When AVIAN INFLUENZA Fills the ED, WILL THE STAFF SHOW UP?
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When AVIAN INFLUENZA (or SARS or Bioterrorism) Fills the ED, WILL THE STAFF SHOW UP?
When the American Academy of Pediatrics, along with the group Trust for America’s Health, issued a report in late October citing serious gaps in preparedness for an avian flu epidemic, at least one medical group had already beaten them to the punch, if unofficially.
Nearly a week earlier, at the Scientific Assembly of the American College of Emergency Physicians, the results of an ACEP poll showed a majority of those surveyed believe their own emergency departments are unlikely to fully meet the demand of a such an outbreak. In interviews, several of them speculated on the reasons why, ranging from a suspected dearth of specialty support to a paucity of essential equipment.
Yet despite this generally alarming forecast, all were resolutely optimistic about one question raised in the possible pandemic: Will doctors stick around to treat the infected?
When it comes to emergency medicine, the answer is yes, at least for the most part, said Robert Williams, MD, DrPH, of Traverse City, MI, a past president of ACEP. His view was widely echoed by others. At a time when a physician’s duty to respond is being debated in the medical literature, ranging from a current article in The American Journal of Bioethics to a recent publication in Disaster Management Response, it is becoming evident that not all health care personnel are so positive about caring for victims in an epidemic.
In fact, surveys published in 2007 indicate the call to duty during a transmissible influenza disaster is not considered a binding obligation by many, including some of those generally considered the front line, such as emergency medicine technicians and paramedic teams. Professional codes of ethics largely don’t even address the issue of duty-to-care responsibilities for such members of the emergency-response teams or for other physicians and nurses in the context of communicable disease. (BMC Med Ethics 2006;7:E5.)
No Mandate to Help
Kenneth Iserson, MD, a professor of emergency medicine at the University of Arizona in Tucson and the director of its bioethics program, recently and systematically examined that very issue in a summary to be published in Annals of Emergency Medicine (Fight or Flight: What Risks Will Healthcare Professionals Take in an Epidemic?).
As he sees it, physicians have no mandate to offer help during a pandemic. To say that a judgment by any health provider to leave or stay in a disaster is an entirely ethical one grossly oversimplifies the decision-making process, he asserted. Does a parent who is a physician have a duty to leave his young children in a quest to help strangers? Or should responding to an epidemic be done by those who arguably have less at stake for putting themselves in harm’s way, such as an unmarried resident or a senior physician without as many family responsibilities?
These questions are not as easily answered as they might appear to be, and lending them moral overtones isn’t helpful, he said. We sure hope our colleagues respond, but it is not an ethically defined responsibility, he said.
In an essay that appeared in the journal Emerging Infectious Diseases posted by the Centers for Disease Control and Prevention on its web site, the British physician and ethicist Daniel Sokol urged more discussion of these duty-to-care issues and of the arguments surrounding them. In his paper, he concludes that there are limits to the participation that should be expected by physicians and other health care providers. Likening flu victims to swimmers caught in a threatening ocean, he observed that if a swimmer in an isolated but supervised beach starts to drown 50 meters from shore, the lifeguard may reasonably be expected to attempt a rescue.
If, however, the drowning person is two miles out and being circled by hungry sharks, then one cannot expect the solitary lifeguard to dive among the sharks to save the swimmer, he said.
Are EDs Ready?
Avian influenza, or bird flu as it is being called, has been found across Asia and occasionally and sporadically in parts of Europe. According to a 2006 report in the Journal of Emergency Medical Services, few cases of human-to-human transmission have occurred. These cases have involved close household contacts, and according to the CDC, there’s currently no evidence of transmission beyond one person. In light of the viral capacity for mutation, however, that could change, perhaps outdistancing medicine’s ability to contain the variants.
Given the possibility of global dissemination by jet travel, this thing could spread very quickly, Dr. Williams said. Asked if some physicians would decline to provide care if it did, he countered that past epidemics have shown the opposite - solid participation on the part of the medical community rather than flight from risk. Health care providers are basically altruistic, he said, though he noted the exception could be physicians and nurses not directly involved in day-to-day patient care.
The reaction of physicians in other areas of medicine, particularly specialists, may be more variable, agreed Arthur Derse, MD, JD, the director for medical and legal affairs at the Medical College of Wisconsin.
Why might they be more reluctant to provide care under these circumstances? Some may not respond because they have gotten out of the habit of handling such emergencies and of working as a team to do so, either because they don’t take call or due to their relative lack of experience with infectious disease. In contrast, primary care physicians and emergency physicians habitually manage those seeking urgent care for that very reason every winter.
The probability of such a flu epidemic may be substantial, said Dr. Derse, who also is a professor of bioethics and emergency medicine at the Medical College of Wisconsin. And if one occurs, the numbers could be overwhelming. It may be the scarcity of resources, such as lack of ventilators, however, that poses the greatest challenge, he suggested.
