The Official Voice of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress
December 2002
4Th Mission
Dealing With A Disaster SurgeBY William Triplett
A small but significant fact went all but unnoticed on September 11, 2001. As emergency fire and medical crews in New York City struggled to help anyone they could find alive amid the cinders and rubble of the collapsed World Trade Center towers, some 68 survivors of the single worst terrorist attack against Americans walked in and registered for attention at the Manhattan VA Medical Center. An additional 30 or so also came in, though they didn't register amid the confusion.
In short, VA doctors and nurses had to deal with about 98 unanticipated cases. The result? "They were overwhelmed," said a congressional expert on veterans affairs. Everyone was eventually treated, but only because more patients did not appear.
The implications of what at first glance might seem merely a detail - a VA hospital emergency room suffered temporary overload - grew ominous as reports of more terrorist attacks later surfaced. Deadly anthrax spores were turning up in the U.S. mail, and while only a minimal number of people died, concern mushroomed about possible biological warfare, or bioterror, attacks aimed at the United States.
Federal, state, and local authorities had conducted a joint exercise involving a bioterrorist incident - with alarming results. A simulated release of aerosolized pneumonic plague bacteria in downtown Denver had wreaked havoc on every level of the emergency response system. Communications broke down as reports of infections spread at breathtaking speed throughout the city, across the country, and then to cities as far away as London and Tokyo because of infected travelers. Stockpiles of antibiotics and other drugs ran out and couldn't be replaced rapidly enough. And every area hospital - including the local VA facility, which participated - was overrun with casualties.
The U.S. government looked closely at the grim lessons learned from the Denver exercise, conducted in May 2000. Still, the government tended to rank the likelihood of bioterrorism fairly low. Because of the intricacies involved, a credible bioterrorist threat almost would have to involve a state sponsor, and what state would unleash a horror that would draw down the world's condemnation?
"Well, now we've seen a state willing to support that kind of thing," said our congressional source, who asked not to be identified.
No agency, public or private, is more painfully aware of this new, volatile state of affairs than the VA. Federal laws effectively rely on the VA's extensive medical system to play the lead role for governmental assistance in responding to a bioterror disaster anywhere in the United States or its territories. Yet, while a number of other federal agencies have received budget increases to combat terrorism, the VA, by comparison, has gotten almost nothing."If 9,800 people had walked into the Manhattan VAMC on September 11 instead of 98, what would they have done?," asked the congressional expert. A bioterrorist attack executed with the precision of the World Trade Center and Pentagon attacks could easily produce upward of 100,000 casualties. And the VA health care system, like the overall American health care industry in the U.S., might not even know what was happening until too late.
"The role of the VA is very important in the event of a biological attack," says Elin Gursky, a senior fellow at the Center for Biodefense Strategy at Johns Hopkins University. For the most part, the VA medical system would be asked to provide "surge capacity," a term health care officials have coined to refer to dealing with the results of a sudden influx of patients who need immediate attention. Most hospitals normally operate at maximum capacity: the more beds that are filled, the more income the hospital generates. As a result, the entire private health care system is vulnerable to a surge in patients.
"We will need additional trained people - physicians, nurses, health care experts - to be able to respond to a surge," Gursky says."We'll need the capacity of VA hospital beds to serve as an overflow for [private and other public] hospitals, and perhaps even be part of a regional triage system, where the VA maybe takes over the less sick patients. In terms of its trained personnel and its facilities, I don't think this country would attempt to do comprehensive bioterrorism planning without VA in an integral role."
The VA has a long history of providing emergency medical assistance throughout the U.S., and with good reason. With 163 medical centers across the country and some kind of clinic in virtually every community, the agency operates the only national health care system that can respond to a domestic medical emergency almost anywhere. Hence, the reason why in 1984 the Department of Defense, Department of Health and Human Services, and the Federal Emergency Management Agency included the VA when drafting plans for the National Disaster Medical System (NDMS). The purpose of the NDMS - jointly operated by DoD, HHS, FEMA and VA - is to provide capability for treating large numbers of patients injured in a large peacetime disaster within the continental United States, or to treat casualties returning from a conventional military conflict overseas.
