Vintage Big Med – G Carttar | Lessons learned from the ice storms: Backup power – Feb 2009

Lessons Learned from the Ice Storms: Backup Power by Greg Carttar

[Feb 6 2009]

As you surely know, Southern and Southeastern Missouri, Northeastern Arkansas, and Kentucky were hard hit by ice storms which took out power and essential services. This narrative is about a community in Southeastern Missouri.

During the day Friday, we were on the way home from a project in Utah on the highway in Nebraska, and began getting calls from communities in Southeastern Missouri needing generators for critical infrastructure. They had been dark for two days. We arrived home in Branson at 0400 to find parking lots encased in ice three to four inches thick.

At 0800, the phone started ringing and we spoke with the local Emergency Manager and the Mayor of a distant community and they told us they needed “generators for their wells.” End of specifications. No voltage, no amperage, no hook-up details.

Later in the morning we finally spoke to the Sewer/Water supervisor and were given exact power requirements for the municipal wells. We prepped our 250KW gennie and headed out at 1400, arriving at the community at 1900. By 1945, we were making 100KW and powering the main water well. The entire water system had been drained dry, and it took 18 hours to pump in the neighborhood of 700,000 gallons of water to refill their system and tower, and to keep up with demand once people realized that they could finally flush their toilets.

They had been without potable drinking water, sanitation water, and fire suppression water for three days by that time. The sewer lift stations were still not functional. They had received a generator “from FEMA” for the main lift station, but had been unable to put it into use because it “had the wrong connector.”

This sounds pretty straightforward, but here is what got them into trouble:

1. The Call had gone out “for generators”, but nobody at the Emergency Management “table” knew what they actually needed in terms of generator capacity or configuration. The S/W Supervisor was not “at the table,” but at least he was available to go up to the well and see what the fuse sizes were, from which we could chose the correct machine. He did know that it was a 480volt pump. There were no provisions at the well sites for connecting emergency power sources. We had to disconnect the pumps from utility lines and pigtail directly into their disconnect panels.

2. Generators did arrive from other resources, but were incorrectly sized and incorrectly configured for voltage. The S/W Supervisor had determined that none of the generators that had arrived were strapped for 480 volts. We later determined that a 180KW 3-phase generator had been delivered for use at a sewer lift station that required 10KW single phase. The feeder cable was too big to be tied into the lift station.

3. While we were running at 100KW, we burned around 200 gallons of diesel fuel in 18 hours for a consumption rate of about 11 gallons per hour. If this gennie had been running at full capacity, it would have burned around 360 gallons in the same time period. The only means that the S/W supervisor had for getting fuel to us was a 55 gallon barrel and a hand pump in the back of his pickup. He was supplying everything that could not drive to a fuel pump with that arrangement. It was all he had. Towards the end of the emergency, we had gradually gotten ahead of their ability to bring us sufficient supply to keep up. Had we been required to run for an additional 8-10 hours, we would have been in trouble.

4. Once we got the water system filled up, a boil order remained in place because there had been an interruption in chlorination, and the city water was not yet judged to be potable, although sanitation was back on track. Even though city water was restored, the bottled water distribution effort had to be maintained, occupying people and using resources. As utility power began to come back on, restaurants which now had power could not resume full service due to the boil order.

5. When the residents figured out that they could now flush, the lift stations began to back up and overflow, precipitating another urgent situation. We were able to use the “tender” generator for our big unit to energize a lift station and overcome the overflow.

This basic circumstance was repeated in community after community.

Based on this experience, these are recommendations that Emergency Managers should take to heart in their planning for subsequent events:

1. Develop a master list of power requirements for all critical infrastructure for which you do not have backup power. It should include voltage, phase configuration, and horsepower/amperage requirements. This means every well, every sewer station, everything that you require to maintain sanitation and potable water. If you have to call on outside resources for generators, you will know exactly what you need.

2. Using a formula such as 2.5 gallons/hour per 10KW of power, project what your likely fuel consumption will be and make sure that you have supply contracts or arrangements in place.

3. Your supply arrangements may have to include providing power to your local petroleum bulk plant so that they can provide fuel to you. If they cannot pump it, you cannot get it.

4. Having a fuel supply is great, but you will also need DISTRIBUTION ability to get it where it is needed.

5. Install either transfer switches, or a means to rapidly connect emergency power to your infrastructure with approved connectors. Camlocks are the most common connector for large circuits, and most rental generators are pre-configured with them, or come with camlock pigtails which can tie to their lugs. If you have camlocks installed on your pumps, it is a plug-and-play solution.

6. Bring the grizzled guys who know how your infrastructure works to the table BEFORE the emergency hits. Invest them in the planning process so that you have good information. They will be very busy after the flag goes up. They may not wear suits, but they know where the bodies are buried. They can save your bacon. Have people who know power who can facilitate hook-ups and people who can make sure that your gennies stay running. None of them will be wearing suits either.

7. Make these plans so that your infrastructure never collapses in the first place, because if it does, the recovery and restart can take a significant amount of time which you do not have to spare.

8. Document, document, document your manpower and expenditures from the moment that you know the storm is coming. When FEMA comes in to do a PDA, you will need to know that information in some detail to develop a reasonable estimate and speed the process of getting a declaration. We sat in on a couple of PDAs after the event and learned a great deal about that documentation and how we need to help a customer document so that they can be reimbursed for extraordinary measures taken.

9. The FEMA person told me, “I want to talk to the secretaries, the bookkeepers, the “girls in the office” that know what the operating costs of the municipality are in normal times, because they have the information to do accurate and reasonable estimates.” Get those folks familiar with the FEMA schedules and have them thinking in those terms BEFORE the flag goes up.

I’m sure that most large communities are better prepared than small ones. That in no way diminishes the emergency that a smaller community experiences.

And, nothing in this narrative should be construed to be a criticism of the EM or Municipal Government in this community, and certainly should not be construed to suggest a lack of competency. Nothing could be further from the truth. They just did not think that it would happen this way.

Not all of the emergency managers who read this are in large cities. Many and possibly most, are volunteer or part-time people. These are the folks I’m trying to reach.

I had a small-town emergency manager say to me over the last few days, “This is NOT what I signed on for.”

Well, yeah, actually it is. With preparation, you can get through this.

YOYO96..You’re On Your Own for 96 hours. Deal with it.

Thanks for your time.

Best Regards,

Greg Carttar

Vintage Big Med – B Schwartz | On becoming senior & Germanic terms that make us sound smarter than we really are – Jan 2008

On becoming senior & Germanic terms that make us sound smarter than we really are  by Blair Schwartz

[Jan 28 08]

Ok, I know…

It has been quite some time since I wrote anything for Big Medicine.

Its not that I lost my passion for writing, nor due to the absence of several much appreciated e-notes from the editor checking up on me for signs of life. It’s just quite simply that between a ridiculous in-hospital schedule, the occasional shift on the ambulance, reading enough to ensure my patients in both domains survive and trying to maintain something resembling a life, I didn’t really have the time to write a proper entry.However, thanks to the government sending me in exile for one month of community internal medicine and intensive care practice (more on this in an entry to come), I find myself with some time to spare. So I figured I’d sit down at the laptop and instead of reading this week’s New England Journal, I’d put some thoughts down on a *.doc file and share them with you.

Since I last wrote, there has been one major change in my medical “career”… I’m now a Senior Medical Resident. I’d love to say that there was some kind of evaluation or examination preceding this vaunted transition, but the reality is that along with most things in academic medicine, it just sort of happens automatically on July 1st. Along with the nifty title however comes some responsibility. After 17h00 and on weekends, I am now the go-to guy for all things Medicine in the hospital. I’m the one the medical students and junior residents come to review admissions with, discuss concerns about crashing patients, provide medical advice to the other services and lead the cardiac arrest resuscitation team. All this as a Senior Medical Resident!!! Makes you wonder if that also entitles me to have a “Senior” moment, but also what it means to be senior.

There’s an old EMS joke that goes “Just because your partner’s certification date is before yours, doesn’t mean they know what they are doing”. While we can ALL think of individual cases in which this axiom holds true, there is something to be said for real life experience. Whether it be skillfully titrating the Narcan in a chronic pain patient as Norm Rooker so eloquently described in his column, knowing that 20+ sprays of nitro to the hypertensive pulmonary oedema patient will prevent you from intubating him long before the IV is in and the Lasix and Labetalol are on board or simply knowing when to load and go. No matter how modular, problem based or dressed up we make our training programs there are still some things that can’t be taught and herein lies the role of experience.

Medicine is no different.

People often ask me why an Internal Medicine residency is five years long and why we spend so many nights and so many hours per week in the hospital. While some of this is due to the old boy’s club mentality of “In my day this is how we did it, and so you will too” the simple fact remains that the only way to gain expertise in a vast array of diagnostic/therapeutic dilemmas and acutely decompensating patients is to be there when it happens. So when you work in a domain that requires you to be an expert in rare conditions and events, if you’re going have expertise in it, you had better spend a whole heck of a lot of time in the hospital and that’s just what I’ve been doing.

Now let’s be clear here. I am far from an Internal Medicine expert, but I’d like to think that I am starting to acquire my own sense of Geschtalt. To many Geschtalt may sound like something most likely to be served on an Eastern European grandmother’s dining table, and to that end, my grandmother makes better Geschtalt than your grandmother. Period.

In reality it refers to a gut feeling, a sort of clinical intuition that doctors get about a case. Having slugged it out in the trenches as a medical student and junior resident I’ve seen my fair share of cases, seen many sick patients of varying degrees of acuity. Slowly but surely I’m becoming more and more sure of those decisions I’m asked to make at 03h15 as my Geschtalt comes into its own.

Some personal Geschtalt highlights this past week to better illustrate this arcane term:

  • Asked to see a patient with pneumonia regarding changing his antibiotics, examined the gentleman, suggested to the doctor to consider speaking to the family about ceasing antibiotics and adopting palliative measures… the patient passed away that evening before either of my suggestions could be carried out.
  • Consulted for fatigue, lethargy, decreased appetite in an elderly gentleman admitted to long term care. Patient seen and examined, when the nurse asked me what I thought of her patient, I said if gambling on diagnoses was ethical I’d put my money on cancer… Stage 4 Non-Small Cell Lung Cancer it was.
  • Saw a patient in her 70s who was going to surgery to correct a hole in her bladder that had urine leaking into her abdomen. The surgeon told me it was either a tumour or Crohn’s. I politely raised Tuberculosis as something to include in the differential, he scoffed, she’s in isolation 😉

I can’t quite convey to you how good it feels to finally start having some Geschtalt of my own, instead of leeching it from my staff or seniors. It’s like a natural high when everything starts coming together. It’s almost like The Force. It flows through you, and when you can control it, you possess a powerful ally. It won’t allow you to lift your car out of a snow-bank, but you get the picture.

