considerations that we identify those people who are on chronic medications, make sure somehow that either they have their medications or we have developed a system where we can identify what medications they were on, whether it be a digitalized card that carries health information or some sort of computer chip or something as simple as a system where their health records can be accessed, you know, with HIPA concerns and all the other health privacy concerns. Sometimes we may have concerns that actually prevent access to critical information. So we need to find the right balance, and I think that patients with chronic mental illness and chronic diseases like diabetes or heart disease will all be in this special category with each different considerations of how they need to get their medications. But lack of medication is identified as one of the major problems in the recent Katrina disaster for all of these chronic diseases.
KELLY: Where are we? Alex, back there.
Q: Avery Comarow, U.S.News & World Report. As I listen to the different views expressed, a thought occurs to me that a lot of what you're talking about requires local planning at more than just your hospital level, whether it's the local county medical society, whether it's a consortium of hospitals. It sounds to me as if it is as important for the hospitals within an area to figure out what certain hospitals will not do and what other hospitals will do rather than trying to view this as trying to do the most that a particular individual hospital can do. And this is especially true, I think, because so many hospitals these days are staffed by agency nurses and temp nurses and who knows where they'll be. How successful are you in listing the cooperation of hospitals in your communities to divide up the responsibilities, the resources, the training, the responses, everything that goes into meeting emergency or surge needs?
BURKE: I think that I'll be happy to respond to that. I think we're very successful within the city and county around Houston and Harris County, there is a very good emergency network of hospitals. We routinely report open bed capacity, most of the hospitals have planned to work toward their strengths in a disaster area. As I mentioned earlier, we have unique opportunities with immuno-suppressed people. We have other hospitals in our center that have unique opportunities with trauma care. We have others that manage heart and other diseases well. And so, we have tried to partner and work to the strengths of each institution. We've also worked with the county emergency medical services to have contingency plans to activate non-hospital facilities for large volume casualties, and that's been a partnership amongst all of the hospitals in the region.
Question here, Brian.
KELLY: Anybody else? I just wanted to see if anybody else wanted to take Avery's question, and then we'll go over there, Jim.
MILLER: I was just going to say in the Baltimore-Washington region, the University of Maryland and Medstar with the five hospitals in Baltimore plus Washington Hospital Center and Hopkins work very well together in both exercise planning, and at the time of 9/11, figured out who was going to transport, who was going to receive, what our capacities were in ICUs, and so forth. So we had that all worked out.
SALEM: I would echo that for the Colorado public health, and I think it's well delineated. Obviously, you know what happens when the first casualty comes in. Bets are off in terms of what happens to the public, however.
RUNNING: And also in the Stanford region and the San Francisco Bay Area, we have various hospital councils that are working together. We've formulated a safety officers' task force, if you will, that also meets with EMS and county, civic, city, other providers that work together to allocate the funds that are flowing down from the government agencies and to work together to utilize those funds in the most effective manner for the region, not just for our own institutions. So for example, in our area, we've just created a disaster action planning guide, if you will, that is nicknamed CHERP – comprehensive healthcare emergency response plan. And that guide then is standardized amongst all of the agencies within our county and other hospitals as well to become an actual templated guide that they can each of them take and utilize to formulate a similar disaster plan so that we all know what we are all doing on the same day when any disaster or crisis occurs. So those types of planning processes, training programs, and working with hospital councils and taskforces all flow together to create a more prepared region.
Brian, we have time for just about one more question.
KELLY: One more? Okay, Jim, over by you. You've got someone.
She just answered that question. Is there no one?
KELLY: We've answered all questions? No more anywhere? Okay, one more.
Q: Thank you. Nancy Shute with U.S.News & World Report. What about communicating to the public? Frank, if I'm in Cleveland, how do I know that you're at capacity? How would I know that there is an alternative facility that I might want to go with? Are you addressing that in advance with the public or are you waiting until a disaster happens?
PEACOCK: We actually have an Internet site that you can go to and figure out which hospitals are open and closed, because we have February, where we have problems with occupancy of all hospitals. I'm not sure all cities are set up that way, but you can just – it's a web site. You click on it. It's yellow, green, and red colors that tells you who is closed and who is on bypass and who is not. In a disaster, part of our disaster plan, our emergency partners plan is that the public relations office has to come in and that's their job is to interface with the press and to communicate with the public. The issues are always is the hospital hit, is the tower still up, can we broadcast? But if that's all the case, then yeah.
BURKE: I think that has to be an integrated network, and you can have some pre-preparation in terms of who are the target locations for patients to go to or people in the community to go to, but in reality once the event unfolds, you have to adjust on the fly based on the reality of that situation. So it needs to be integrated with the police department, with 9-1-1 operators, with the fire department, so as people call for help from their home, they get up to date information and directions through those agencies. And obviously the news media locally for television and radio is another source of information.
KELLY: Okay, we've got some other things we need to do. I don't know that this discussion is going to make me sleep any better, but I am reassured that we have such terrific people here putting their expertise and time into it. I want to just thank our panelists for giving us the time and their nicely candid answers. Thank you.