In the absence of gravitas: crapola

HalProfile2009Mar22by Hal Newman

The latest in a countless series of grave warnings sent by email with an ever-changing list of signatories, this one was supposedly from a PhD MD RN MSc and opened with this phrase:

“No one should take the swine flu vaccine-it is one of the most dangerous vaccines ever devised”

In the absence of intense myth-busting information communicated by credible leaders, this kind of crapola propagates. Several times a day I find myself being called upon to explain why I believe it’s essential that we all get vax’d against H1.

Here’s my response:

For me, it has become a very serious risk v benefit model.

And understand, Di and I sweat each and every time we get the kids inoculated against something. We wonder – just a little bit – about the safety of the vax. There’s that moment of dread that lasts from the time the needle breaks skin to the time it takes for us to be convinced of no evil and debilitating sequelae.

And then there’s H1N1.

There’s nothing abstract about this – it’s not like the concept that I might be hit by a truck. Might. Maybe. Likely never happen.

H1N1 is a real threat. It has replaced the seasonal flu virus as the dominant flu bug crisscrossing the globe. Just think about that fact for a moment. Wow. H1N1 is the king of the microbe heap and it’s only been in circulation since April.

H1N1 has a disproportionately awful impact on the very young, on pregnant women, and on people with underlying medical conditions. How many asthmatic kids do you know? My own daughter is still prone to croup at age 11 – when she was younger she weathered some critical moments in ERs and ambulances. How many young people are medically fragile? How many adults are medically fragile? The answer will blow you away when you realize just how high the percentage of the population are considered at risk.

From the CDC briefing on Oct 16

“There are now a total of 86 children under 18 who died from this H1N1 influenza virus, the 2009 H1N1 influenza virus. We had 11 more influenza pediatric deaths reported in week 40, which is the week that ends October 10. Ten of those are confirmed to be due to the new strain, the 2009 H1N1 strain and the 11th is probably due to that but the typing hasn’t been completed. About half of the deaths that we’ve seen in children since September 1st have been occurring in teens between the ages of 12 and 17. These are very sobering statistics, unfortunately, they are likely to increase.”

From the CDC briefing on Oct 20

“More than half of the hospitalizations are occurring in young people under the age of 25. We are seeing 53% in people under 25 years of age. 39% of hospitalizations are in people 25 to 64 years of age. And only 7% of hospitalizations are occurring in the elderly. Almost a quarter of deaths are occurring in young people under the age of 25. Specifically, 23.6% of the deaths are in that age group. About 65% of the deaths are in people 25 to 64 years of age… With seasonal flu 90% of fatalities occur in people 65 and over. Nearly 60% of fatalities are occurring under age of 65.”

Bottom-line: Get the shot.

. . .

I understand why it’s probably a good idea to prevent access to some websites from within the hallowed halls of hospitals, however can anyone explain to me why the IT department of a major academic/pediatric hospital would block access to the government’s H1N1 pandemic information website?

In the absence of gravitas: crapola.

Tachycardia with a hint of all-out gallop

HalProfile2009Mar22by Hal Newman

For whatever reason, the national media haven’t quite zero-zeroed in on the realities associated with H1N1, the vax, and high-risk groups. Certainly, the tone of local and regional coverage has shifted from cautionary optimism to creeping negativity.

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Whether the media gets it right or wrong at this point is unlikely to make a dent in the public perception of being at the heart of something wicked this way comes.

If you were to take a pulse of America right now, I believe you’d find it in tachycardia with a hint of all-out gallop as intense fear rides on the cusp of all-out panic.

The indicators for me arrive on the hour in the form of email queries from healthcare professionals, community leaders, and emergency management colleagues wanting to compare notes on what personal steps they can take to protect themselves and their loved ones from H1.

To further confuse and confound, there are mixed messages being sent by federal, state and county health officials to the public they serve, e.g. 1020 State officials understand and share frustration associated with H1N1 vax shortages [Massachusetts].