It is this Yodaesque mastery of Geschtalt that makes me hold the real senior physicians in high regards. The docs with 30, 40 and in a few instances 50 some odd years of clinical experience, never cease to amaze. Many of these medical elder statesmen learned their craft in the era before we even knew about DNA as the backbone of genetics, when penicillin and sulfa were all that existed to fight infection and bedpans were made of frigidly cold white metal. Yet I’d gladly trade in what I know about somatic mutations and all the vancomycin in the world for their degree of Geschtalt.

I’m reminded of the time as a 2nd year medical student on my neurology rotation when I saw a young woman with a headache. After I was finished with her, she asked me if she needed a CT-Scan. Feeling confident this was a Migraine I told her it wouldn’t be necessary, to which she replied that she really thought she needed one. I reviewed the case with my staff, a veteran neurologist and he agreed with my plan of action. I reported to him her concerns and with a smirk, replied “It’s understandable Blair, but don’t worry, I have more white hair than you”. She left the office contented and sans scan.

Sure, some Senior physicians may not be as up to date on the latest guidelines or therapeutic modalities, and you’ll find that just about all of them will be the first person to admit it and unassumingly confer with younger colleagues to be sure their patients get the best care available in 2008. That being said, I can’t help but listen eagerly in anticipation as a senior doctor starts a conversation by saying “ I am reminded of a case I saw back in 1959….”, they always end up being absolute gems.

So in my quest for mastery of both the art and science of Internal Medicine and my slow but hopefully steady evolution in Seniority; I will spend the 36 hours on the ward. I will be in-house three out of four weekends per month. While at times it will be brutal, I will be exhausted, sarcastic and even cynical at times. The fact remains that one day I hope to be a master of Geschtalt, and to that end, I look pretty good in a hooded cape.



Vintage Big Med – B Schwartz | A Series Of Firsts – Oct 2006

A Series Of Firsts by Blair Schwartz

[Oct 19 06]

It’s been a while since I last posted an entry on Big Medicine, but that is the nature of the Internal Medicine Residency. A program designed to immerse you (quite literally at times) in the art and science of medical diagnosis and management, occasionally letting you up long enough to realize how bloody exhausted you are while at the same time acknowledging that there isn’t a single other gig in the universe you’d rather have. It really is odd that way.

As is to be expected, the first three months of residency have been punctuated by ups and downs and more than my fair share of first time experiences. To give you a bit of a perspective from the eyes of an R1 (or Intern in some areas) I’d like to relay a few of these to you.

My First Day: July 3rd, Overnight in the Emergency Department doing Internal Medicine Consults. I arrived 30 minutes early as is my nature, and spent a good 15 minutes making sure everything was in order. Took some time to get used to my new long white coat, with its different pocket layout. I was paired overnight with a 2nd year resident, a colleague that I knew from the same medical school.

The contrast could not have been more evident. I was dressed in my pristinely bleached, still having the creases from the package, white coat. His was a stained and crumpled coat testifying to having paid his dues in the trenches of medicine. We took sign out and as we were about to tackle the box full of our work for the night I asked him if he had any pointers. Without missing a beat “Take your time on each case, have fun, and try not to kill anyone on your first night……. Oh and if you need me, I’ve got my pager”.

With that trite and yet totally reassuring pep talk under my belt I set forth into my night of firsts.

My first prescription was for an Insulin sliding scale. Perhaps fitting since as a kid I was fascinated early on by the discovery of Insulin. It was likely a combination of being proud of a Canadian discovery that saved countless lives and the fact that a seemingly crazy idea of taking extracts from a dog and giving it to a human being actually worked.

I moved on quickly to tackle my first case: Hypercalcemia; incidentally found in someone who came in for a cough. Hypercalcemia had always been my favorite electrolyte disturbance as a medical student (I’m an internist, give me some slack here), largely for the sheer elegance of its diagnostic workup and the relative ease with which it is managed. So I jumped into this case head first, requested the workup and in the end ended up with hyperparathyroidism, my first diagnosis.

The next day would be the shift with my first procedure. For most residents it consists of an IV insertion, Arterial Blood Gas or putting in a Foley.

Not me.
No Sir… My attending comes and tells me that we have a patient with a pleural effusion who needs to be tapped and that I should go prepare all the equipment. As I am gathering my supplies, preparing to stick a 14 Gauge Cathlon into a man’s chest I begin to wonder what the hell I am doing here.

Three days ago I was a medical student who would have never been asked to do this. What exactly happens at midnight on July 1st every year that we are all of a sudden competent and independent medical providers?

I spent longer than usual searching for that vacutainer as I reviewed the steps in my head. I had read about thoracentesis several times, I knew its indications, steps, and contraindications cold. I’d even seen two of them, which immediately conjured up chills as I thought of the See One, Do One, Teach One mantra our school employs. I’d also essentially done a nearly similar procedure before on the street as a treatment for a suspected tension pneumo, but this was different.

On the road you stick a needle in the chest of an acutely ill patient with the intention that if you don’t, they will die. Here I have a relatively well, stable guy who just needs some fluid taken off so we can make a diagnosis, slightly different stakes.

As I prepared my patient for the procedure I explained to him what I’ll be doing and the most amazing part for me is that he didn’t ask that question that EVERY R1 dreads: “You’ve done this before, right?”. As I continued with my longer than normal disinfection of the skin my attending gave me that look as if to say “Blair, Less stalling and more sticking of large bore needle into chest”.

Without delay I froze the skin and gently nudged my catheter into his pleural space. Perspiration had collated my mask to my face and my heartbeat remained in the nice maximal range until I saw that flash of amber coloured liquid in my syringe.

I believe at that very instant several people in attendance took a collective sigh of relief. I plugged the vacutainer and proceeded to take off about a litre of fluid. I explained that he might cough towards the end, a common event as the lung begins to re-expand.

As I passed on this golden tidbit he coughed rather violently and thrust back into my drainage apparatus. The fluid quickly changed from amber to grossly red. I muttered a few choice words that were about parallel with my breath, then removed the setup and applied pressure. My attending thought it was pleural irritation or a small vessel. I spent the rest of the day thinking I’d perforated his pulmonary artery or some part of his heart. All that night, as I couldn’t sleep, I dreaded coming in the next day to hear that he had gone to the ICU, the OR or worse yet the Eternal Care Unit as a result of my procedure.

At that time it became readily clear to me just how easily a physician can harm his patient, how I can take a relatively healthy person and quickly change their status. The patient did just fine, it was likely what my attending thought, but still that was a stat dose of humility and for the first time Primum Non Nocere was more than an easy way to sound smart by speaking Latin.

My first continuity of care took place about a month into residency. I was on the ward and was surprised to see a familiar face admitted onto our service. The patient I had seen bleeding in her washroom in my last column had survived to admission on the medical service. Proving once again, that when it comes to an individual patient the only statistic that matters is 50:50, it’ll happen or it won’t.

She was in a palliative stage of her liver disease, entering into and out of delirium as is so typical of hepatic encephalopathy. I had several discussions with her husband who was at her bedside, nearly round the clock. We talked about the course of her disease, how it was affecting him and what we could offer to take care of both his wife and his needs. For the first time I could say that I really had my own patient.

As a medic I worked in that snapshot of acute care; assess and stabilize, do the best I could to make that brief time with them as comfortable as possible. I always regretted not being able to have a certain degree of follow up. Sure you’d occasionally hear about the big cases, the cardiac arrest you brought back or that stabbing to the neck who you kept alive by tamponading their neck vessels with your gloved hand, but you never knew the rest.

Now I get to see and follow disease, get a real sense of what my interventions are doing and also support my patients and their family for more than 30 minutes. One Saturday morning that I was on call she didn’t wake up. I declared her, did the paperwork and called the husband. Continuity of care means dealing with all elements of the cycle.

Thus far there have been many similar moments to those I related to you above. Some nights are easier than others, some cases more straightforward and others that we never really do get a handle on. I’ve had the pleasure of working with health care providers from all backgrounds and levels, with different methods of training and approaches to patient care. Yet in spite of all this diversity, from the newest first-aider to the most grizzled veteran medic, from the newest nurse or greenest resident to the nurse who remembers the chief of surgery as a resident, there is one common theme amongst them. That unflinching desire to render assistance in whatever capacity possible to their fellow man.

There is one experience as a resident that proved this fact beyond a shadow of a doubt, my first Code Orange.

I was on the pulmonary service that day, hunkering in the ER’s isolation room reviewing my third rule-out TB consultation of the morning with the attending. Bedecked in our gowns, gloves and N95 masks my EMS pager buzzed with a message from a colleague watching TV that there had been a shooting at Dawson College. As we exited the negative pressure room and removed those infernal masks the code orange was called, preparing our hospital for an external disaster.

Within minutes the whole hospital came to life. The ER was cleared of any patient who could tolerate the move and the emergency cart was wheeled up with all the additional supplies one could possibly have to use. There was an influx of nurses, pharmacists, unit agents, technicians and physicians of all varieties… some who came in early for a shift or just on their own accord, after hearing the news. Others quickly closed in the OR or interrupted rounds in the ICU to be ready to lend a hand. Amidst the countless bodies in the ER patiently waiting for the influx of patients, people were not wondering how this could happen, nor musing as to how many shooters there were or what video game they played. Each and every person was uniquely focused on making sure that the patients who would come in that door would get the best care our hospital could offer.

Throughout this crisis I stood in the nursing station and watched. Far enough away not to interrupt, but close enough to lend a hand if asked. At a colleague’s request and a throwback to my dispatching days, I kept my eye on the phone from the ambulance service that would announce incoming patients. Mostly though, I watched what was truly an unforgettable sight. We ended up getting 2 non-critical patients, each of whom was likely seen by 10 specialists within the first 5 minutes (take THAT golden hour).

Despite the paucity of patients that day, I can honestly say that amidst one of the darkest hours of my fine city’s history I was able to find one of my proudest moments as a member of the healthcare community.

To all those who answer the call: Cheers and Good on ya!

Vintage Big Med – B Schwartz | Cycles – June 2006

Cycles by Blair Schwartz

[Jun 28 06]

I’d like to take you back to a time in your life.

In the time leading up to the day you are filled with a sense of excitement, anticipation, fear and perhaps even a little dread. Your daily activities are occasionally permeated by visions of what that day will be like.

The night before you try to get a good night’s sleep, but your mind is racing and thoughts are flitting. You awake over an hour before you set your alarm, check to see if anyone else is up and saunter to the kitchen to pass the time with cheerios and milk. After what seems like an eternity of watching the numbers on the stove’s clock turn you are joined in the kitchen. The subsequent activities are a mere blur as people scurry about making last minute changes amidst harrowed requests to “please hurry up”.Yes… I’m referring to that day we all remember so fondly, the first day of school.

