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Scenario for Security

Health Sciences Center Helps Utah Prepare for Bioterrorism

By Susan Sample

It's a July afternoon, hot but breezy in the hospital's ambulance bay. A young shock trauma nurse waits just inside the door. She's heard the call from the California Highway Patrol: a red Mazda RX7 speeding on Bayshore Freeway crashed into a cement divider, flipped into oncoming traffic.

"My idea of a weapon of mass destruction (WMD) back then was a really bad car crash with multiple patients," said Caryn Summers, R.N., B.S.N., a Utah native who managed the emergency department at the Palo Alto Veterans Affairs Medical Center in the early 1980s.

But just as suspense escalates into terror in summer blockbusters at the movie theaters, so, too, has the scenario changed that the nurse prepares for in 2002 at University of Utah Hospital.

It's a July afternoon. Maybe there's a breeze. Summers can't feel it, outfitted in her blue personal protective equipment and respirator. In the ambulance bay, it's "hot": curtains have been pulled, cordoning off a zone for contaminated patients. She's got one minute to triage each by color. Red: life-threatening, keep in the ER. Yellow: urgent, needs treatment. Blue: non-urgent, send to Clinic 10. Green: walking-wounded, delay, send to Clinic 1. Brown: expected to die, make comfortable. Black: deceased, send to morgue.

"I never thought I'd have to worry about anthrax or our nuclear repository being used as a WMD, but 9/11 has changed our whole perception," said Summers, clinical nurse coordinator for University Hospital's Emergency Department (ED). "With bioterrorism, there is not only going to be triage at the scene, but people running to the ED. The country has come to recognize that emergency departments are actually 'first-responders.' I must say, though, that I worry a lot less now that I've had training."

Last fall, Summers and three other ED staff completed a one-week U.S. Department of Justice course on how to handle Chemical, Ordinance/Explosives, Biological, and Radiological Weapons (COBRA). In March, she and three others from University Hospital's ED completed a Technical Emergency Response Training (TERT) course on teaching others how to respond to and operate in a WMD environment.

"I went to the training with trepidation," admitted Summers, now a certified TERT trainer. "What I came back with is peace of mind. I'm prepared in my professional life and my personal life. I'm prepared in my heart."

Like Summers, Utahns may feel a sense of security. As communities across the nation begin developing plans to prepare for bioterrorist attacks, the U of U already has written, and revised, scripts that draw on players from all areas of the health sciences center: University Hospital to the Utah Poison Control Center to the School of Medicine.

"University Hospital has gone above and beyond all other health-care facilities I've visited in regard to preparedness," said Rick Schlegal, deputy director of the Department of Justice Center for Domestic Preparedness, at a spring presentation in Salt Lake City. "The Emergency Department staff demonstrates facility protection, operations security, and efficacy of patient treatment with their knowledge of personal protective equipment, decontamination, antidote administration, and disaster preparedness."

"Today, the Salt Lake area is at the fore in its preparedness for a terrorist threat," Dave Maurstad, regional director of the Federal Emergency Management Agency (FEMA), Region VIII, said in the Salt Lake Tribune last April. "Among the many legacies of the 2002 Winter Games, I believe the most valuable will be a nation better prepared for disasters of all kinds."

The Olympics may have brought Utah's preparedness to the forefront of the nation's attention, but the state has been poised to respond to disasters involving chemical and biological agents for many years. About 40 miles from Salt Lake City is the Tooele Army Depot, site of the region's only operational chemical weapons incinerator. Nearby at Dugway Proving Grounds, the U.S. Army studies the detection of biological warfare agents.

"I don't think of bioterrorism preparedness as an effect of 9/11, because we've been saying forever that it's a matter of when "not if," said Barbara Insley Crouch, Pharm.D., M.S.P.H., director of the Utah Poison Control Center (UPCC) since 1992. "Our awareness started out with a more narrow focus, the Chemical Stockpile Emergency Preparedness Plan (CSEPP). Even before that, we talked of trucks transporting hazardous materials on I-80."