When the NDMS was first established, DoD had lots of domestic patient beds available. But as DoD downsized, closing many bases, it lost those medical facilities, leaving VA as the only pre-deployed federal health care resource, meaning it is the only one of the four partner agencies that can provide direct clinical care in the field. Even prior to establishment of the NDMS, VA medical facilities routinely engaged in emergency planning with local private hospitals in their respective areas.
As part of the NDMS, the VA is responsible for running about 80 percent of the federal communications centers, which coordinate response activities with community hospitals in the area of a medical disaster. The VA is also in charge of providing patient care during a disaster, but almost never does that happen within a VAMC. It's usually a matter of working with community hospitals and partners.
In the early 1990s President Clinton wanted the government to be able to protect the country from more than just medical disasters. He issued two directives that eventually formed the backbone of the Federal Response Plan (FRP), which established the architecture for a systematic, coordinated, and effective federal response to any kind of disaster or emergency situation. Under the FRP the VA's responsibilities grew and changed.
The FRP puts two federal agencies in charge - the FBI for crisis management and FEMA for consequence management. FEMA's responsibilities include medical care and public health, both of which are directly overseen by the Department of Health and Human Services, HHS mobilizes the National Disaster Medical System, which then allows the VA to act as an equal partner with HHS. The FRP requires that HHS ask the VA for help and services, which the VA then supplies. Thus, the VA is the main support for mass care.
Because of these plans, the VA has developed a capacity to respond to just about any disaster - and it has. "VA has responded to every single domestic disaster of the last 20 years," says the congressional source. "Hurricane Andrew, Oklahoma City, and even the catastrophic flooding in Houston last year. In fact, the VA hospital in Houston was the only one that did not have a generator in the basement," and was therefore able to keep functioning while generators at other hospitals disappeared under water. For Hurricane Andrew, the agency deployed more than a thousand medical personnel to South Florida.
Then came September 11.
As a result of the temporary overload at the Manhattan VAMC, VA Secretary Anthony Principi established the Emergency Preparedness Working Group (EPWG), a panel of experts charged with determining what the agency must have in place to prevent another overload if a similar attack should occur in the future. Moreover, all VA facilities would have to be able to continue fulfilling their primary mission - caring for veterans - while dealing with a surge in patients.
The EPWG, given short notice and little time because of fears that other terrorist attacks might be imminent, delivered its report last November. "It's quite comprehensive, and it looks at everything from personal protective equipment and decontamination to security and law enforcement," says Dr. Kristi L. Koenig, head of the VA's Emergency Management Strategic Healthcare Group (EMSHG).
"What the [EPWG] found was that VA is in some ways more prepared than the medical world in general, because they've had to be - VA works all the time with DoD as backup for DoD in times of war," said the congressional source. "Still, things needed to be done."
One thing was an increase in security, training, and equipment at VA medical facilities. VA medical staff had to be able to protect themselves and their patients in the event of an attack. Otherwise, the primary mission of caring for veterans would be jeopardized. "We have to make sure all our facilities are hardened anf that e have continuity-of-operations plans in place so that we can continue providing that care." says Koenig.
What the VA refers to as its fourth mission is an amalgam of responsibilities, such as preparing for the arrival of casualties from an overseas war the U.S. may be fighting or preparing to respond to a domestic disaster. Typically the VA focuses on one of those responsibilities at a time. "But after September 11 all these missions were coming into place at once," says Koenig. For example, while preparing to respond to more attacks on American soil, the agency also had to gear up for the possibility of casualties from the war in Afghanistan. Moreover, the VA also suddenly had to contend with a slightly reduced workforce. "Some of our employees were being called up as reservists," Koenig says.
Consequently, the EPWG recommended a review of virtually all VA emergency and contingency plan the VA had devised to that point to make sure they reflected the new reality.
The EPWG also found, as VA already knew to a large extent, that communication during emergencies was often poor. In particular, it's imperative to develop and use a communication system that does not depend on telephone lines; also, when using radios, a clear plan for everyone to use the same frequency is vital. Information management systems were also discovered to be vulnerable.
The report concluded with an estimate of how much it would cost to bring the VA's level of preparedness up to where it should be - $250 million. "That's actually pretty reasonable," said the congressional source. "But then the administration said, 'Pare that down to what you absolutely have to have.' The group said, 'Okay, we can work with $77 million. We won't be able to do everything, but we can at least get every single VAMC capable of protecting its own patients.' The administration then said, 'Hmm, okay, here's $2 million.' That's all they got from the administration's emergency supplemental funds. The VA has a great plan, but no money. Still, they'll do the job because they have to - they have no choice about protecting veteran patients. But something will lose out. The money will have to come from elsewhere in the VA budget.''