This time may be more remote for some than others, but the feelings associated with it are so universal and strong that I don’t really feel the need to describe them further. As I sit now one week removed from the start of my residency these feelings are brewing again deep within me and truly the similarity between these two occurrences is uncanny.

The night before my first day I will lay out my new hospital clothing, be sure I have socks that match and fill my “schoolbag” with all of my supplies. I’ll go to bed early with good intentions and undoubtedly spend the better part of the night tossing and turning with excitement and a good healthy dose of self-doubt. I’ll awake early in the morning, completely unrefreshed after three furtive hours of sleep. This fact does not bode well for someone doing the first night shift, but I suppose it is a professional reality for the next several years. Gone is the bowl of Cheerios, replaced instead by the travel mug full of coffee and whatever leavened product is easily available in the kitchen. I’ll walk myself to the bus and arrive at the hospital, well in advance of the orientation session and choose to mill about outside rather than be the first to enter the classroom.

I’ll wait until someone breaks the ice by entering or more likely an administrator pops their head out to beckon the nervous gathering crowd inside. We’ll sign the attendance sheet and grab an envelope with our names on it, possibly even containing a “Hello my name is….” sticker!! I’ll scan the class looking for a familiar face and be sure to sit next to them and not really make an attempt to engage the new foreign faces in conversation.

Our chatter will be silenced by the entry of the attendings and chief residents. One by one they’ll go over the rules of the hospital, give introductions and as in grade school point out one of the more important facts, the location of the restrooms (though hopefully now we don’t need to ask for permission, nor go in pairs). We’ll sit eagerly awaiting the first recess break, with that fruit roll-up or prepackaged pudding now also replaced by a cup of coffee, and resume our banter.

I get a chill down my spine every time I think about this… in some ways, I really do miss grade school, with its glue sticks, coloured pencils, Velcro shoes and school nurses to take care of you… ok fine, I’ll kind of have the latter now.

Since I last contributed not too much has happened. I had some dental surgery, read books that I personally wanted to read for the first time in quite a while, did a whole bunch of shifts back on the ambulance and I attended my medical school convocation.

It would be far too easy to quickly gloss over my medical school graduation and that is something that I’d like to point out. It is disheartening, though not surprising that the rich historical nature of this ceremony has fallen to the wayside. In its current incarnation convocation ceremonies are one huge big commercialized photo opportunity. Professors get all fancy in their academic robes, the graduands don their cap, gown and hood all because these are what is needed for the picture. You know the one that will be hung on the wall or kept in grandma’s wallet to be broken out when she speaks about how proud she is of you to her friends at the hairdresser. Now I’m not naïve enough to think that this disregard for the historic or traditional nature of a ceremony is unique to the convocation process. It’s a generalized trend of our generation, perhaps most popularly known in the commercialization of Christmas. Yet there is a difference. Just about everyone knows the story of Christmas and what that holiday is supposed to represent, many just choose to ignore it and focus their celebration in other more personal manners, be it conspicuous consumption or just plain family together time.

Convocation on the other hand is one step closer to extinction in that just about nobody who partakes in it knows the historical and symbolic nature of the ceremony. If you were to ask my fellow graduates about the regalia we were wearing you’d likely get responses such as: “They’re just what we wear at graduation”, “Its pretty cool….”, “I think they look great” (I do agree with the last comment, and frankly intend to wear a full academic regalia, complete with doctoral hood and cap at least once in my medical career on rounds…. But that isn’t the point here). We have forgotten the origins of universities amidst the medieval trade guilds. We don’t recognize the convocation as the gathering of the guild of master teachers before their soon to be colleagues. We choose to throw it up in the air haphazardly, rather than take the time to realize that the biretta or square academic cap has the exact same shape as the master mason’s mortar board. Few with a Bachelor’s degree know this term alludes to the apprentice of a small land owner and equally few physicians know the term Doctor, literally means to teach.

So convocation now is about dressing funny, enduring speeches, walking across stage to get your degree and posing for countless pictures. I suppose this is the way we now choose to mark this important change in our lives, but one can’t help be just a little bit discouraged at this loss of history.

I’m going to end this piece with a story from a recent EMS shift of mine, that really reinforced in me the importance of pre-hospital care and I don’t mean clinical intervention.

I was working the day shift with a relatively new, but quite competent partner. The tones dropped for a 82 y/o F with potentially life threatening hemorrhage. I through our truck in gear and coaxed our venerable turbo diesel to give me at least one more good run. We pulled up to the building, grabbed our gear and headed into the apartment. We were greeted at the door by the clearly anxious husband of our patient who in a hurriedly, albeit jittery manner pointed us into the washroom. The floor was covered in fresh bright red blood, that per the patient was rectal in origin. In the tight confines of the bathroom my partner gloved up and set about his assessment as I took the husband aside for more information. As I held his hand, the tattoo on his forearm indicated to me that he had survived far more than 60 years of marriage. I looked him in the eye and told him that we’d take the best possible care of his wife and proceeded to gather a history to try and piece this all together. He answered politely and concisely, as if he’d done this far too many times before, though the flow of our conversation was interrupted several times by his apologies to me for being so nervous. I learned that his wife had idiopathic cirrhosis and had been in and out of hospital several times, a quick look at her medication list showed Pantoloc and Propranolol leading me to suspect she had likely bled before. I thanked him for his help and asked him to prepare everything we would need for the trip to the hospital and returned to help my partner with our patient. She was pale, anxious and her significant oedema and floridly ascitic abdomen attested to her diagnosis. My partner reported a strong bounding pulse at 120 with a pressure of 140/80…(The body’s ability for compensation truly is mind blowing) The most striking feature of the physical exam though, was her eyes. She had that look that every EMT knows all too well. The longing, but silent gaze asking “Am I going to die?”. On this my partner deferred to me. In an instant I flashed to my time on the transplant service, mentally recalled the mortality of a GI rebleed in cirrhotic patients, factored in her vital signs and knew the answer. I calmly and thoroughly explained to her what was going on and the need for her to be evaluated and treated quickly in the hospital and seeing which team was on the transport crew, reassured her that she would be in good hands. To which she replied “I already was”. I gave a quick report and they knew full well this was a patient to load and go. As they were loading her into the ambulance we again looked at her eyes. This time there was a degree of resolve/acceptance, but more important to us was the absence of anxiety. Her husband thanked us profusely and apologetically as I helped him into the front seat of the transport unit.

As prehospital providers we go on countless runs where all we seem to offer is transport, vital signs and perhaps some oxygen and we question what our role is. This symptom is commonly associated with the “I’m just an EMT syndrome”. Sure it is nice to spike a line or push lasix, but that doesn’t replace nor negate the paramount importance of pre-hospital emergency CARE. The importance of the work done by the personnel in this field cannot be understated. I don’t know if this patient survived once she was hospitalized, but I do have a sneaking suspicion that the time we took to treat her as a person went a whole lot farther to her overall well being than a bag of saline would have. People ask me why as a doctor I still feel the need to work in a limited scope first response service. The effect we can have in these situations is unparalleled anywhere else in medicine. While religion may be the opiate of the masses, most prehospital workers would take a mainline of calls like these any day of the week.
I realize that my entry today was really three smaller and seemingly disjointed pieces. Yet when you look at all three on a broader scale, it is kind of fascinating to see the trend of cycles. In spite of the stochastic nature of our universe and the freedom of human self-determination, some things just happen again and again…

I’ll check back sometime after my first day of school as a teacher.

Vintage Big Med – B Schwartz | On the jingling of ‘change’ – May 2006

On the jingling of ‘change’ by Blair Schwartz 

[May 12 06]–I’m sitting now at the end of medical school and on the cusp of my residency. Truly an impressive time of transformation. As I sign contracts and insurance forms, it quickly becomes apparent to me the responsibilities that I am about to assume.

I no longer get to use the well-worn answer “That I’m Just a Medical Student” when answering patient’s questions. No, now I need to introduce myself as Doctor Schwartz and fight that urge to use those finger air quotes as I say doctor. I can sign my own orders for Tylenol™, perform procedures, fill out mountains of paperwork and work 30 hr shifts all on my own.

Yet, in spite of all these awe inspiring changes, right now, the one I am perhaps most looking forward to is being able to finally wear a full length white coat.You see, as if the endless scut, and running around doing others bidding wasn’t enough, we medical students were imposed one final subjugation: The Short Coat. It looks impressively like the standard white coat, with the final indignity of ending just below your butt. I’m sure there is some perfectly good historical reasoning for this decision, but one can’t help but ponder some ulterior and perhaps unsavory motives. All the same, it certainly does make for an interesting look as the ward team meanders about on its rounds.

The wizened attending in the lead, making small talk with the chief/senior resident amidst forced laughter all adorned in their long white coats. This group is followed by the junior residents, also adorned in the venerated long coat, out of earshot from the lead party whilst torn between straining to hear what was being discussed in front and carrying on their own banter about lack of sleep or poor progress of contractual negotiations. Lastly there are the medical students, easily discerned in the short coat, scurrying along at a frantic pace, hoping that the guffaws from up front are not in reference to their recent miscue and scouring the floors to pick up ANYTHING someone from in front may have inadvertently dropped.

I’ve witnessed this scene from within and as an innocent bystander and I can never help but to think of a medieval army. Led on by the horse mounted knights and their lord, followed by the well trained and venerable armored foot soldiers and at the rear are the efficient, methodical but defenseless and largely expendable archers.

The white coat is certainly a hot topic in the medical community, with physicians divided as to whether we should in fact still be wearing them. The theories surrounding the origin of this garb are diverse. Some claiming that by adopting the traditional garb of the “scientist”, physicians were attempting to portray the scientific nature of their craft and separate themselves from the numerous charlatans of the day.

Others take an elitist approach, that the donning of a pure white healer’s habit set a hierarchical boundary between the physician and patient as recommended by the medical ethos at the time. Still others are more practical and smock-like about it, why would you want to expose your clothing to the myriad of medical fluids that you encounter on a daily basis?

Whatever the origin, it certainly is a hot button issue with some branches, most notably psychiatry, leading the charge AWAY from the white coat and other disciplines leaving it to the individual physician to make the choice.

As a future resident, I am a member of the clan of those who do wear a white coat. Not because I think people need to be convinced of my scientific nature, nor my superiority or even to protect my clothing, because lord knows I don’t own anything worthy of protection. It is however, a functional decision. In spite of all the history and symbolism, for the average resident the white coat is a functional object and thus I present to you:

The Anatomy & Physiology of the White Coat.

