How can we be prepared for emergencies?

I read with interest the article in the NY Times magazine about decision making at Memorial Hospital during Hurricane Katrina. See the link at the bottom to the article. It describes the long series of events that occurred after Hurricane Katrina that led to the deaths of a large number of patients, many of whom were not expected to die.

Who and what else is involved in the wrongful deaths? We might consider:
-prior administrators had decided not to pay for the cost of improving the electrical system so that flood waters would not cut power completely
-officials who allowed the circumstances that lead to the floods occurring in New Orleans (including our overall lack of foresight in building anything below sea level!).
-lack of coordination between the hospital and the LifeCare unit; why would this subunit in the hospital come second to the hospital at large? What was the coordinated disaster plan and evacuation plan for this unit of critically ill people? How had communication ensued that LifeCare could not independently evacuate their patients?
-A lack of knowledge or training related to principles that should be used to carefully allocate resources in the midst of an emergency that is long term. When should such principles be used? Are the most ill evacuated first or last? When would people not be evacuated? What is abandonment in a situation like this? How can workers in the midst of such a great crisis be expected to think logically and make the best decisions? Was this a group think situation, with individuals only seeing one way out of an extremely difficult situation?
-How were decisions made about who was a priority to rescue and evacuate? Why wasn’t more help available to move or transport patients when the hospital staff was exhausted? What was the rationale to send away the helicopters at that point? How could this be better planned for in the future?
There is also a more general consideration, for a different blog... How comfortable are we that every day lethal combinations of drugs are given to people who are at the end of life? Generally this is done to ‘comfort’ the seriously ill in their last moments. Comments by the physicians and nurses do indicate a knowledge that death is hastened in these circumstances. Does this comfort with hastening death make it easier to decide to hasten death in a person not otherwise expected to die immediately yet who is seriously ill?

There was a disaster plan...
-The person in charge, a nursing administrator knew that disaster plan… had authored it, managed work groups to develop it, and implemented that plan during the Hurricane. This is a good example of how difficult emergency planning is. Particularly for large entities. How can we envision every emergency that we would be faced with? How can we know exactly what our deficiencies in planning are, until we are faced with the reality? In this case it could be argued that it is easy to imagine the emergency and sequelae of a hurricane in New Orleans. This is true, but think of all the expected and random events that could occur in such a situation. Generally disaster planning is rather linear. You assume a particular situation and its parameters and decide upon how we can best be prepared for all aspects of that situation and its ramifications. Should the emergency plan have figured out details for evacuation if the streets were flooded? Should the plan have identified what to do if there was a ‘complete’ power failure (and for how many hours or days)?

A problem is that planning probably did not ever imagine the conditions that continued for days in this situation. In the midst of a crisis situation, best decisions cannot be made. Decisions are made based on the information and resources available. It seems to me that in the midst of this terrible, terrible situation, many of the caregivers experienced cognitive constriction. Cognitive constriction is the inability to imagine any other means out of or to resolve a situation. It is a common symptom experienced by those who are suicidal, and is described by Edwin Schneidman (1996) in his book, The Suicidal Mind. It sounds like elements of 'Group Think' are also present.

Now it is easy to see that in the midst of this incredible crisis, that there were many alternatives available. Unfortunately in crisis situations problem solving abilities may not be at their best. Which of course is the reason we plan for disasters.

The article does not tell us how communication or decision making were handled after the initial implementation of the plan. It appears that many were working based on limited or varied information. It is unclear what information offered by individuals involved and reported in the article is presented to protect the providers involved.

Should providers be called into question about decisions made during those long and terrible hours following the floods of Katrina? Absolutely.

Should there be protections for health care providers who do provide care? Absolutely.

I believe there is a middle ground here. Without questions we will never learn from a situation so that we might respond better the next time. We do need providers to feel able to respond without personal risk during a crisis. We also need to learn how to prevent a similar situation from occurring within a disaster.

A harder question is what we as a society expect in the midst of such a crisis or disaster? Most people expect that somehow normal functions of all kinds will resume quickly after a crisis.