"We've been a step ahead. We were the first state to publish guidelines for hospital response to chemical, biological, and radiological warfare," noted Deborah Kim, A.P.R.N., M.S.N., former manager of University Hospital's Emergency Management/Hazardous Materials programs, who helped develop the CSEPP guidelines in 1993. "Our challenge now is to maintain a high level of awareness when we don't know when the disaster or attack is coming."

"Before the Soviet Union collapsed as a political and economic entity, we had a balance of terror: each side was able to release state-sponsored weapons. Everyone had nightmares about nuclear weapons," said John B. Hibbs, M.D., chief of the medical school's Division of Infectious Diseases. "Now the global political system has changed drastically. Biological weapons, along with high explosives like dynamite and fertilizer, are probably most readily available to weak and dispossessed subnational and transnational small groups intent on carrying out acts of violence. It's using something relatively inexpensive and already in nature--microbes, viruses, and toxins--in malevolent ways."

The Centers for Disease Control and Prevention (CDC) has identified six biological agents as "Category A," the highest priority: anthrax, smallpox, botulism, tularemia, viral hemorrhagic fever, and plague. "Anthrax and smallpox are the two biological agents most likely to be used, based on the relative ease with which large amounts of material could be produced," said Hibbs, distinguished professor of internal medicine. "They're relatively stable agents, and both can be dispersed by aerosol fairly readily.

"Smallpox has an added danger, because once an individual has it, it's so communicable. There are at least 10 secondary cases for each individual infected," explained Hibbs. "If smallpox is released into nature again, it will be a devastating problem. Almost everybody is susceptible."

Smallpox was eliminated with the last known case occurring in 1979 in Somalia. Immunizations against smallpox already had ceased in America; some 150 million doses of the old vaccine remain in storage. Even those who were immunized prior to the 1970s are no longer protected, since vaccine-induced immunity wanes significantly after 20 years, according to Hibbs. "Were smallpox to be reintroduced, it would be difficult to find enough vaccine. It could create a worldwide pandemic."

What adds to the terror of these biological agents is the element of surprise. "Bioterrorism is different than chemical terrorism, because it's basically sleuthing. You have to look for the clues; they're not going to jump out at you," said emergency manager Kim. "And it's not just people. You have to look at the whole environment. Is public works picking up more dead birds than usual? Are sewer workers seeing more dead rats than normal?"

"The symptoms from chemical agents are bad. With nerve agents, you see respiratory distress and muscle twitching, then paralysis within minutes," said Crouch. "It's harder to track biological incidents. It's not obvious something has happened. The symptoms don't appear as quickly, and they're subtle. It can be hard to separate out symptoms of anthrax and other biological agents from the "u."

Although poison prevention education, intentional overdoses, and adverse drug reactions comprise a large portion of the more than 50,000 calls the UPCC receives each year, the center also handles environmental and occupational exposures. "We take a broader public health role than people realize," noted Crouch. "We get called when people don't know who else to call. By evaluating the situation, we can prevent unnecessary ER visits and reduce hysteria."

When sulfur dioxide spilled at the Thatcher Chemical plant in Salt Lake City in 1991, victims needing immediate attention were rushed to the hospital. Those with minor mucous membrane inflammation who later experienced tears and coughs dialed poison control.

About 80 percent of the calls the poison control center receives are managed over the telephone. The UPCC, located in the University's Research Park, has an extensive reference library to draw upon. Callers requiring medical attention will be referred to their closest emergency department. If that is University Hospital, they may be seen by UPCC medical director E. Martin Caravati, M.D., M.P.H., who also heads up University Hospital's Consult Service, the only medical toxicology inpatient consult service in Utah. Caravati, professor of emergency medicine in the medical school and a board-certified medical toxicologist, also consults with health-care providers on patient evaluation and treatment.

Open 24 hours a day, seven days a week, the UPCC plays an important public health role by helping to track calls and identify trends that might indicate a widespread incident. The Utah center is part of the Toxic Exposure Surveillance System, a national database of the American Association of Poison Control Centers, and the Agency for Toxic Substances and Disease Registry's Hazardous Substances Emergency Event Surveillance (HSEES), originally established for disease surveillance of people who helped with Superfund clean-ups. (See pg. 23.) The UPCC also maintains a close relationship with the Utah Department of Health, operating as a cooperative public service of the department and the U health sciences center.