In fact, in its evaluation of preparedness in the recent report, Pandemic Influenza: Warning, Children at Risk, the American Academy of Pediatrics and the Trust for America’s Health, call on the Department of Health and Human Services to convene an independent task force to study and make specific recommendations about the use of masks, respirators, and other protective equipment. And, as some recent findings seem to indicate, such measures may influence participation by the health care community.
EPs Set for Pandemics
In the study, Will First-Responders Show Up for Work During a Pandemic? a group of Michigan investigators surveyed about 100 paramedics and found that the answer is no among a majority of them if no vaccine or protective gear is available. Even when full protection is available, less than 40 percent indicated they would remain on duty if their immediate families lacked such protection. (Disaster Manag Response 2007;5[2]:45.)
Yet, most emergency physicians can be counted on in the event of a pandemic, Dr. Derse countered. One reason, he reiterated, may be because they have annual experience at it. EPs handle patients every flu season, and although a widespread epidemic would be far different in scope, the response would be the same: largely, supportive care delivered to patients within typical transmission-preventing protocols, he pointed out.
Dr. Iserson added that during the SARS epidemic, many physicians continued to risk their own health by returning to work day after day during the course of the outbreak, a reaction that has significant historical precedent.
To the suggestion that the public might be better served if some physicians stayed away from infected patients to remain healthy, preserving their ability to provide leadership and oversight in the wake of the pandemic, Dr. Williams offered a verbal scoff. If you have a hopeless battle to fight, you’re not going to send in your best soldiers? That is just not right. It’s their job to care for people, he said.
How does an emergency physician decide to stay or leave in an infectious disaster? By way of an individual moral compass, with inner workings that involve both a personal value system and accurate risk assessment.
That is the implication of a study led by Kenneth Iserson, MD, MBA, who, along with a multi-center team, concluded that nothing in the daily lives of emergency physicians truly prepares them for the scope of a future pandemic. Limited epidemics, such as Hantavirus outbreaks, suggest that many emergency physicians would stay to treat patients. But a pandemic could test that commitment if there is not good communication and risk prevention.
When disaster strikes, in addition to a strong moral foundation, physicians need good factual information, and the lack of it can corrode trust, potentially leading to heated emotions and panic, the authors noted.
Perhaps the most important step, or one of the most important, they say, is the availability of reliable, up-to-date information upon which health care providers can make decisions during such events. (Ann Emerg Med. 2007, unpublished in print at press time.)
The flu epidemic, if it comes, may mimic the last one in some ways, according to interviews with emergency physicians. Dr. Iserson observed that the so-called Spanish flu of that period is now often cited in discussions of avian influenza, a time when many in the health care community toiled long hours among the sick. He harks back to an even earlier era, in which physicians and nurses had equal reason to fear patient contact, yet many stayed at the bedside: the yellow fever plague of the late 1700s. Some of them had families begging them to come home, and many faced an uncertain future among the death and contamination.
Dr. Iserson pointed out that physician Benjamin Rush, who served when yellow fever swept through Philadelphia in 1773, urged his wife in a letter to accept his decision to stay and fight the ravaging disease. It would be as much your duty not to desert me in that situation as it is mine not to desert my patients, he wrote his worried spouse.
Would human behavior be the same today? Some emergency physicians at the ACEP meeting suggested it would, suggesting that little has changed in their professional view since that devastating 1918 flu blight, which killed more people than World War I. Nearly a century ago, neighbors rallied to help others during illness.
The record shows, however, that in other cases, they pitted themselves against each other. Some towns even placed city limits in a sort of lockdown, in which residents could not venture in or out to protect the flu from infiltrating. The Colorado town of Gunnison was one of them, and there were others in the timbered regions of the Pacific Northwest.
In The Last Town on Earth, writer Thomas Mullen chronicles what happens in one such town, after citizens are posted to guard the road leading to the community. Two of the residents act as sentries behind a sign that reads, in part, neither stranger nor friend may pass, a demarcation that bars entrance to anyone. In the book, a tired and hungry stranger is shot when he tries to pass, seeking refuge. Before the bullets fly, one citizen sentry warns him: ‘This town is under quarantine. You can’t come any closer!’
Though a work of fiction, Mr. Mullen’s account of this remote town closed to outsiders during the worst plague in modern American history has contemporary resonance, the Seattle Times stated in a recent review. Even the author himself seems surprised at the chord he struck. In a commentary published along with the book, Mr. Mullen notes that this may sound unbelievable today, when newspaper articles about bird flu and the 1918 pandemic appear daily, but back when I conceived of the story … the bird flu was barely on our radar screens, and the 1918 flu seemed to have vanished from collective memory.
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Source: Emergency Medicine News:Volume 29(12)December 2007p 20-21
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