University at Albany Center for Public health Preparedness

Systems or Symptoms? Finding the Right Balance in Preparing for Emergencies

Original satellite broadcast: April 13, 2006

Moderator: Hello and welcome to the University at Albany Center for Public health Preparedness Grand Round Series. I'm Peter Slocum and I'll be your moderator today. Before we begin, I would like to remind you to please take a moment after the broadcast to fill out your evaluation. Your feedback is very important to the development of future programs. I would also like to remind you we'll be taking your questions later in the hour: 800-452-0062. You may also send questions by fax at any time to 518-426-0696. Todays program is entitled Systems or Symptoms? Finding the Right Balance in Preparing for Emergencies. This program is a special collaboration with the New York Consortium for Emergency Preparedness Continuing Education, and is funded by the Health Resources and Services Administration. Our guests today are Dr. Kristine Gebbie, Director of the Center for Health Policy at the Columbia School of Nursing and Dr. Steven Silber, Chairman of the Emergency Preparedness Committees at the New York Methodist Hospital and the New York Presbyterian Healthcare System. Welcome. Systems or symptoms which one is more important?

Dr. Gebbie: It is a balance. There's no perfectly right answer. It isn't either-or. There's a trick in every place of figuring out which balance works for you and for folks with whom you work. We spend a lot of time juggling that. This next kind of little quiz will help explain why we think it is a balance.

Moderator: Let's start our juggling here. Dr. Silber, you have a bit of a quiz to lead us into it?

Dr. Silber: Sure. I thought it would be a good warm-up. So let's go to the first slide. Here we have a popular rash more concentrated on the trunk. What do viewers think this might be? This is rubella. I think most people might recognize that. Moving on, this is a papular, pustular rash - more concentrated on the extremities. What might this be? This is smallpox. Here we have a round lesion on an extremity with a clear center. Has anybody seen this before? This is ringworm. Here we have another round-ish lesion on the extremity, a bit of an aquatic center. This is an anthrax lesion on an extremity. This looks like an X-ray of a patient who came to the emergency department with shortness of breath, cough and fever. Let's go to the next slide. This is another X-ray of another patient who came to the hospital with shortness of breath, cough and fever. The first X-ray was a patient diagnosed with a general run-of-the-mill right lower lobe pneumonia, and the second was of somebody who was subsequently diagnosed with Q fever which is a potential terrorist agent. If I were to see this in my emergency department, I don't think I would have made a diagnosis off the bat of Q fever.

Dr. Gebbie: And that is part of the challenge - many of these things do look alike. But at some point somebody says the word "Emergency. This is an emergency, and the question is what do you do then? Do you run from where you are? Do you stay where you are? Do you know where you should go? Do you know who's in charge, and do you know what your job is when you hear the word "emergency"? That's the every day challenge every hospital, health department and medical practice has to face.

Moderator: It's easy for clinicians to be drawn into these images, isn't it?

Dr. Silber: Absolutely. Clinicians are trained to solve the puzzle, to recognize symptoms, diagnose specific problems, initiate treatment and monitor the patient response. This is something that's inherent to what we have done for a living.

Moderator: These images are sexy; that's what people--

Dr. Silber: Sure. When you see something unusual like we saw in the initial slides, you know, they're new, unusual, and potentially lethal. It's sexy to think you might be the first clinician to diagnose the index case of a bioterrorist event, although it's not likely at all.

Moderator: Thats why we spend time training people on symptoms.

Dr. Gebbie: Right - we do its also an easy kind of training. One hates to say that because it's a fairly high level of training, but teaching about symptoms is very straightforward. You can lay out content knowledge. Its very didactic. You can get from the beginning to the end. You can test whether people learned it. You can do it in self-study modules, in groups, at home, independently, and there usually is - in the end - a right answer. For each of those slides, even those two X-rays that initially look somewhat similar, there's a right answer - and that makes the training much more straightforward.

Moderator: But ultimately, there's a problem basing our response just on symptoms.

Dr. Gebbie: There is, and part of the problem is illustrated in this next slide which shows you the beginnings of how many things you might have to know if you were going to depend simply on symptomatic training to get you from here to there.

Dr. Silber: In addition, once a diagnosis is made, however it is made, there has to be a system for verification and subsequent response. I'll give you an example of sort of how we think. I was at a HRSA education meeting in October and there were about 100 people in the room and everybody's developing their own educational training models. And I said, "How many people in this room work in a hospital?" About 90 out of 100 raised their hand. If there was an incident in your hospital at this point, how many would know exactly what to do? About five people raised their hand. Thats why it shouldnt be simply symptoms-driven. Its why you really need to develop a system.

Moderator: That slide was just the A's and Bs of the CDC catalog of all the diseases and conditions

Dr. Gebbie: -- that are considered potentially important and all the chemicals that might be used in a chemical event.

Dr. Silber: If you spend all your time learning that, you'll never learn how to respond. That's the system vs. symptoms issue.

Moderator: So let's talk about what happens when we take the symptoms approach as opposed to the systems approach.

Dr. Gebbie: It immediately gets complicated at that point. Symptoms are themselves complicated. They involve many different roles, many different disciplines. The absolutely right answer is rare because it's a dynamic process that changes on the ground. The goals and outcomes have to be re-specified as you move along. As you're working in systems, you find conflicts between what Person A wants to do and Person B wants to do or what Office A wants to do and Office B wants to do, so those conflicts have to be resolved, and the usual hierarchy based on letters after your name or typical job assignments do not apply. So people who are very comfortable with their day-to-day roles that they learned from when they first went to dental school, nursing school, medical school, have to relearn some different roles and it can be very hard to teach them that.