Firstly, the white coat should be well fitted. Square on the shoulders with a loose flare towards the bottom. The latter is absolutely imperative as it permits the coat to billow out in an awe inspiring cape like manner as the physician rounds the corner into the hall en-route to an obviously important intervention. Then we have the accoutrements, often consisting of an ID card which serves to inform all who will take the time to read it that we do indeed work here. In addition to the ID card there are the pins, an attempt to express some sort of personality in the often bland medical machine. Some will go for the flashy waiter look and adorn every empty space with a button of some sorts. I choose to wear a small silver Maltese cross indicative of my membership in the Order of Saint John, but also because I love the confused looks from hospital staff as they try to figure out why a Jewish doctor is wearing a cross.

Then we have the pockets… oh the pockets!

The breast pocket is where we keep our pen light. It will fall out frequently & break, or be lost in the halls of the ward. It will never work on the rare occasion we actually need it, and yet, in spite of this we always buy another one. It is kept company by the pens, and much like a swordsmen has blades for every purpose, we too have a role for each pen. First there is the “throwaway”. Often a pen that we grabbed from somewhere, a cheap pen; perhaps picked up at a hotel or from some pharma rep. It is what we use for a quick signature, to jot down a note or two on rounds or when someone asks us to borrow a pen. Quick and dirty, it is akin to the dagger. Then we have the “writer”, the workhorse of the day. This is the pen we truly cherish, the one we purchased from the office supply store. We admire its grip, the manner in which it writes and its overall elegance. We use it to write orders, prescriptions, progress and admission notes. Like the old English Longsword it is our trusted companion and we would never go into battle without her. Some amongst us have the fortune of a “fancy pen”, perhaps a gift upon graduation or from a grateful patient. With names like Cross™ or Mont Blanc™ these are seldom seen out in the open, but like the ceremonial swords of the Queen’s Own, they do come out on special occasions.

Then we have the index cards. What once infused fear by its association with learning my multiplication tables has now morphed into the multi-purpose information recorder. Be it lab values, tests to check, patient information or the home phone number of that special someone they store them all. No coat pocket is complete without a stack of crisp white index cards and already used slightly grey ones strewn about.

Then there are the pocket guides. Varying colours and sizes covering a wide array of medical knowledge, from pharmacopea to anti-microbials and everything in between. These are the resident’s crutch, a tool to double check that he is not about to prescribe someone 10 times the lethal dose. Then there are the miscellaneous medical supplies: gloves, tape, gauze, tongue depressors, culture swabs, cathlons, vacutainers…etc, anything that a resident may need in the course of their day (and you thought paramedics had full pockets).

Then we have the large amounts of loose change. It would seem folly to include something that is a nuisance to many in a treatise on the white coat, but its importance can not be overemphasized. Some might say that AMEX is what nobody should leave home without, but remember the coffee machine at 03h00 doesn’t take credit.

I’m filled with both excitement and what I hope is a healthy apprehension about my upcoming transition. I know it won’t be an easy journey, but I have to admit that I just can’t wait to slip into that long coat and hit the wards. Just remember to listen for the jingle from the bottom of the coat pocket, and when you do hear it, smile quietly to yourself knowing that you are in good hands.

Be well and practice Big Medicine.

Vintage Big Med – D Newman | Chronicle of a bio-attack: London 1664-1665 – 2001

Chronicle of a Bio-Attack: London 1664-65 by David A H Newman [from a 2001 column]


Daniel Defoe was 5 during the 1664-65 London Plague. He wrote his ‘Journal’ (available as a Dover Thrift Edition reprint 2001) in 1722, drawing upon parish records, civic documents, and the memories of the living.

The Plague epidemic started slowly in September 1664, peaked terribly in the summer and fall of 1665 and then suddenly faded out. Official records suggest that one in four died. The true proportion was much greater: many people left town at the first hint of trouble.

Defoe describes a society caught up in a nightmare: not knowing what to do or where to turn. His “Journal” is presented haphazard. There are no chapter or section headings. It starts, moves on more or less chronologically, and ends. He repeats himself and is not always consistent. But he offers insights that could serve us well today. I have reorganized and compressed his material: my apologies to his Shade, but I hope I have been true to his purpose.

London, 1665

London at the time of the Plague was by no means in the dark ages. It had a population of close to 500,000. It was an age of exploration and discovery. Science had become ‘popular.’ The Royal Society had recently been founded. Many scientists were also physicians: Gilbert (magnetism) and Harvey (anatomy) of particular note. Other illustrious names of the time: Newton, Hooke, Halley, and Boyle.

There were many more: it wasn’t unusual to find a group of them drinking together at say one of the better known coffee houses and talking about navigation, the structure of the universe, the state of naval architecture, and just about anything else. But when the plague came, what they knew was not enough.

Limited Early Warning

There were no newspapers, wire services, or TV journalists in 1664 “to spread rumors and reports of things, and to ‘improve’ on them.” The word came from abroad by letter from one merchant to another, and locally by word of mouth. This took time.

“But it seems the Government had a true account (of what was happening abroad) and several councils were held about ways to prevent its coming over; but all was kept very private.”

Description of Symptoms

There are three forms of Plague: bubonic, septicemic, and pneumonic. From Defoe’s descriptions, it appears the 1664-65 epidemic included bubonic and septicemic, and possibly pneumonic as well.

“The plague operated in a different manner on differing constitutions: some were immediately overwhelmed with it, and it came to violent fevers, vomitings, insufferable headaches, pains in the back, and on up to ravings and ragings with those pains, dying in dreadful manner.”

The Bubonic

“Others with swellings and tumors in the neck or groin or armpits … The swellings when they grew hard and would not break, grew so painful that it was equal to the most exquisite torture; and some, not able to bear the torment threw themselves out of windows or shot themselves. Others, vented their pain by such loud and lamentable cries to be heard as we walked along the streets that would pierce the very heart to think of, especially when it was to be considered that the same dreadful scourge might be expected every moment to seize upon ourselves.” “These were the worst visited, yet they frequently recovered, especially if the swellings could be brought to a head, and to break and run.”


“Others, who did not develop these swellings died suddenly” “nor could physicians know certainly how it was with them till they (autopsied) them.” “Many that had the plague upon them knew nothing till the inward gangrene had affected their vitals, and they died in a few moments. This caused that many died in that manner in the streets suddenly, without warning.”

“Many persons never perceived they were infected until perhaps several days later, the ‘tokens’ came out on them: mortified or gangrened flesh in small knobs as broad as a little silver penny and hard as a piece of callus or horn. At that point they were beyond curing.”


Version One

“The first death occurred around Dec 20, 1664 in or about Long Acre; whence the first person that had the infection was generally said to (have caught it) from a parcel of silk imported from Holland, and first opened in that house. But after this, we heard no more of the plague until the 9th of February 1665 and then one more was buried out of the same house.”

Version Two

At the end of November 1664, two visitors from France died of the plague. The families tried to conceal the cause of death (fearing reactions of neighbors) but word spread. The authorities sent “two physicians and a surgeon” to inspect the house and they reported it was the plague. This was printed up in the weekly “Bill of Mortality” by the parish clerk, in the “usual manner: Plague: 2. Parishes infected: 1.”

In December, a third man died of plague in the same house. People all over town grew nervous. But there were no further deaths for six weeks, and everyone assumed it had been an isolated occurrence.

But on the 12th of February 1665, a fourth man died — this time in another house but in the same parish. The weekly mortality reports began to show increases beyond the norm, and rumors spread that there had been many more cases of plague than the authorities were admitting. But the numbers, though on the increase, were still low, and confined to one part of town.

Lack of Trend, at first

“It is true it was a very cold winter and a long frost which continued three months, and perhaps the disease was’ frozen up.’ But the principal recess of this infection was from February to April — after the frost had broken and the weather mild and warm.” “The numbers waxed, but then waned; and people were eager to assume all was well.”

The weather turned warmer, and there were reports of deaths from two other parishes — yet the total deaths were but 54 for the whole city, and when in the next week the numbers dropped, there was a collective sigh of relief that the worst was over.

Then it became evident that the plague had in fact spread “beyond all hopes of abatement.” The official numbers were too obviously fabricated: the true death toll was many times higher than was reported, and everyone knew this.

“Perhaps it was that the disease was there, but in small numbers, and households could better conceal the truth about cause of death from the official rolls — until the numbers grew so high that no concealment was possible.”

It was a hot summer, and “the infection spread in a dreadful manner…the bills rose high; the articles of the fever, spotted fever, and teeth began to swell.”

By mid-July, the plague was progressing through the town. It kept mainly to the more crowded, poorer, sections, but perceptibly, was moving on the more affluent.

“The question is this: Where lay the seeds of the infection all this while? How came it to stop so long, and not stop any longer?”



All that could conceal their illness did so: “to prevent their neighbors cutting them off, and also to prevent the authorities from sealing their homes: this was not yet practiced, but was threatened, and people were terrified at the thought of being sealed in and isolated to die.”


The wealthier people removed themselves from town in large numbers. “For some weeks that there was no getting at the Lord Mayor’s door without exceeding difficulty: to get passes and certificates of health, for without these there was no way to being admitted to pass through the towns upon the road, or to lodge in any inn.”

This exodus continued through May and June, spurred by rumor that the Government was about to establish barricades on the roads to prevent people from London passing — for fear they would bring the infection with them. It was not a good time to fall ill; if you complained, it was assumed you had the plague.

“It was thought that there were not less than 10,000 houses abandoned by their occupants, besides the numbers of lodgers and particular members who were fled out of other families, so that in all it was computed that about 200,000 people were fled and gone.”

Some (who left later on) “perished in the street or fields for mere want, or dropped down by the raging violence of the fever upon them. Others wandered into the country, and went forward any way, as their desperation guided them, till not getting any relief, the houses and villages on the road refusing to admit them whether infected or no, they perished by the roadside or in barns — none daring to come to them or to relieve them, though perhaps not infected, for no one would believe them.”

Many of the poor — being destroyed not only by the infection but as much by the consequences of it (lack of employment) — in desperation, fled the city, but only found death on the road; “and they served for no better than the messengers of death, for some carried the infection with them into the country.”

The country folk did what they could: carrying out food and placing it at a distance. When the wanderers died, the country folk would dig a hole at a distance from them to windward, and then, with long poles and hooks, drag the bodies into these pits and cover them. Those that so died, and others unknown, are not included in the statistics.

“The face of London was now strangely altered. Sorrow and sadness sat upon every face. Everyone looked on himself and his family as in the utmost danger. The shrieks of women and children at the windows and doors of their houses, where their dearest relations were perhaps dying, or just dead, were so frequent to be heard as we passed the streets.”