If you ever wonder how rumor generators get primed, read this piece out of North Dakota and imagine the news being transmitted on a national game of broken telephone: 1020 DoH recommends revax of some individuals against H1N1 [North Dakota].

With so many people with functional limitations [the vulnerable at the moment] mixed into the at-risk groups, this ongoing crisis represents a significant challenge for us all. How do we ensure a fully-inclusive response?

When I’ve tried discussing H1N1 with some of my colleagues, there has been tremendous pushback with an accusation of my ‘having given in to the hype.’ The claims of hype tend to fade as more people we know are affected by a nasty bit of influenza that has a habit of going hard after the very young.

Does H1N1 represent the perfect storm with an even more devastating legacy than that of Katrina? Katrina struck the Gulf Coast and still managed to impact an entire generation, create its own diaspora and continues to have a lingering effect on millions of people. Katrina had a beginning and is still looking for an end.

H1N1 is an ongoing evolving global crisis with nothing to link it to the episodic view we have for emergency management. And unlike all those other crises occurring out there – famine, civil war, genocide, malaria, HIV/AIDS – this one is affecting us right here in our homes. So H1N1 has our rapt attention and even with all eyes on the ‘prize’ we’re still unable to manage this ongoing emergency.

Sometimes it feels as if the professionals would rather not disturb the peace with discussions focused on what happens when the victims of emergencies or the emergencies themselves don’t act in ways predicted by the plan.

Were it only so easy if disasters had neither victims nor responders but only featured rulemakers who could wear funny hats.

Standing with Serge

by Hal Newman

I’ve been looking at medical surge as a series of ever-larger waves crashing ashore in that they continue picking up more and more debris and carrying that further inland until finally they begin to ebb.

All the surge plans I’ve seen are based on the notion that the emergency healthcare system will need to handle more and more patients until finally the peak flow is reached.

There is a fair bit of ‘resurrection medicine’ built into these plans – the need to reach into death’s door and pull the victims back into the land of the living.

Shouldn’t we be looking at creating critical care field triage levels that would prevent the surge waves from carrying patients requiring resurrection-medicine from reaching the ERs? Isn’t it about time we took a hard look at plans that would include field-based palliative care units?

Any idea on the total number of mechanical ventilators and respiratory techs there are in any given major jurisdiction in the United States or Canada? Anyone have a breakdown on that number per hospital – just the major centers?

So now that we’re seeing a strong run on tickets for a possible Kick Your Ass tour for A/H1N1 in the fall, does anyone have any idea what we can anticipate in terms of both clinical attack and absentee rates when it comes to the respiratory techs themselves? Has anyone got any ideas about who to train and how to train them in Ventilation for the Uninitiated?

Does anyone have numbers for pediatric vents and resp techs at pediatric centers? It seems that the vast majority of hospitalizations in a more virulent return of H1N1 would be among children below the age of 15. Unless I’ve missed something, we just do not have the collective pediatric resources to provide care on that scale.

The estimates I’ve heard sure don’t give me any peace of mind – and the fact that the actual numbers seem to be so closely guarded also gives me pause. Certainly don’t get the vibe there are overwhelming numbers of either ventilators or the human beings required to make them effective lifesaving tools.

As my friend Roy says, “It has been nearly five years since the discussion of vent shortages in the United States began with SARS as the stimulus. So, in five years the US has apparently done little to increase the number of ventilators available for pandemic flu surge and train a much-enhanced healthcare cadre to manage ventilator systems in compromised patients.”

The problem is, as Roy so aptly quips, “Vents are not particularly sexy or worthy of discussion in a healthcare system barely able to manage a bad season of colds and flu.”

My educated guess would be that roughly 85 percent of the available mechanical ventilators in Montreal hospitals are currently in use. Combine that with an average ER occupancy rate in the 90-something percent range and we’re not talking surge – we’re talking about a damned near bankruptcy of the emergency healthcare system.