"Our reference base and our training are so extensive, we're a natural liaison to University Hospital," said Crouch of the UPCC, a program of the U College of Pharmacy. "If there is an incident with weapons of mass destruction, the hospital will be a key player. We're here to support it."

Across the nation, hospitals have joined health departments, poison control centers, and provider associations to help states develop coordinated community response plans for bioterrorism and infectious disease outbreaks. Four University faculty and staff members are participating on Utah's Bioterrorism Hospital Advisory Committee: Crouch, Kim, Andrew T. Pavia, M.D., professor and chief of the Division of Pediatric Infectious Diseases, and Jeff E. Schunk, M.D., professor of pediatrics.

Last May, the group submitted a plan to the federal Health Resources and Services Administration (HRSA), which is awarding some $125 million in fiscal year 2002. Utah's share will be $1.11 million to be distributed through the Utah Department of Health's Bureau of Emergency Medical Services, according to director Jan Buttrey. A total of about $11 million will be given to the state for bioterrorism issues as part of the President Bush's homeland security package.

An additional $4.6 billion was approved in a broad bioterrorism bill last June to stockpile smallpox vaccine, improve food inspections, and boost security for water systems.

Among issues the Utah advisory committee has discussed are: identifying special needs of children, pregnant women, the elderly, and those with disabilities; determining how to deliver food, water, and electricity to patients during a disaster; and planning how to increase the number of patient beds, such as converting nursing homes or other buildings into temporary hospitals.

"Bioterrorism brings up new issues for us," said Kim. "We don't like to admit defeat to disease, but we'll see a progression of death over time and numbers that will be unbelievable.

"What do we do with people who die? If it's an intentional act, everyone who dies is part of a crime scene and subject to autopsy. A body can't be embalmed, if the person was infectious. It may have to be cremated, but a lot of people have objections. In a diverse community, we have many different religious practices and rituals."

Kim is on a state subcommittee for another particular aspect of bioterrorism preparedness: re-packaging and distribution of oral antibiotics from the National Pharmaceutical Stockpile. Each regimen contains a 10-day supply of antibiotics to provide post-exposure prophylactics to more than 200,000 people, in addition to medical supplies, such as bandages, gloves, tourniquets, and endotracheal tubes. The kits, which are part of the National Pharmaceutical Stockpile, are housed at 10-12 undisclosed locations that are moved across the country as needed. During the Olympics, a stockpile was in Salt Lake City.

"After 9/11, we developed our own internal response plan and supplies for a bioterrorist attack. We can take care of staff and patients for 72 hours," said Kim. "The threat of bioterrorism is that it will completely overwhelm hospitals, because there's the likelihood that our doctors, nurses, technicians, and their families will themselves become patients."

Hospitals are not the only ones to join the ranks of "first-responders" in a world haunted by bioterrorism. So, too, are physicians, even those whose practice is limited to private suburban clinics. "If symptoms don't appear for several days, patients will show up in their offices, and those physicians will be exposed," speculates Larry Reimer, M.D., professor of pathology and adjunct professor of infectious diseases. "That's why bioterrorism is so effective. The subtleties may escape someone who's not thinking about bioterrorism."

As assistant dean for curriculum at the School of Medicine, Reimer wants to ensure that future physicians do have a heightened awareness. He has supported, as part of the state's HRSA grant, additional educational training that follows the intent of the "First Contact, First Response" initiative announced by the Association of American Medical Colleges (AAMC) last fall.

"The AAMC stated that medical education should target bioterrorism for medical students and graduate medical students, and in continuing medical education," said Reimer.

At Utah, medical students will be exposed to the subject during three of their four years. First-year medical students learn about microorganisms associated with biological agents in a microbiology course. Last spring, the class added another hour of discussion and expanded the list of biological agents introduced. This fall, third-year students will research and discuss bioterrorism in case presentations for the "Topics in Medicine" class. Fourth-year students in a redesigned public health class also will address bioterrorism.

"We're not sure yet how to implement changes in housestaff education, since there are so many different programs. It probably will be department-based," said Reimer. Already, the departments of internal medicine, surgery, and family and preventive medicine have held "Grand Rounds" lectures on different aspects of bioterrorism.

