In the year since 9/11 disaster medicine has come into its own. Now a recognized specialty, the practice of disaster preparedness, disaster planning, disaster response, and disaster recovery as it relates to the practice of medicine and the function of healthcare and healthcare institutions has moved from the realm of the emergency manager and hospital safety officer and into the realm of the healthcare professional. As with any burgeoning specialty, disaster medicine drew from its strengths and grew from its roots. Disaster medicine had its beginnings in the disaster field office. Field response units formulated much of the early information regarding the practice of this newest medical specialty.
Just as patients flow from the field to the hospital, the science of disaster medicine grew next in the areas of triage and hospital-based decontamination. Soon nonemergency room staff were being drawn from their primary duties on the hospital floor to actually step outside the hospital to provide triage and initial treatment in the event of a mass casualty incident. From the triage and decontamination tents disaster medicine moved quickly into the emergency department bringing with it new concepts in toxicology and mass casualty patient care. Lessons drawn from military medical experience and from civilian emergency room experience are melded in textbooks as well as discussion groups inside disaster medicine and within the hallowed halls of emergency medicine professional organizations.
But in this expanding universe of knowledge, the hospital floor and the Intensive Care Unit were all but forgotten. Michael Osterholm and others have discussed the impact of mass casualty events and pandemic influenza on the ability of hospital Intensive Care Units and other high acuity departments to meet the needs of disaster response. Unfortunately, while models created by Schultz and Ramirez had demonstrated that with a small application of behavioral health savvy surge capacities can be increased not only by the required 20 percent under the US Department of Health and Human Services guidelines but by as much as 400 percent, this vast expansion of surge capacity relies in small part on the ability of the inpatient services to accommodate additional admissions. A simple review of historically corrected pandemic predictions compared to hospital capability surveys demonstrates the dangers of not expanding hospital inpatient capacity as aptly as intake capacity has expanded.
When the lessons of the disaster field office are applied to businesses these businesses learn first to determine what is the goal of their organization. In the intensive care unit and other high acuity areas of the hospital, the goal is the same as it is in a field disaster hospital, the preservation of life. In the environment of the intensive care unit, triage has already taken place for you. These patients are already determined to be critical and further triage can only serve to determine which individual’s care will utilize so many resources as to endanger the care of two or more other individuals. In this circumstance, it is the absolute moral and ethical obligation of those providing the care to make a resource-based decision. When the continued care of one patient will utilize sufficient resources to endanger the care or life of two or more others than the care of that one patient, then that one patient must be reassigned to the expectant (black tag) treatment area. This is not a do not resuscitate order (DNR). This is simply a statement of available resources. Patients are constantly re-triaged based on available resources and current medical conditions. A critical patient upon the loss of vital resources may temporarily be moved to an expectant category until resources or conditions are such that the patient may be re-triaged back to a critical or possibly has improved sufficiently to be “downgraded” to triage category yellow (urgent).
On the other hand, if treatment of an ICU or a high acuity patient does not utilize sufficient resources to endanger the care of two or more other individuals then that high acuity care should and in fact must continue as an ethical and moral imperative.
The key to making these decisions is to identify the critical processes that are required for the provision of essential high acuity medical care. Once these processes are identified specific, measurable parameters must be established to determine if additional resources are needed to bolster that process. This ensures that valuable limited resources are not squandered on processes that are not in danger of collapse as a result of a surge. More importantly, as the number of patients under treatment expands it ensures that resources are wisely allocated to maximize the surge capacity.
Resources will always be limited in a disaster because of the very nature by which resources are now obtained. Our “just in time economy” has eliminated most stockpiles from healthcare institutions. Few hospitals have more than two or three days’ worth of medication, disposable supplies, or food on hand at any given moment. They rely on regular re-supply from vendors, who themselves maintain only limited warehouse storage. In the event of a large-scale disaster needs quickly exceed resources (the very definition of a disaster) and supply chains break down. With resources even further limited essential processes fail and a disaster becomes a catastrophe as the ability to respond is lost.
The frugal application of resources to essential processes in the provision of healthcare combined with a continuous re-triage of patients ensures that precious resources are utilized in a fashion which maximizes their impact and benefit.
This lesson has already been implemented in virtually every hospital in the United States, but it has not been implemented in a patient care area. Information technology departments utilize the constant monitoring of key operational processes with clear and well-defined parameters to determine how best to dynamically shift available resources. Your information technology professionals speak in terms of “bandwidth” rather than “bed space” and “memory allocation” rather than “ventilator availability.” However, with well over a quarter century of experience in process analysis and resource allocation, your information technology professional is an invaluable resource in the method of evaluating your essential processes and resource allocation.
