Like a special forces team without a target, the biggest problem for doctors on the front lines of healthcare today is not knowing where the enemy lurks or how it may strike. For a healthcare system responsible for handling the aftermath of terrorism in its many forms, preparing for the unexpected in the post-9/11 world is an unprecedented challenge.
After the attack on 9/11, emergency room personnel in New York City anxiously awaited injured survivors from the World Trade Center. Weeks later, physicians and healthcare providers across the country faced a deluge of worried patients who feared they might have been exposed to anthrax spores. And earlier this year, a thwarted "dirty bomb" plot had doctors rushing for a refresher course in treating radiation exposure.
As these events have shown, unmasking a terrorist attack can be as simple as reporting a suspicious rash to the local health department. But at the same time, hospitals have to be prepared for something as complex as mass hysteria and a rapid influx of casualties.
That means doctors and healthcare providers have now joined the ranks and are an integral part of the country's defense in the war against terrorism. And they're finding that the learning curve is both steep and broad.
Preparing for the Unknown
"Hospitals across the country are looking at ways of becoming prepared, but there are a lot of problems," says emergency room physician Howard Levitin, MD, of St. Francis Hospital and Health Centers in Indianapolis. "Number one, no one has really defined what preparedness is."
Levitin recently completed a study of the nation's healthcare system's ability to respond to a bioterrorist attack. It was funded by the Agency for Healthcare Research and Quality (AHRQ) -- the research arm of the Department of Health and Human Services.
"For example, the media often reports that hospitals aren't prepared for bioterrorism. Well, if you look at the anthrax cases that occurred in October, I'd say we were well prepared," says Levitin. "It's not a big effort to take care of a few additional sick patients, and that's what we saw during the anthrax events."
"If we define preparedness as being prepared to take care of tens and hundreds of patients, then hospitals are not prepared, and it will be difficult to ever be prepared because they have a hard time meeting the patient load they see every single day," Levitin tells WebMD. "We can't handle the flu, let alone think about handling a bioterror event."
Before last fall, Levitin says federal domestic preparedness programs for healthcare professionals focused on how to deal with large-scale biowarfare with high numbers of casualties.
Bioterror: Spotting the Signs
The biggest difference between biological agents and conventional weapons of war is that the germs that cause potentially deadly diseases can spread long before any telltale signs appear, making them virtually impossible to detect before the damage is already done. And the first to respond to a bioterrorist attack is likely to be a healthcare provider rather than a police officer or firefighter.
Before 9/11, many physicians were unaware of the signs of diseases such as anthrax and smallpox -- likely targets for terrorist use. Experts say that's now changed.
"What happened was that people went from being totally ignorant of these [bioterror] issues to being informed as to where to get information," says infectious disease specialist Jon Temte, MD, PhD, associate professor of family medicine at the University of Wisconsin.
Temte says primary care and emergency room doctors now have much better access to information about potential bioterrorist agents provided by organizations such as the CDC and the American Academy of Family Physicians (AAFP).
He says a focus group conducted among physicians six months before 9/11 showed that many felt they wouldn't recognize the signs of anthrax or know how to contact the public health department about it. But another survey six months after 9/11 showed that while some doctors said they might not be able recognize an isolated anthrax case, they would recognize a cluster of cases. And they said they knew how to contact the proper authorities.
Temte says those findings also reveal one of the major problems facing the U.S. healthcare system in addressing bioterrorist threats and other major public-health concerns.
"We have a pretty well-trained physician force across the country," Temte tells WebMD. "But the gaps ... have to do with the perspective we take. Doctors are still oriented to the individual rather than the community. I think that is a perspective that needs to change."
Bolstering the Front Lines of Healthcare
Temte says hospitals are better prepared for dealing with disasters than individual physicians because healthcare organizations have to go through accreditation processes that require disaster training, and doctors do not.
Although no significant, post-9/11 changes have been made to the emergency management standards all hospitals must meet for accreditation, some of the language within the standards has been revised based on the experiences of organizations that responded to the terrorist attack.
The revised standards call for more cooperative planning between organizations. Those that provide services to nearby areas must pool information and resources in case of an emergency.
In addition, the AHRQ recently unveiled a new hospital bioterrorism preparedness tool that healthcare organizations can use as a checklist to assess their ability to handle potential victims of bioterrorist attacks and evaluate existing emergency plans.
"In this context of bioterrorism, the hospital and healthcare providers are the front line," says Helen Burstin, MD, MPH, director of the center for primary care research at AHRQ. "One thing that becomes very clear is that in the event of a bioterrorist attack, people will go to either their local physician's office or emergency room."
"Since they are so clearly part of the picture in a way that they may not be for other natural disasters, you really need to make sure that the hospitals are prepared to handle it," Burstin tells WebMD.
While awareness of the potential for bioterrorism may have waned since the initial explosion of interest last fall, experts say that, in general, healthcare providers have learned some hard, but necessary lessons and are better equipped to deal with disaster than a year ago.
"There is a smoldering interest, and with sufficient need it's going to burst into flames again," says Temte. "If everyone is on the lookout for bioterrorism, we are going to have a lot of misdiagnoses. For now, we're at point where we have more information available and that's a good place to be."
Reviewed by Michael W. Smith, MD, Sept. 3, 2002.