Roy’s educated guess is that the same percentage of current daily use holds true for the 100,000 or so ventilators available across the United States at any given moment.

“Disaster preparedness typically includes plans that address the need for surge capacity to manage mass-casualty events. A major concern of disaster preparedness in respiratory therapy focuses on responding to a sudden increase in the volume of patients who require mechanical ventilation.” – Mechanical ventilation in mass casualty scenarios. Augmenting staff: project XTREME, Hanley ME, Bogdan GM. 1: Respir Care. 2008 Feb;53(2):176-88; discussion 189

While I recognize the wonderful work done by major trauma centers that kick themselves into overdrive to deal with 20-30 seriously injured patients from a single incident, I believe it’s time to take a real-world look at what happens when there are 100 or 200 or 300 or maybe 1,000 people who are sick or injured?

Or when there are tens of thousands of people concerned about their children who are presenting with the signs and symptoms of pandemic flu.

And perhaps it’s not a one-time event.

I live in Montreal where the EMS system runs on a Basic Life Support platform and where firefighter-first responders have been limited to a SSU [sticky side down] approach when it comes to providing care for patients prior to an ambulance crew’s arrival.

The idea that somehow the combined Fire/EMS system would be able to successfully triage, then transport more than 100 critically ill patients from a single incident without completely outstripping available resources is pretty well pure science fiction.

The EMS system is constantly short of ambulances and crews. There are a finite number of firefighter first responders. And that’s when the going is relatively good. Throw in an icy night and a few multi-patient car crashes and maybe simultaneous multi-alarm fires [definitely not unheard of in a major metropolitan area].

And we don’t need to be talking pandemics or terrorism. We could be talking about an ethyl-methyl-bad-stuff incident at one of the multiple chemical facilities that are smack dab in the middle of a heavily populated center. All that’s required to tip the balance between feasible and outright chaos is a higher percentage of critically ill patients.

If the walking wounded aren’t – then we’ve got a serious problem on our hands. It’s not as if we’re going to tell the populace to get a pick-up truck and an air mattress and take their neighbors to the ER on their own. One major incident doesn’t come with permission to suspend operations for the rest of the population. Just standing with Serge and talking with Roy watching the waves crash on Tundra Beach.

Be well. Practice big medicine.

Not so private musings

by Hal Newman

Despite the recent rah-rah session aka the Flu Summit in DC and all the good tidings that flowed forth from that ‘rather vacuous’ gathering, I have serious concerns about what awaits us as H1N1 circles the globe and comes streaming back towards us as a virulent mo-fo capable of creating the tipping point that sends healthcare systems well over the edge and into semi-permanent surge status.

WHO has recently recommended that all nations should immunize their healthcare providers as a screaming priority in order to protect the health infrastructure. Remember, folks, that’s the same health infrastructure that’s currently operating well beyond normal capacity on an ongoing basis despite the fact real life has been in the fat dumb and happy zone in between natural disasters and man-made catastrophes for years.

There are problems with the production of a workable flu vax [perhaps as far down the road as 10+ months] and there are rationing schemes afoot with country-specific customizations on order of priority of the following groups: pregnant women; those aged above 6 months with one of several chronic medical conditions; healthy young adults of 15 to 49 years of age; healthy children; healthy adults of 50 to 64 years of age; and healthy adults of 65 years of age and above.

And so, as my pal Roy says, even mid-2010 does not mean global coverage, just those that can afford it or have special arrangements. Perhaps it’s time we considered home schooling..

Do not take the mainstream media’s inability to deal with its own Attention Deficit Disorder lightly. While it’s somehow amusing to watch CNN’s Situation Room monitors flicker with images ranging from Jocko’s funeral services to the uprising in the streets of Tehran, keep in mind these are the times we need to be looking at our emergency services’ capabilities with the eyes of a malevolent red team because the wicked things that are inbound will surely stretch the anticipated limits and then some.

There are challenging times ahead. Just my two vicious bits.

Be well. Practice big medicine.