Virtually every supplier of data management equipment and software, from imaging to electronic medical records to registration and accounting software is utilizing this process to ensure continuity of their part of the operation. The patient care component is the only portion of hospital operations that has not learned to triage itself.
A careful evaluation of the healthcare process utilizing these information technology techniques will quickly show that in addition to those items already on our resource list including medication, food, bandages, and other disposable supplies the most valuable and most limited resource is the healthcare professional themselves. It has been said that it takes at least seven years to grow a doctor, at least two years to grow a nurse or a respiratory therapist and many more years to ensure the experience necessary to operate in these professions and every other patient care profession with any degree of expertise.
The loss of a healthcare professional through injury, illness, or stress has a significant negative impact upon both operational capacity during a disaster as well as the short and long-term recovery following the disaster. Lose just one of these professionals and you impact the care of thousands or even tens of thousands of patients into the future.
Ensuring the resilience of healthcare professionals within the high acuity arenas of the hospital is the single most effective and most efficient means of expanding surge capacity beyond the emergency department.
There are six areas of human functioning:
Each of these areas of human functioning has a corresponding form of resilience, a canteen which is filled in the time between disasters and drawn from during the response to a disaster. These six canteens of resilience are:
- Relationship (social)
- Functional (behavioral)
Physical resilience is exactly as the name would imply. It is the physical capacity to continue working in light of physical and even emotional stress. Physical resilience is enhanced through the maintenance of good health and a healthy lifestyle. Eating a balanced diet both at home and at work, including during the disaster; regular exercise; and adequate rest, even during the disaster, are essential to “filling” your canteen of physical resilience and maintaining that resilience while responding to a disaster.
Emotional resilience deals directly with what we feel and how we respond to it. The old saying “attitude counts” was never more true than when filling your canteen of emotional resilience. Loving and being loved, including loving yourself; enjoying the everyday joys of life, and ensuring that you have the opportunity for boundless joy and genuine happiness fill your canteen with the sweet emotions that counterbalance the many unpleasant and at times even horrific scenes that we all encounter when responding to disasters. On the other hand, if you have filled your emotional canteen with despair; self-loathing; angst, and animus then you will have nothing but bitter drags from which to drink when in the midst of a disaster response.
Intellectual resilience is bolstered by the very act of learning and practicing the skills which you have learned. It is as we gain experience and knowledge we slowly imprint new patterns which we may later use to compare and ultimately recognize as familiar situations and events that unfold during an event. The more of these patterns that we have in our intellectual canteen the more quickly we can recognize and adapt to the ever changing disaster environment. Just as we learn the patterns of a heartbeat or the patterns of respiration we can learn the many patterns that exist within medicine, patterns which occur more frequently and more rapidly but are no different when they occur during a disaster event. When we can recognize these patterns quickly we can respond quickly thus bolstering our intellectual resilience.
Relationship resilience bolsters our social functioning. It is through our relationships with those that we hold dear, spouses and significant others; children and grandchildren; parents; relatives; friends; coworkers that we fill our canteen of relationship resilience with memories and comforting mental images that carry us through our times of separation. It is also these relationships that safeguard our lives and our emotions. Disaster response is a high-risk sport not unlike scuba diving and for that reason requires that you have a buddy to check on you and ensure that you are not becoming overwhelmed, ensure that none of your canteens of resilience are running dry. It is through these relationships that we not only fill our canteens but keep them full and keep watch on each other.
Functional resilience bolsters our behavioral function. The skills that we have practiced in our day-to-day lives as we have moved through our careers are that with which we fill our canteen of functional resilience. Like the patterns in our canteen of intellectual resilience, the skills of our functional resilience are no different at times of disaster response than they are at times between disasters. We need only be able to access those skills more quickly and perform them more calmly.
Spiritual resilience is somewhat different because the canteen of spiritual resilience is not filled by what we believe, but rather by the fact that we believe. Research in the area of resilience has shown that the very act of believing enforces an even intelligence beyond ourselves, a higher purpose for higher power, bolsters our resilience, improves our function and our likelihood to master adversity.
It is through the maintenance and enhancement of resilience both for each individual healthcare professional as well as for the processes by which we provide high acuity healthcare in the intensive care unit and other areas of the hospital that we maximize the surge capacity of these most critical areas as well as ensuring that those that staff them do not become the collateral casualties of our disaster response.