Portents and Superstitions

A comet appeared several months before the plague came, and another just before ‘The Fire’ (1666). In hindsight, “these things had a more than ordinary influence upon the minds of the common people.” Prophecies, astrological conjurations, dreams, and old wives’ tales took hold. Would-be preachers ran through the streets with apocalyptic shouts and further alarmed the populace.” There were instances of crowds caught up in “mysterious visions.”

“This folly presently made the town swarm with a wicked generation of pretenders. Purveyors of nostrums had a field day: ‘Infallible preventive pills against the plague’; ‘Sovereign cordials against the corruption of the air’ ‘Anti-pestilential pills’.” [We in our day are also bombarded with such claims].

Supposedly eminent healers from abroad [the gurus and miracle workers always hail from far away] set up shop and touted their prowess: “newly come over from where he resided during all the time of the great plague last year, and cured multitudes of people.”

“But there was still another madness beyond all this, which may serve to give an idea of the distracted humor of the poor people at that time: in wearing charms, philters, exorcisms, amulets, and I know not what preparations, to fortify against the plague…that it was to be kept off with crossings, signs of the zodiac, papers tied up with so many knots, and certain words or figures written on them, as particularly the word Abracadabra, formed in triangle or pyramid.”

But these charms did not help, and all too many poor souls were “carried away in the dead carts and thrown into the common graves of every parish with these hellish charms and trumpery hanging about their necks.”

By the end, all the predictors, astrologers, fortune-tellers, and what they called cunning-men, conjurers and the like “were gone and vanished: not one of them was to be found. Many went to their long home, not able to foretell their own fate.”

Who to Turn To in Extremity?

As the plague spread, the populace gave up their trust in the quacks, but then, not knowing what to do, or who to turn to, they ran frantically around: calling on God, and asking one another “What shall we do?”

Many “turned to prayers, fasting, and ‘humiliation’, and imploring the mercy of God. But “neither can I acquit those ministers that in their sermons rather sank than lifted up the hearts of their hearers.”

With imminent death looming, many, especially the dying, repented of past actions. “But none durst come near to comfort them.” “Some of the ministers did visit the sick at first, but it would have been present death to have gone into some houses. The very buriers of the dead, who were the hardenest creatures in town, were sometimes so terrified that they durst not go into houses where the whole families were swept away together — but time inured them to it all.”

Actions by the Authorities

“At the start, the Lord Mayor and the sheriffs, the Court of Aldermen, and a certain number of the Common Council men, or their deputies, came to a certain resolution, and published it: that they would not quit the city themselves, but that they would be always at hand for the preserving good order in every place, as also for the distributing the public charity: for doing the duty and discharging the trust reposed in them by the citizens to the utmost of their power. And they were in fact continually in the streets and at places of the greatest danger. [We have witnessed similar courage and leadership, by many in our own time; and ‘sauve qui peut’ cowardice from a few].

The finances of the City were in good shape, and used generously to sustain the poor. (many were unemployed now because Trade was ‘stopped’, and also, the city was largely depopulated or closed up). Few ships ventured up the river, and none were allowed to leave. Every family retrenched their living as much as possible. The Royal Court contributed considerably (but kept their physical distance). Many of the wealthy who had left town gave generously for relief of the poor.

Bread and Provisioning

Thanks to the authorities, even at the height of the epidemic, provisions were always to be had in full plenty, and the prices not raised much.

“Neither was there any want of bakers or ovens kept open to supply the people. The Master of the Bakers’ Company, was, with his court of assistants, directed to see the orders of my Lord Mayor for their regulation put in execution: the due assize of weekly bread observed; all the bakers obliged to keep their oven going constantly.”


There were only two ‘pest-houses’ to house the sick. “If there had been, and if a person, as soon as he fell sick, could have been removed there, the number of fatalities would have been greatly reduced.” “Very good physicians were appointed, so that many people did in fact come out of them well again: in all the time of the visitation, there were but 300 buried from the two houses, in total.”

The lack of hospitals meant shutting up the well with the sick at home. This was a powerful inducement for the others to escape — to further transmit the sickness.


There was a necessity in this extremity to look to law and order, and it was done.

Starting in June, the authorities established emergency regulations. Houses in some parishes were “shut up” — guarding against entry or exit. The dead were taken and buried immediately. The plague ceased in those streets: early vigilance is an essential weapon in the struggle.

This shutting up of people in their own houses was first used in the London plague of 1603 under “An Act for the charitable Relief and Ordering of Persons infected with the Plague.” Anyone found to be sick with the plague was to be immediately sequestered in the same house, and even if he recovered, “the house shall remain shut up for a month.”

*To quarantine the infection, “the sickroom beddings and apparel, etc. must be well aired with fire and “such perfumes as are requisite within the infected house.”

*Any person who visits a person known to be infected or who entered willingly into a known infected house, “his house too is to be shut up.”

*No one can be removed from the house where he fell sick except to the “pest-house or a tent” or to a house where the owner/occupier accepts full responsibility. If a person owns two houses, he may send either his sound or his infected people to the second house: the second house also being shut up then for a week, in case of undetected cases.

*Every house visited by the plague is to be marked with a large red cross.

*Searchers, Chirurgeons, Keepers, and Buriers are to hold a red rod of three feet in length, open and evident; they are to abstain from company, and must not enter any home except their own or to where they are officially sent.

*Hackney-Coachmen [Taxis] must air their coach and place it in quarantine for 5 days after carrying an infected person.

The shutting up of houses was at first looked on as very cruel and ‘unchristian.’ “But it was a public good that justified the private mischief.” “But it was not to be depended on. It served to make those confined desperate, and they resorted to extremities, including assault upon the watch, and even murder to break out.”

From those shut up “we heard the most dismal shrieks and outcries of the poor people, terrified by the sight of the condition of their dearest, and by the terror of being imprisoned as they were.” For, if one member of a household fell ill with the plague, and the rest of the household were ‘shut up’ with the sick person, it was almost certain that all would die. Some are on record as actually dying of fright; many were traumatized to the point of going mad; and some lost their memory of those events.


On the other hand, many families, warned that the plague was coming, put up provisions and shut themselves in; not being seen or heard of until the epidemic was over: “keeping their houses like little garrisons: suffering none to go in or come near them.”

In the beginning of August, the plague grew ‘very violent’, and ‘my doctor friend’ coming to visit me, and finding that I ventured so often out into the streets, earnestly persuaded me to lock myself up and my family; to keep all our windows fast; shutters and curtains close; and never to open them.”

“People walked in the middle of the street, so they would not mingle with anyone that came out of houses, or meet with smells and scent from houses that might be infected.”


The master of any house, as soon as anyone in his household complained of “blotch or purple or swelling in any part of the body or who fell dangerously sick “without apparent cause of some other disease,” had to notify the Examiner of Health within two hours.

Examiners made sweeps of neighborhoods to list “what persons be sick, and of what diseases, and upon doubt, to command restraint of access until it appear what the disease shall prove.” Every infected house was to be under watch day and night.

Women Searchers, “of the highest and most honest repute”, were appointed to inspect the dead to make sure of cause of death. “No Searcher during this time of visitation was permitted to use any public work or employment, or keep any shop or stall, or be employed in any common employment whatsoever.”

Any “Nurse-Keeper” who removed herself out of an infected house before 28 days after the decease of any person dying of the infection, both she and the house to which she removed herself was also quarantined for a further 28 days.

Disposal of the Dead

Thanks to the authorities, even at the height of the epidemic, no dead bodies lay unburied or uncovered: *The dead are to be buried before sunrise or after sunset. No neighbors or friends are allowed to attend. *No corpse dead of infection is to be buried or remain in any church at a time of common prayer etc. (where others are present for services). *Children are not allowed to come near the corpse, coffin, or grave.

*All graves are to be at least six feet deep. “They dug several great and deep pits into which they put 50 bodies each; then they made larger holes wherein they buried all that the dead-carts (in that parish) brought in a week.” At the beginning of September the numbers of bodies to be disposed of was increasing: “people that were infected and near their end, and delirious also, would run to those pits, wrapt in blankets or rugs, and throw themselves in, and expired there.” (At the height of the epidemic, the numbers to be buried across the city ran to 10,000 a week, concentrated in a few parishes!)

There were problems excavating large and deeper pits: the water table was encountered at twenty feet depth.


[These regulations are all sensible; more so in a time when they had no clear idea of what the Plague was, or how it was spread].

*No clothes, stuff, bedding, or garments can be removed from infected houses. (Dealers and trade in second hand clothing and goods were ordered closed down). Some turned to fumigation and fire to purge infected houses and goods: burning brimstone, sulfur, pitch, and even gunpowder!

In 1666, the Great Fire did indeed destroy remaining traces of infection in much of the City. But not in all. Defoe asks: “How has it been that the plague has not come back in all those great parishes where the fire never came, and where the plague raged with the greatest violence?”

*The streets are to be swept clean: every householder must do so daily before his door. *The sweepings and filth of houses is to be carried away daily.

*No poor quality produce or fish or meats is to be sold. Breweries and drinking establishments are to be inspected for “musty and unwholesome casks.”

*No hogs, dogs, cats, tame pigeons, or conies, are to be kept in any part of the city (see below under “How the Plague was Spread”).

Restraints on Public Gatherings and Converse

*No wandering beggars. *“No plays, bear-baitings, games, singing of ballads, or such-like causes of assemblies of people. No public feasting till further order. *A Curfew on taverns, ale-houses, and coffee-houses.


The Medical Profession

Physicians were appointed “for relief of the poor.” The College of Physicians was asked to publish recipes for cheap and effective remedies: this helped at least to turn the populace away from the quacks, their nostrums, and the use of outright poisons.

But “the violence of the distemper, when it came to its extremity, was like the fire the next year. The fire, which consumed what the plague could not touch, defied all the application of remedies; the fire-engines were broken, the buckets thrown away, and the power of man was baffled and brought to an end. So the plague defied all medicines, the very physicians were seized with it, with their preservatives in their mouths, and men went about prescribing to others and telling them what to do till the tokens were upon them, and they dropped down dead. Many of the most eminent died of the infection.
Abundance of quacks too died, who had the folly to trust to their own medicines.”

“Not that it is any derogation from the labor or application of the physicians to say they fell in the common calamity; it is rather to their praise that they ventured their lives so far in the service of others. Doubtless they helped many by their skill, and their prudence. But they could not cure those that had the tokens upon them, or who were mortally infected before the physicians were sent for.”

How the Plague was Spread

There were many theories about how the plague was spread. The more enlightened assumed an ‘infection’ transmitted by some unknown agency — possibly airborne. Others considered it a punishment from Heaven and therefore without agency.

“The plague is carried from house to house in the clothes.” It first broke out in a house where goods from the Levant by way of Holland had been carried. It spread from there carried by those made sick to those with whom they had conversation.