The VA already has begun taking steps to improve preparedness. A statement from the agency's office of public affairs says that: "We are enhancing our emergency operations center to keep that system functioning fully in the event of a crisis of any nature. This center has instituted daily, around-the-clock coverage, with secure data and voice communications links, to closely monitor VA's operational status, and to track the location of essential personnel for mobilization in the event of a crisis. Additionally, VA's information technology capability is being improved system-wide.
"Second, to make sure VA can respond fully in the event of a crisis, there will be an immediate review of the [EPWG's] recommendations, identifying those needing immediate action and a fast-track decision process adopted to implement them.
"Third, VA has expanded its Office of Policy and Planning to include operations to support [Office of Homeland Security director Thomas] Ridge in fulfilling the mission of providing for homeland security, and oversee on a daily basis emergency and operations activities."
Specifically concerning the threat of bioterrorism, however, VA's state of preparedness is less encouraging. In theory, the VA would respond on two levels - local and federal. Locally, the VA would provide humanitarian assistance in the form of treating anyone who walked into a VA medical facility. "If someone comes to your door, and he's not a veteran and he's dying on your doorstep, as will happen, you're going to take care of him if you have the ability to do so,'' says Koenig. "We're not authorized to take care of non-veterans, but in this kind of scenario, we provide humanitarian assistance, and we've done it over and over again already.''
This would involve more immediate, almost isolated forms of assistance, as opposed to VA's role on the national level as part of the Federal Response Plan. In a typical emergency, local officials would request help from the state. If the state couldn't provide it, a request would go to the federal level, which would trigger a White House declaration of a disaster, in turn enacting the FRP. More than likely, though, a large release of smallpox bacilli, for example, would automatically activate the FRP. There would be no time for the normal process to work its way up the line: Too many people would die.
The Department of Health and Human Services' office of emergency preparedness would call Koenig's office and make a request for assistance in whatever form - medical personnel or supplies, for instance. "We're not required to provide whatever they ask for,'' Koenig says. "We only do it if it doesn't degrade our ability to do our primary mission. However, because we have a nationally integrated health care system, up until this point we have generally been able to provide whatever's been requested.''
Nevertheless, bioterrorist threats have pointed up shortcomings within the VA and in the country's entire emergency health-care response system. "One of biggest concerns I have is risk communication,'' says Koenig. "I don't think we did very well with that after the anthrax. We were all still learning, and I'm not sure we gave really good, quick, and clear messages as [the incident] was unfolding. You wouldn't have thought you could contract anthrax the way it was contracted'' based on information the government was releasing.
A particularly vexing problem that came out of the simulated release of plague in Denver - an that still has not been resolved - is the question of how to enforce a quarantine. The VA, proactive to a large degree on the matter, had tried to answer this question prior to the Denver test, but it was the Denver test that graphically demonstrated the near-impossibility of restricting the movements of people who may be infected. The only sure means was to shoot them.
From the standpoint of medical response, possibly the most insidious aspect of bioterrorism is the delayed recognition of a bioterrorist attack. It is not easily determined whether a sudden outbreak of disease is the result of bioterrorism, which more than likely occurs unseen. It's also nearly impossible to know exactly where or when the release of agents took place - and therefore where to send authorities to combat or disinfect it. All you know is that suddenly you have a lot of sick and dying people on your hands.
Currently the VA has no plans to have experts on bioterrorism posted to any of its medical centers. Instead, according to Gen. Mick Kicklighter, the VA assistant secretary for policy and planning as well as the acting director of the agency's Office of Operations Security & Preparedness, existing VA health care personnel will be trained on recognizing and responding to bioterrorist events. "Hopefully we'll get some warnings [of a bioterror attack], but if not, we will have, I believe, a very significant training program connected with this preparedness," Kicklighter says.
"I don't think we'll be getting any new people," adds Dr. Robert Claypool, Kicklighter's deputy. "We'll just be training the people we have. But we are looking at, if the budget supports it, being able to [hire] additional individuals who will have expertise in decontamination training." Ultimately, says Koenig, any decision to bring in resident bioterror experts to any VAMC will be the decision of the VAMC director. "The responsibility for that has been delegated to the individual facilities,'' she says.