"Even before this year, when I brought up anthrax and said it could be a biological agent, the medical students were very curious and wanted to know more," said Reimer. "In educating medical students, we'll run through diseases and unique characteristics of biological agents, but we also want to make sure they know how to approach diagnosing disease, how to use appropriate assessments and diagnostic tests, and then know what to do next.

"You need to know who to contact, how to establish lines of communication. Education will be about making sure those lines are identified and that refresher courses are held," said Reimer. "You want to make first-responders as aware as possible."

Bioterrorism has increased awareness about an area of medicine where the threat is hardly new. "Bioterrorism is an extension of what we already do in public health. It just puts a new urgency on our commitment to the prevention and control of infectious diseases," said George L. White Jr., Ph.D., M.S.P.H., professor and director of public health programs in the medical school's Department of Family and Preventive Medicine.

In an article that now seems prescient, White and Royce Moser Jr., M.D., M.P.H., professor and chief of the department's Division of Occupational and Environmental Health, discussed "Preparing for Expected Bioterrorism Attacks" in the May 2001 issue of Military Medicine.

White likes to draw an analogy between public health and the fire department: "People don't think about the are department until there's a fire. Then they expect the department to arrive with the best technology and save lives.

"When people start becoming ill, the public wants to know why. It's true that the majority of the great advances in our life expectancy are the result of public health initiatives, such as sanitation and immunizations," added White. "But people forget that. We take a lot for granted."

He hopes that increased awareness will bring additional funding for public health programs, such as surveillance systems, a view shared by other health-care providers.

"There was the feeling that infectious diseases had basically been controlled," said Hibbs. "So, during the latter part of the 20th century, the public health infrastructure was allowed to deteriorate. There's a need to rebuild. Even if there were not a bioterrorist attack, rebuilding public health surveillance systems would be valuable in terms of monitoring emerging infectious diseases.

"We don't want the threat of bioterrorism to interfere with the way we live our lives or practice medicine. It should not create fear or panic," added the chief of infectious diseases. "But it's something we need to be prepared for."

Related articles by U faculty and staff:

Adi V. Gundlapalli, M.D., Ph.D.; Jonathan Olson, B.S.; Sean P. Smith, B.S.; Michael Baza, B.S.; Robert R. Hausam, M.D.; Louise J. Eutropius, B.S.N., C.I.C.; Stan L. Pestotnik, R.Ph., M.S.; Karen Duncan, R.N., M.S.N.; Nancy Staggers, Ph.D., R.N., F.A.A.N.; Pierre Pincetl, M.D., and Matthew H. Samore, M.D. "A Rule-based Computer System to Facilitate Public Health Surveillance: Deployment by a Hospital Infection Control Unit." Annual meeting of the American Medical Informatics Association, San Antonio, Texas, Nov. 9-13, 2002.

Deborah H. Kim, M.S.N., Pamela W. Proctor, B.S.N., R.N., and Linda K. Amos, Ed.D., R.N., F.A.A.N. 2002. "Disaster management and the emergency department: A framework for planning." Emergency Nursing. 37:171-188.

Col. Royce Moser Jr., USAF, M.C. (Ret.); Maj. George L. White, U.S.A.F., B.S.C. (Ret.); Cynthia R. Lewis-Young, M.D.; Larry C. Garrett, M.P.H. 2001. "Preparing for expected bioterrorism attacks." Military Medicine. 166:369-374.

Caption

The Mark I kit (left) contains atropine and 2-PAMChloride, which are used for rapid treatment of exposure to a nerve agent, such as sarin. The kits are designed so that first-responders (health-care professionals who first treat victims exposed to weapons of mass destruction) may inject themselves through their personal protective gear or exposed patients. The LCD-2 Detector (right), received by University Hospital in preparation for the 2002 Winter Olympics, detects chemicals such as GB, sarin, VX, and mustard gas.

We always welcome your comments about the magazine. Address letters to: Editor, Health Sciences Report, Office of Public Affairs, University of Utah Health Sciences Center, 50 North Medical Drive, Salt Lake City, UT 84132. FAX: (801) 585-5188. E-mail: Susan.Sample@hsc.utah.edu.

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