“The best physic against the plague is to run away from it.” “Consider separating the people into smaller bodies, and removing them (before the plague comes) farther from one another, and let not such a contagion as this, which is indeed chiefly dangerous to collected bodies of people, find a million of people in a body together. The plague, like a great fire, if a few houses only are contiguous where it happens, can only burn a few houses. But if it begins in a close-built town or city, and gets a head, there its fury increases; it rages over the whole place, and consumes all it can reach.”

Infection generally came into a house because members of the household went out to shop — for food and other necessaries, and in so doing, came into proximity with others on the street and in shops, etc.

“Nothing was more fatal to the inhabitants of the city than the supine negligence of the people themselves, who, during the long notice of warning, made no provision for it by laying in store of provisions, or of other necessaries, by means of which they might have lived retired and within their own houses: those who did were in great measure preserved by that caution.”

“However, the poor could not lay up provisions, and must go to market to buy; this brought abundance of ‘unsound’ people to the markets, and a great many went thither sound brought death home with them.”

At the height of the plague, The Lord Mayor caused country people who brought provisions to sell in the city to be stopped at the outskirts (in informal markets) where they sold what they brought and then went away. This precaution encouraged country folk to bring the food to the city that the people needed.

“We were ordered to kill all the dogs and cats; for they are apt to run from house to house and from street to street, and are capable of carrying the infection in their fur. All possible endeavors were used also to destroy the mice and rats — especially the latter, by laying poisons for them, and a prodigious multitude of them were destroyed.”


There were many robberies and “wicked practices”. “The power of avarice was so strong in some that they would run any hazard to steal and to plunder, and particularly in houses where all the inhabitants have been dead and carried out, and without regard to infection take even the clothes off the dead bodies and the bed-clothes.”

At the Height of the Plague

From the middle of August to the middle of October, the official records show thirty to forty thousand died of plague. Another ten thousand were recorded as dying of other causes — but most of those were probably due to one or other form of plague, or its consequences.

But it was impossible to know the real totals: clerks, administrators, and those on the ‘front line’ were overwrought simply trying to gather and bury the dead. The true toll probably reached two thousand a day at the height. There were likely at least 100,000 victims of the plague in 1665 alone. “There was not a town within ten or twenty miles of the City but that was more or less infected.”

“Whole families and indeed whole streets of families, were swept away together. It was frequent for neighbors to call to the bellman to go to such-and-such houses, and fetch out the people, for that they were all dead. By then, the work of removing the dead bodies had grown extremely dangerous; innumerable of the bearers died of the infection. Yet there was such need of employment that others of the poor were always ready to take on the work. So, not withstanding the great numbers dying and sick, the bodies were always cleared away and carried off every night, so it was never to be said of London that the living were not able to bury the dead.”

With those died, and those who had left town, there were not one-third as many people in town during August and September as there had been in January and February.

“After funerals became so many that people could not toll the bell, mourn or weep, or wear black for one another; nor so much as make coffins for those who died; so after the fury of the infection appeared to be so increased, in short, they shut up no houses at all. It seemed enough that all the remedies had been used until they were found fruitless.”

“People began to give themselves up to their fears and to think that all regulations and methods were in vain. I do not mean a religious despair, or a despair of their eternal state, but I mean a despair of their being able to escape the infection or to outlive the plague, which they saw was so raging and so irresistible in its force.”

“People in this despair turned bold and venturous: they were no more shy of each other, or restrained indoors, but went anywhere and everywhere, and began to converse: ‘tis no matter who is all sick or who is sound.’ As it brought people into public company, so it brought them in large numbers into the churches. ‘A near view of death soon reconciles men of good will to one another, and bring us to see with differing eyes than those with which we looked on things with before.’ But as the terror abated, those things all returned again to their less desirable state.”


“It was even at the height of this general despair that the plague began to slacken, surprisingly, even as it had come.”

In September, the plague abated in the west and north-west parishes (so dreadfully visited at the first), but raged elsewhere in the city through the beginning of October. Then, as October wore on, the plague diminished both in numbers infected and in its intensity so that the proportion of deaths among those infected dropped. People grew careless, and for a time the numbers increased again. But the contagion was ‘exhausted,’ and winter weather came: the air was cold and clear, with sharp frosts. Most of those fallen sick recovered.

Not withstanding the violence of the plague in London, it was never on board the fleet.

Vintage Big Med – D Newman | The London Plague of 1664-1665: Summary – 2006

The London Plague of 1664-65: Summary [from a 2006 columnn] by David A H Newman


The following account is based on Daniel Defoe’s famous “A Journal of the Plague Year.” He wrote it in 1722 — the result of interviews with survivors and extensive research into parish records, brought together by a remarkable novelist and investigative reporter (in the true sense).
The Arrival of the Plague

The plague had visited 60 years before, and a few times each century for centuries before that, but with the exception of the terrible “Black Plague” of the 13th century, each visitation was no worse than those of the other scourges – flu, smallpox, and starvation.
There was no reason to expect anything different.

When the plague reached London it wasn’t a surprise; it had been reported in Amsterdam and elsewhere on the Continent. It moved slowly from town to town.

There were 3 plague deaths from late December 1664 through January 1665; they were all in the same house where visitors from the ‘Continent’ were staying. A fourth death was registered in early February: this time in another house in the same parish.

The winter was long and bitter cold and this seemed to inhibit the infection. Then it turned warmer: more cases were reported, but not in epidemic proportions, and confined to one part of town. But the reports were incomplete and it soon became evident that the plague had spread “beyond all hopes of abatement.”

When do you know that you face an epidemic: at the first death? when the trend is clear? And when do you know for sure what illness people are dying from?

London had a population of 500,000 in 1664. It was home to many illustrious scientists and physicians. But when the plague came what was known was not enough. “Where lay the seeds of the infection? How come it emerged when and where it did?” Why did the plague never again return in such a virulent form?

The plague came in bubonic, septicemic, and pneumonic variants. Symptoms were not always evident: many didn’t know they were infected for several days; they continued to move freely and spread the disease “till the inward gangrene affected their vitals and they died in a few moments” nor could the cause of death be known for certain until an autopsy was performed.

When should ‘The Authorities’ let the public know? To declare an emergency might cause panic and disruption; not to speak out might doom many who might heed the warnings and take precautions.

Fear and rumour compounded the risks. Quacks came from all parts to sell their nostrums at exorbitant prices. None of them worked; by the end the quacks had fled or were dead.

It seemed all regulations, precautions and remedies were useless. Abandoning hope, many went out and gathered freely, as if there was no infection. The plague spread faster.

The plague killed nearly everyone there was to kill in the infected parishes. At least 100,000 died. “Whole streets of families were swept away together.” It finally self-destructed like a fire that had consumed all its fuel.


Decentralize your “Assets”

“Let not such a contagion as this, which is chiefly dangerous to collected bodies of people, find a million of people in a body together. The plague, like a great fire, if a few houses only are contiguous where it happens, can only burn a few houses. But if it begins in a close-built town, and gets a head, there its fury increases: it rages over the whole place.”

Run for your Life

Get out of town early. The wealthy and those who could afford it left town. This exodus continued through May and June; spurred by rumors that the government was about to set up barricades on the roads. Without a Pass and a Certificate of Health “there was no way to being admitted to pass through the towns upon the road, or to lodge in any inn.”

Many of the poor, out of work and desperate, fled to the countryside. Many were not sick, but having no place to go, were forced to wander until they died of exposure and malnutrition, or from the disease.

“Country folk would carry out food and place it at a distance. When the wanderers died, the people would dig a hole to windward, and drag the bodies into these pits with long poles, and cover them.”

The Lord Mayor and other officials stayed at their posts. They used the City treasury to help sustain the poor. By order of the Lord Mayor, even at the height of the plague, bread and other basics were made readily available and price-gouging was forbidden. .

Avoid Contact

To quote an old maxim: “Shun it as if it were The Plague!”

Some families stockpiled food and other essentials and shut themselves in for the duration: keeping their houses “like little garrisons and suffering none to go in or come near them.” [Reminiscent of the early 1960’s nuclear attack panic — bomb shelters in backyards, taking to the back woods, gun in hand to fend off neighbors.]

But in many households, someone had to venture forth to shop for food and other necessities, and inevitably came into proximity with others on the street and in shops, and brought the infection back into the home.

[Conventional disaster planning suggests keeping 72 hours of food and water on hand. In the event of a pandemic, 6 months of supplies would be a minimum!]

Destroy the (presumed) Carriers of the Infection

Not knowing by what agency the plague was communicated, they did what seemed reasonable: “We were ordered to kill all the dogs, cats, mice, and rats: for they are apt to run from house to house and might carry the infection in their fur.” [With Avian Flu, should we slay all the birds too?]

[The irony of killing off the cats and dogs was that they were the main anti-rat weapon, and it was the virus carried by the fleas on brown rats that carried the plague; but no one knew that at the time. Still, fleas do transfer to other carriers, and cats and dogs might have carried the disease that way.]

Get the Facts: Inspect and Verify

If anyone in a house had plague symptoms or fell dangerously ill without apparent cause of some other disease, the head of the household had to notify the authorities within two hours. But given what would happen to one’s household if one did report (see below), few would want to.

Examiners made sweeps of neighborhoods to list “what persons be sick and of what diseases, and upon doubt, to command restraint of access until it appear what the disease shall prove.” If you fell ill it was assumed you had the plague and you were quarantined at home until it proved otherwise.

Inspecting and verifying works when there are just a few cases. But when entire streets and neighbourhoods are stricken, few will dare go there.

Quarantine the Sick and Anyone or Anything in Contact with the Illness

The rules were first promulgated by James I during an outbreak in 1603: “Anyone found to be sick with the plague is to be shut up in the same house, and the house is to be quarantined for a month,” marked prominently and placed under watch day and night so no one leaves or enters.

Officials charged with visiting, examining, or nursing the sick, or with carrying away the dead, were ordered not to engage in any ‘social’ contacts. They had to carry signs warning others to keep clear [like a leper’s proverbial ten-foot pole with a bell on it.]

Sickroom beddings and apparel had to be fumigated or burned. Nothing could be removed from infected houses. The entire trade in second hand clothing and goods was shut down.

But when the plague spread the law became meaningless. Those under house arrest in close quarters with the plague knew they would die miserably if they stayed; so many tried desperately to escape. Those charged with standing guard had an incentive to accept hefty bribes to look the other way, or to desert (because duty and death marched together).

Plays, bear-baiting, games, singing, ballads, such-like causes of assemblies of people, and public feastings were banned. There was a curfew on taverns, ale-houses, and coffee-houses. Few ships ventured in and none were allowed to leave.