What is reasonable in situations of 'chronic' disaster functioning like this?

Here is the link to the NYT Magazine story: http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=16&th&emc=th

Latest Greed package from Wall Street: Profiting from your sick family member’s insurance policy?

When the banks and real estate market were plummeting, I believe much of the credit goes to the ‘credit default swaps’ falling apart. I was marveling that it could be ok to take out what was basically an insurance policy on someone else’s risk. Yet again, Wall Street is coming up with another way to profit on individual misfortune, by investing in individual’s life insurance policies. Check out this link to the article describing the brilliant ‘new idea’ in Saturday’s New York Times:
http://www.nytimes.com/2009/09/06/business/06insurance.html?th&emc=th

How could this be good for the economy or the individuals involved? The basic idea is, the banks will bundle up and sell our insurance policies as an investment instrument, so that when we die they can collect the money! Imagine that?! Is that what insurance was developed for? For bankers to make profit from? I don’t understand it. Insurance is a regulated industry, how can this be possible to do? I am sure it will be marketed as a public service: When you or I are most needing money, the banks will be happy to cash in that life insurance policy you have been paying on for years. Then they will hold it, and it appears hope that you die young so they will get a bigger payout!

I know someone who still smokes, maybe he smokes at night, gets sleepy and is at risk for burning his house down… let’s buy his insurance policy rights! Maybe we can also take out a policy on his house when it burns down!

How can we go so wrong? By the way what happens when a lethal pandemic does hit and all those chronically ill people cannot survive it? Or a natural disaster? Will we again need to bail out Wall Street or the insurance companies having to pay out all those policies at once? Hopefully the higher risk of death from other events in ill people is a consideration of the computer model they are running. On the other hand, regardless of computer models, there is always the risk of the worst happening all at once… didn’t we just live through that in the past year?

Greeting others and the H1N1 flu… What makes sense?

Here is an article to read… kind of interesting. http://www.nytimes.com/2009/09/04/health/views/04greet.html?th&emc=th

Chan suggests we re-examine our cultural behaviors in greeting, given that the H1N1 flu continues to circulate this year. Interpreting the article in this way offers some interesting considerations of how we greet others, and of how this is done in a variety of cultures. I actually do like the idea of considering these common behaviors and how other cultures handle things like greetings and showing respect. Some of the comments are interesting. I do find our culture continues to become more casual and less formal over time. I enjoy many of the effects of that, but having and showing respect for others is also very important to me.

Unfortunately some of the comments take this to a more disturbing level… which to me moves towards a bit of misophobia (fear of germs, thank you phobialist.com!). Of course you might expect individuals with anxiety related to germs to be more apt to comment on an article like this. The rate of confirmed cases of H1N1 in the US is not among the top 10 in the world (see Wikipedia link to data below). Does the rate of H1N1 we see in that table relate to cultural practices and greetings (i.e. Brunei, Australia, and New Zealand have the highest rates)?

I suggest we take a common sense approach to preventing illness…
• Cough or sneeze into your elbow or shoulder, or use a tissue/handkerchief to not disperse your germs
• Wash your hands frequently and particularly at mealtime
• Stay at home if you are sick or have cold/flu symptoms (which of course is a problem for workers if absences are not tolerated)

Stay aware of the ‘facts’ of the flu…
• How prevalent is it in your area at this time?
• What are the symptoms?
• What is the severity?

Try not to get caught up in the media frenzy! This article reports the swine flu has killed about 2000 people worldwide this year, but does not tell us any comparative information. This compares to approximately 36,000 influenza deaths annually and over 226,000 influenza related hospitalizations annually in the US alone! (reference: August 2008 ACIP Recommendations on Prevention and Control of Influenza, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm ). Always check out the facts…

Actually Wikipedia nicely presents what looks like excellent validated data on the H1N1 flu and reports approximately 3,300 deaths have been confirmed worldwide. Check it out: http://en.wikipedia.org/wiki/2009_flu_pandemic_by_country and thank you to whoever is keeping that Wikipedia page going with some good data! The references used here look very good!