The VA is also participating with other federal agencies to develop something called "syndromic surveillance," which Claypool describes as "a concept where you look at getting an early-warning system or a tripwire for a bioterror event through the recognition of an unusual constellation of symptoms and signs."
But even with bioterror experts located at every VA facility, other preparedness issues remain. "If we had anthrax released in aerosolized fashion, affecting lots more people than were affected last year, causing 500 cases, we could deal with it," says the congressional source. "But 5,000? You just have to look at the number of hospital beds available on any given day to know that that's going to be a problem. A hundred thousand cases of smallpox is numerically possible, but we don't have much play in our medical system - and that's a byproduct of 20 years now of HMO and managed care principles, that we should strip down to minimal inventory, minimal everything, and go to outpatient services. VA's been doing that, too. But VA will be better off than other hospitals in that VA is already putting in place regional pharmaceutical stockpiles just for VA use.''
So far the agency has established 143 such stockpiles or caches. According to Claypool, they would allow VA medical facilities to treat anywhere from 1,000 to 2,000 casualties for a day, possibly two, which could be crucial since it will likely take at least that long for the Department of Health and Human Services to release and deliver its supply of pharmaceuticals to an affected area. "The 143 caches are designed specifically to support our medical centers, for patients who present to our centers, for our veterans and for our staff," he says.
Though the VA is designated as a supporting player in a bioterrorist incident, the sheer size and geographic diversity of its medical facilities all but guarantee it will be a lead player on the actual scene. "One thing you can say is that if a bioterrorist attack hit today, VA would end up being involved,'' the congressional source said. "Because when people get sick, they don't pick up a phone book and say, Which of the hospitals is best likely to deal with infectious diseases of unknown etiology?' They go to the nearest hospital or where they've always gone. So veterans would go to VAMCs.''
But whether the VAMCs will be able to care for them and provide assistance to the communities affected by the attack and continue with the VA's primary mission - caring for veterans - is an open question. A staffing shortage currently plagues the health care industry at large, and the VA is not immune. "Whatever we have to face, we will try to make sure we have minimum disruption in our ability to take care of veterans and their families," says Kicklighter. "If we have excess capability, and the country asks us to help, maybe in bringing resources from other medical centers [not located near the attack], then we'll do everything we can to help save American lives and reduce pain and suffering. Whatever we face, the VA will continue to function as a VA. We won't close down."
Would a VA medical center be authorized, then, to turn away non-veterans should the facility's ability to care for veterans be compromised by an attack in the area? "It's hard to answer a question like that unless you're right on the ground," says Kicklighter. "Our mission is to take care of veterans, but if we're in a situation where we're overwhelmed, we'd just do everything we can to make the right choices and do everything we can to take care of veterans and help our community as much as we could. But in this world, we now have to think of things we never wanted to think of, and massive numbers of casualties, that's one of them."
A U.S. war against Iraq could further strain VA capabilities and resources. A U.S. war against Iraq and a bioterrorist attack on U.S. soil could do far worse. Says Kicklighter, "I think we're moving in the direction to help support our nation in whatever situation there is, whether it's taking battlefield casualties or from the home battlefield, or from both battlefields. But that's a scenario we hope and pray doesn't happen.''
The White House has increased the HHS budget anywhere from $3 billion to $6 billion, depending on how you view it, specifically to combat the threat of bioterror. HHS could transfer funds to the VA to pay for any VA services or personnel needed in a national disaster, but HHS is not required to pay for everything it asks from VA. HHS and VA have also had their disputes in the past over allocation of resources. And disputes eat up precious time.
That the VA is supposed to provide only assistance - and not assume the lead role - is no comfort to VA doctors, nurses, and clinicians who know that the rest of the country's emergency health care system is less prepared to deal with mass casualties from bioterror. In practice, the main responsibility will devolve almost instantly to the VA. How long it can hold on until it, too, is overwhelmed is the ultimate question.
"Since probably the 1918 flu pandemic, we've never truly overwhelmed our health care capacity in this country," says Koenig. "We've had major disasters in terms of property damage and death, but live patients with potentially treatable illnesses and symptoms - that's just a lot of theory now. Other countries have had the experience, but not here. It's hard to get people to conceptualize what that would be like."
It may not be so hard one day.
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