Have Enough Hospitals, Staff, Supplies, and Transportation ready Before “It” Happens

To be shut in at home with the plague meant death. Being treated at one of the two hospitals meant a chance of recovery. More hospitals and more physicians and nurses to staff them would have significantly reduced the mortality rate, would have provided a much more effective quarantine of the sick, and the general population would have been better protected [as was the case in Toronto during the SARS outbreak.]

The system could cope with small numbers of victims but could not handle the scale of the emergency: an epidemic can overwhelm resources and facilities — more so if the infection runs its course through a victim in a matter of hours or just a few days..

At the start, there were many courageous doctors and nurses who valiantly did what they could, but they caught the infection and died: so by the time the epidemic reached its peak, the resources available to fight it had been reduced to a minimum.

Dispose of the Dead

The numbers to be buried at the peak (10,000 a week) almost overwhelmed the authorities. Only the most desperate and destitute, (and a few saintly souls), could be persuaded to take on the task of collecting and burying the dead (and the near-dead!). But “not withstanding the great numbers of dying and sick, the bodies were always cleared away and carried off every night, so it was never to be said of London that the living were not able to bury the dead.”

Prevent Crime

Greed, desperation, and an attitude that anything goes, led to break-ins of houses from which all the residents had been carried out dead. Some even stole the clothes and boots from the corpses of plague victims.

Do what is Necessary

Hippocrates said: “Desperate Circumstances may need Desperate [Creative] Responses.”

Vintage Big Med – D Newman | Pandemic flu planning: A flow is a quantification of assumptions – Dec 2006

Pandemic Flu Planning: “A Flow is a Quantification of Assumptions” by David A H Newman

[Dec 6 06]

References. I have made use of three references: 1] Government of Ontario Flu Pandemic Plan, Chapter 17 Acute Care Services & 17a: Tools; 2] Shoppers Drug Mart Healthwatch Pamphlet: Flu; and 3] Government of Ontario Pamphlet, “What you should know about a flu pandemic.”  April 2006.

My own comments are enclosed in brackets [like so].

Flu and Pandemic Flu Facts


Flu is caused by influenza A and B viruses.

It is spread mainly by virus in the air.

It finds a comfortable home in your airways. It starts to be contagious 1 day before you first experience symptoms and remains contagious for at least 5 days after symptoms start.

Flu can lead to serious complications: pneumonia, bronchitis, sinus infections, ear infections, dehydration, and in very serious situations, death.

Ordinary flu happens every year: usually from November to April – and then stops.

Pandemic flu usually comes in two or three waves several months apart. Each wave lasts 2 -3 months.

5%-20% of the population may get the flu in any given year.

A yearly flu shot reduces risk of catching flu by 70-90%.


A pandemic is distinguished by its scope: it is a worldwide epidemic.

A pandemic flu strain often develops when an animal or bird virus mixes with a human virus to form a new virus. Because people have little or no immunity, the disease can spread faster than with an ordinary flu.

The symptoms are the same as with an ordinary flu but can be much more severe.

There were three flu pandemics in the 20th century: the most deadly, the “Spanish Flu” in 1918-19 killed 20,000,000.The death rate was highest among healthy adults in their 20’s and 30’s. [The Median Age of Ontarians is 37].

A flu pandemic could happen any time.

We can’t predict just how society will be affected until we learn how strong the virus is.

There is no existing vaccine for pandemic flu. It will take 4-5 months after the start of the pandemic to develop a vaccine.

Drugs used to treat ordinary flu may also help people with pandemic flu but we may not have a large enough supply, and we won’t know how effective they are until the virus is identified.



Based on CDC’s U.S. FluSurge Forecasting model and an assumed 35% Influenza Attack Rate —

Over an eight week pandemic:  [there might be 3 such waves in a pandemic year]


Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
3675 6125 9188 11638 11638 9188 6125 3675

Peak admissions/day: 1814


Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
726 1209 1814 2298 2298 1814 1209 726


If you live in Ontario: during the first wave —

You have 1 chance in 3 of catching the pandemic flu

If you catch it, you have 1 chance in 2 of needing to visit your family doctor

and 1 chance in 70 of needing to be hospitalized

If you need to be hospitalized, you have 1 chance in 5 of dying there.

An unknown proportion of the population will develop health complications.

These levels are at least six times greater than typical hospitalizations for influenza and pneumonia during inter-pandemic periods.

[If you don’t get the pandemic flu in the first wave, your odds improve greatly:

*improved natural immunity from the 1st wave experience

*probable availability of a pandemic flu vaccine

*much better understanding of how to deal with the virus]

Resources needed by Hospitalized Influenza Patients:

100% using an acute bed for 5 days

15% using ICU beds for 10 days

7.5% using ventilator support for 10 days

If the Assumptions hold:

At the peak of the pandemic, influenza patients will use:

52% of all Acute Care Beds

170% of ICU Beds

117% of Ventilator-supported Beds

Current Demand for hospital services is already high: ICU Beds are utilized 90% daily.

The FluSurge model does not take into account Health Care Worker absenteeism but the Plan assumes that staff will contract influenza at the same rate as the general population in their communities. [History suggests staff will come down with pandemic flu at a much higher rate, and fatalities will be disproportionately high — especially in the first weeks. If so, the net effect will be to seriously reduce availability of trained staff as the pandemic goes on: the impact will be particularly grave should a second wave and then a third wave hit]

[The Model does not consider how patients will be moved to and from hospitals: Ontario is a big province with a population of 12 million (5 million households). However, Ontario is 80% urban, and most live in the so-called “Golden Horseshoe – from Oshawa to Niagara, including the Greater Toronto Region].


There has to be a Phased Approach:

*Deferring non-influenza care

*Dynamic use of influenza Triage

*Dynamic Use of Admission/Discharge Criteria

These will vary according to available and needed local hospital resources.

Specifically —

*Defer Services for Non-Life-Threatening patients.

*Discharge ALC (Alternative Level of Care) patients to Long-Term Care.

*Discharge acute patients and inpatients to home care.

*Create “flex-beds” from reserved or recently closed beds.

*Deploy freed-up beds for influenza patients.

*Use Ventilator Capacity anywhere sufficient oxygen is available:

ER, post-anesthetic care units.

*Cohort infectious and non-infectious patients.

Re-deploy staff.

*Defer holidays and leaves of absence.

*Establish 12 hour shifts.

*Train non-clinical staff to handle support services: meals, personal care, patient movement, cleaning, etc. and support for health care workers and families (child care, pet care, etc)

*Coordinate with other hospitals.

*Encourage participation of public in Home Health Care courses before the pandemic.

*Cross-train clinical staff.

[Wait until the Pandemic strikes. Then count backward 1 year, and initiate training].



With the assumed 35% Attack Rate the phased development of Surge Capacity will not be enough to meet the Peak Demand. Accordingly, a Mass Emergency Care condition will have to be declared: this will have “substantial legal, regulatory, and logistical implications.”

The type of Triage contemplated is only justifiable in an Overwhelming Crisis i.e. when all resources are in danger of being exhausted.


*All patients will be cared for – one way or another. [True, but not very comforting.]

*Triage is a practical application of Ethics [Everything is.]

*Fairness and Justice will prevail. [How about Compassion?]

*Based on Clear and Transparent Criteria.

Timely Accurate Information is vital

Health Care providers will need real-time data about patient outcomes during a disaster; in order to modify criteria and prevent over- or under-triage. The Protocol will evolve with time and use.

Triage Models

No Triage systems have been developed yet for use in critical care or medical illnesses but there are models available to draw on:

Illness Severity Scoring Systems: “cumbersome and impractical during a disaster when human resources are scarce.”

Military Triage Systems: “devised specifically for Trauma and not for medical conditions or biological events.”

SEIRV Triage System: “developed for use in Bio-Terrorism attacks.”

Categorizes patients but does not address Resource Allocation.

Uses ‘Inclusion’, ‘Exclusion’, and ‘Minimum Qualifications for Survival (MQS)’, to guide triage decisions – “which should be part of all Critical Care Triage Systems.”

Sequential Organ Failure Assessment Score (SOFA): “may be useful as a component of a Triage System.” It uses general physiologic parameters applicable in a wide variety of conditions.

Inclusion Criteria

Identifies patients who may benefit from admission to critical care: focusing primarily on respiratory failure.

Exclusion Criteria

Identifies those needing a level of resources which cannot be met in a pandemic, and even if ICU resources were found they would have a very poor chance of survival (SOFA Score of > 11 i.e. mortality rate of > 90% even with full critical care). For example —

*Severe burns

*Cardiac Arrest not responding to prompt defibrillation or cardiac pacing .

*Needing large blood transfusions

*Underlying “significant and advanced” illnesses with poor prognosis and high short-term mortality (as in advanced cancer and end-stage organ failure)

MQS — Minimum Qualifications for Survival


*Place a ceiling on the amount of resources that will be allocated to any one individual.

*Early identification of patients who are not improving and are likely to have a poor outcome.

In other words — find a ‘balance’ between those who are sick enough to need the resource and will do poorly if they don’t get it, but are not so sick that they are unlikely to recover even if they do receive intensive care. In other words, every patient who is admitted to critical care should survive. [And those not admitted will surely die? Self-fulfilling prophecy.]


“Effective Triage depends on an established, skilled, and practiced infrastructure.”


This is a Multi-disciplinary Team:

*Making clear and transparent decisions with support from ethical and legal experts.

*Using consistent Criteria flexible enough to allow local responses.

*Primarily responsible for:

— Modifying the Protocol as the pandemic evolves – based on analysis of

[as it happens] data

— Command and Control over the critical care resources in the field.

— The key decision – when to activate the Protocol.

“These issues are too important to be decided by the individual Triage Officers in the field.”


“The best triage decisions are made by senior physicians with training in triage and significant clinical experience.”

They must be given proper training beforehand, as well as on-going support during a pandemic.


The quality of decisions by the Committee and by Triage Officers depends on the availability of accurate [up-to-date and sufficient] information. There has to be a reliable two-way Communications Network between the Field and the Committee.

[Given the current lack of effective communications and a near-total absence of reporting of system-critical information in all aspects of health care, it’s hard to believe that the Plan – which results from considerable research, intellect, and experience – will work as stated: but it is a very good start.]


On Tuesday, November 21, 2006, The Hamilton Spectator headline read:

“No pandemic care for elderly” as the page 1 lead-in to an article by Joanna Frketich.

On page 8 of the same issue, an article by Peter Van Harten was headed”

“Pandemic rules hard to swallow?” with the sub-head “MD predicts major ethical debate.”

I’m amazed there weren’t more such headlines, but it takes a certain amount of effort to locate and then read such things as pandemic plans, and supreme court decisions.

Does one have to be able to read as a criterion for attending journalism school? Evidently the Spectator people can, and do. I wonder about some of the others.

The debate over ethics will surely take place – if not before the pandemic, then after. As with all disasters — natural and non-natural – the political propensity to re-hash will once again raise its very ugly head.

One element (among many) in the Draft Triage Protocol Exclusion from Admission criteria set is Age > 85. So Seniors might be well advised to hide their birth certificates and lie about their age.

Triage is never easy. If a pandemic comes upon us the hard choices could become very hard. “Tennis anyone?”

Be well.

Vintage Big Med – D Newman | Ethics and Triage: A Nasty Scenario – Dec 2006

Ethics and Triage: A Nasty Scenario by David A H Newman

[Dec 12 06]

If only the rich could pay the poor to die instead of them, Then the poor would make a very good living. (Ancient Yiddish Joke)

A Flu Pandemic has begun. The hospitals are crowded. Staff is overworked: many have come down with the flu – one sort or another. The ‘normal’ flu doesn’t vanish just because of a pandemic. Even before the flu’s came, the usual ailments and conditions have just about taxed the limits of the system’s capacities; and the pandemic is a long way from peaking.

It’s bitter cold outside. People, old and young, are dragging themselves, or loved ones, or neighbors, to Family Practice offices, and to hospital Emergencies. Taxis refuse to take them – this stuff is dangerous! – public transit is barely operating: drivers are sick, or calling in sick and maintenance is non-existent. Who would want to ride the bus and breathe in undiluted virus? So people drive, or walk, or stumble, or are wheeled to their local version of purgatory.The paramedics and first-response people, like many doctors, nurses, and orderlies, have, in some cases, literally worked themselves to death. Others are genuinely seriously ill at home. In any case, hospitals won’t allow ambulances to unload: the situation has become too serious for ambulances: they are irrelevant against the scale of the emergency. This puts the First Responders in a Catch-22 bind: what are they supposed to do with the living, the dying, and the corpses? The fire-paramedic and police stations have become hospital wards, and mortuaries.

Family Practice offices are crowded; there weren’t enough to begin with, and now more and more are closed – the doctors and nurse practitioners have strived valiantly for weeks, working round the clock; but many have succumbed to the illness and are too sick to carry on. Some have already died. The sufferers keep arriving – and are told to go to “Emergency.”

The Emergency is so crowded it’s impossible to move: too few staff, too few Triage Officers’, too many forms and too few to fill them in. More tests needed? – long waits; supplies dwindling.

It’s not just in “Emergency” – the corridors are lined with sick and dying. The ‘lucky’ ones have beds; others are wrapped in blankets on the floor. The sound of coughing, hacking, groans rasps and rattles adds to the background. The place doesn’t smell- it reeks.

The only ones around to help are family and volunteers; but they too are a dying breed.
The kitchens have shut down. The Tim Hortons a few blocks away is the main source of hot soup and beverages.

The chaos extends outside the hospital. Every few minutes a car pulls up to the curb and someone terribly sick is pushed out or loaded into a wheelchair; and then abandoned. People are desperate. People don’t want to watch loved ones die. They want to get them to where help is available, but there is no more room at the inn.

There’s no room and the authorities have instituted a quarantine. There are fierce barriers to admission – -even to approaching the hospital. Police and Military, guns evident, are supposed to enforce the ban, but they didn’t sign up to turn away the sick and dying to perish of exposure on the street; at the very gates of supposed aid and comfort. They try to keep a semblance of order: lining up the wheelchairs – many with their frozen dead occupants — in neat rows. Some are in tears; none will ever be free again in their minds. This is not a job: this is hell.

Worse yet are the ones who have lost it, watching their loved ones going downhill with no access and no hope. Some arrive in a rage, screaming threats, demanding access — armed and very dangerous. Are they to be gunned down on the spot? Is there time, patience, and skills to talk them into calm? Can it be done?

Pharmacists (legitimately part of the Front Line) are also besieged as people line up to request, demand, and plead for something – anything – to help their loved ones. They are worked off their feet doing what they can, but they are hampered by government irresolution in deciding what powers pharmacists should have. It would have been an enormous assist to everyone if government had given them emergency powers to prescribe and dispense on the spot; and if government had also picked up the tab for all pandemic-related drugs. Some go ahead and prescribe anyhow; but supplies are dwindling.

As in all pandemics, even in our supposedly enlightened age, the miracle-workers with trumped up testimonials from the crowned heads of Europe, quacks with nostrums, and ‘end is nigh’ callers to repentance all have their moments of glory — and riches: its remarkable how expensive the goods and services are which these selfless folks ‘freely’ offer. Human nature is eternal in its often excellent ways — and in its folly.

At the other end of the chain, the mortality rate among those admitted to hospital is much higher than predicted: in part because the virus is especially virulent; in part because the system has broken down; and in part because all attempts to establish interior quarantines (cohorting) have been defeated by increasingly over-worked staff, and a shared air-circulation system. The usual crop of hospital-specific infections is proliferating.

There are no more resources left and little chance of getting any anytime soon: suppliers and distributors are at their limits and manufacturers are forced to ration dwindling output.

The hospital mortuaries are full. Autopsies will have to come later — much later; if at all. Meanwhile, bodies, neatly toe-tagged, are stacked like firewood in a more-or-less exterior courtyard. The weather is cold enough: they will wait there quietly. Anyhow, morticians have closed up shop for the duration. Those with the courage and strength retrieve their dead and go to join the long lines at the crematoria.

The death rate is also high among the thousands cleared out from the hospitals to make room for the pandemic flu sufferers: sent home, or to long-term care facilities, or otherwise moved out of sight and out of mind. They live, or die, or will be debilitated for the rest of their lives.

Scalpers are thriving: they don’t mind the cold as they wait patiently on the streets around the hospitals for new arrivals. The going rate for an admission for one is $25,000 (up front in cash). There are enough takers to make the middle-men wealthy, and to handsomely reward the good folks inside who are ready to pocket the bribes. Being a triage officer, or a key person in the paperwork chain, is a license to print money.

Anyhow, a disproportionate number of highly placed bureaucrats and politicians, and their friends, family, and lovers, seem to get rooms and beds and ventilators, and the world’s gone mad around you, so why not get some benefit? After all, you’re one of the few still on the job, taking the big risk with your life, so why not?

There are still some who are trying hard to stay ethical – to do the right thing because it’s in their nature. But it is hard; because so much has gone wrong and it’s not a matter of pointing blame. It doesn’t mean the Plan was flawed. It doesn’t mean that society, and the system, were at fault. There may have been flaws and errors, but that’s only because we are human and frail and mortal and come with the full set of emotions. This emergency is overwhelming – like a millennium storm it has surged through our cities and buried our best plans and hopes in an abyss of tragedy. (It happens).


Worst Case scenarios seldom happen: by definition, they are unlikely. But when they do happen, they tend to be much worse than anyone could imagine.

I wrote this scenario to try to answer a lurking question: are Ethics and Triage at all compatible? Worst Case scenarios test the limits and when I think about what could happen at the limit, I don’t at this point see any room for Ethics (or Morality) in a Triage situation — unless, and this may be key – the Ethics are built in to the Triage Design.

However, stating a set of lofty humanitarian principles up front is not the same as ensuring they are followed in the field. With the best will in the world, Triage has to be based on other principles – such as making the most effective use of limited resources, and the greatest good for the most.

Fairness is a worthy test of a system – in the sense that Triage and what follows must not be arbitrary, and should be equitable (without fear or favor). In the main, that is feasible – though there will always be queue-jumpers. But Fairness has little to do with Compassion.

Hard choices — sometimes the trade-offs are wrenching, at best.

I’ll try to work some more with these issues. Your views, in the light of your own experiences, would help.

Be well.

Vintage Big Med – D Newman | Danger Pay – Aug 2007

Danger Pay by David A H Newman [Aug 27 07]

Back when SARS threatened Toronto, the Ontario government of the day introduced strict quarantine measures reminiscent of the often drastic quarantine laws applied in times of plague — [as in London 1664-65].

Quarantines are difficult to enforce, but the quarantine worked for Toronto and SARS was contained. But, as can happen when something new attacks in epidemic proportions, people died and some of them were healthcare workers.

They died in part because we didn’t know enough — we never do — and in part because people wore the wrong masks, or they weren’t properly fitted, and because the hospital culture took a while to get over an under-estimation of the dangers. We will be ready for SARS next time, but next time it won’t be SARS, and there will be casualties. One outcome of the re-hash of the SARS experience is a call for danger pay — looking ahead to an anticipated pandemic. Undoubtedly healthcare workers will face risks and uncertainties; some will be casualties and some will die. It’s not enough to say that it goes with the territory and the Hippocratic Oath — I’m not sure it does when it comes to the crunch.

In the exceptionally virulent plague outbreak in London [1664-65], many of the best doctors and nurses died in the first weeks, as they worked valiantly and desperately to help the sufferers. This was not the dark ages; London was a capitol of enlightenment, home to many men and women of science and medicine. But when the plague came, in a particularly horrific form, they didn’t know enough. Regardless of how advanced we think we are today, the same truth holds — we never know enough, and too often, the best among us die trying to stem the tide.

Danger pay or compensation or insurance may well be justified. But think about it: pandemic is just one form of disaster affecting the many, and the response to disaster involves the many. There are many unsung heroes. There are many who suffer, and too many who die. Pandemics, like disasters in general, do not differentiate between the professionals and the rest of us. Doctors and nurses, and orderlies, and many other healthcare workers, are on the firing line. But so too are the paramedics, firefighter first responders and a host of others including volunteers. And then there are the collectors of the dead, and the ones who dig the pits and dispose of the corpses. How about the folks trying to maintain law and order while the world around panics and goes ballistic? And finally, there is the largest category of them all: you, me, and everyone else; the patients and the potential victims. We are all in it together, so where does danger ‘pay’ begin and end, and with whom?

A few callous souls have argued that if ‘we’ don’t get danger pay ‘we’ will simply down tools and refuse to show up at work; the ‘we’ variously referring to doctors and other healthcare workers. It’s an interesting argument. Fortunately, there is a precedent —

A few years ago, emergency room doctors in Winnipeg walked out. They claimed, likely justifiably, that they were overloaded, the system was breaking down, and no one cared. So they downed tools and the entire emergency system shut down. I think the walkout lasted for two weeks or thereabouts. The mortality rate in Winnipeg dropped alarmingly; of the order of 30 percent. In due course, the emergency people returned to work.

But one seems to have absorbed the underlying issue: if there were no healthcare system, would we be worse off or better off? What would happen if all the patients downed tools and walked out? How would the politicians cope with a pandemic of angry voters? Let them try to quarantine that!

Remember Bob: “You have the power.” So vote as you like, but vote often.