Dr. Silber: Its also culturally difficult to change your role from being the person in charge to being the person within the system. In the Incident Command System, you'll find when it's first being taught that the physicians always want to run the show, but they're not used to being system-driven. The nurses are better used to being systems-driven, so the best person to be in charge in a hospital is the nursing vice-president.

Dr. Gebbie: And that may surprise a number of people. The other piece of this is, while the system itself may be complicated, the individual jobs or roles may not be. The individual roles can be laid out very clearly for what you should do, so that if your job is keep operations running or if your job is get these patients into beds or whatever it is, you can take actually roles within systems that have widespread applicability and use them over and over again in a way that resolves some of those conflicts we talked about earlier.

Dr. Silber: One of the keys really is to actually practice your roles, because just learning the roles on paper doesn't really get you to where you need to be and the goal is to have the best chance of success. Practice is the way to go.

Moderator: Especially if you're asking people to adopt different roles than they usually adopt. And it's particularly complicated because you're working in a hospital system already and the connection between the operating team is laid out according to that function. But talking about emergency response, those people might play very different roles in response to one another.

Dr. Silber: We try to keep the roles as functional and relative to the usual role as possible, but that's not always what's necessary in the disaster.

Moderator: Right.

Dr. Gebbie: And even if the role may be somewhat the same, they may be reporting to a different person, so instead of being able to just say, "Hey, Harry, what do I do?" They have to remember to say, "Mr. Unit Leader, what do I do now? Where do we go?" Mr. Unit Leader is not somebody they have seen before or somebody they met once at a meeting and that process becomes very difficult to learn if you don't practice it.

Moderator: Let's back up for a minute. Give us a basic definition of systems as you're applying it here, the old dictionary technique.

Dr. Gebbie: We'll flash that for people to see because a system can be organized or disorganized, but certainly a connected group of objects. It takes more than one thing to be a system. There have to be relationships. We use it in natural settings and also organizational settings. And in this response, the last definition on the screen is the one that we're most comfortable with: an organized scheme or plan of action, one that gets you from here to there in a very straightforward and sensible way.

Moderator: and the interdependency of these systems is really the key to making it function effectively?

Dr. Gebbie: Exactly - because every one piece has an effect on the other. You can think of various games or artworks that are a bunch of interconnected wheels and all you do is move the little one over here and suddenly something is happening on the other side of the board or the other side of the room, and that's really what we're talking about. If you don't acknowledge that the system is interrelated and that the pieces affect the other, then you aren't able to understand why it's so important that you do what you're assigned to do when you are assigned to do it and not keep wondering about it.

Dr. Silber: Its really all about teamwork in order to be a successful response plan. You have to have teamwork. Everybody needs to rely on the other person. Everybody needs to know what the other person's role, relative to theirs are, and it's what makes things move forward in a successful, organized manner.

Moderator: Would you say that some of the disasters we have seen in the last decade or so, both natural and man-made, would they help underscore that point?

Dr. Gebbie: Absolutely. The list is almost endless.

Dr. Silber: And being in New York during 9/11, there were a number of issues that I think a lot of people are aware of already, but the pre-hospital response was not coordinated. That caused a tremendous amount of traffic difficulties. There wasn't a unified command structure between the police department and fire department. And there were large communications gaps that were very potentially dangerous during that, as well. There were individuals without any expertise who responded and set up rescue stations that added to the confusion and congestion and, you know, there could have been potentially secondary injured and casualties. New York Downtown Hospital, actually had just trained an Incident Command just prior to that. A friend of mine is their emergency department chairman, and said they were very well prepared, even though they're the epicenter and a very small hospital. Another friend of mine in New Orleans is an administrator of a small hospital at Jefferson Parrish where they were never trained in Incident Command and there was a tremendous amount of confusion there, as well. On 9/11, I drove past the Trade Center to get to my Institution. I knew I had to be at the Command center and I was the best person for the role at that time. I think that's very important.

Moderator: So fulfilling that role that you're assigned in an emergency response as opposed to freelancing.

Dr. Gebbie: If you're trained in a clinical role, that temptation to help is very, very great. But through all of these events -- whether anthrax or SARS or hurricanes or tornados -- the list goes on and on -- there are key elements that we have learned to consider that crop up in every after-action report as what you've got to worry about. It starts with communication - knowing how to communicate, with whom you communicate what mechanisms to use. Understanding coordination both how to coordinate resources within an institution, taking the right stuff where you need it, but internally to make sure your institution is in the right place in relationship to other places. In the case of emergencies, often the nearest place isn't where you need to be. It is farther away as a backup or in some other location. And then there's a question of staffing -- whether it's too many staff at the beginning and then nobody left to take over the second shift, or too many staff in the wrong place, too many specialists without the support staff they need. All of those issues keep coming up over and over again. And the use of a systems approach - careful, thoughtful use of a system gets you to a system of basic order where things happen as they should. Where not only are you doing what you need to do, but you're doing it in such a way that the workers are safe. We have far too many incidents where the people responding ended up needing care - exposed, ill, needing care when they should have been able to help. It means the leadership doesn't quite know what they're pulling together, how theyre supposed to be making it work so that you aren't getting people connected to the right resources at the right time.

Dr. Silber: I think the word "connectivity" is actually the most important word that you mentioned. Everybody needs to be connected. Everybody needs to know what their role is in the bigger picture. What if all the staff from an emergency department went to the scene of a major accident, and meantime, the patients were taken to hospital while everybody was on the scene. So the connectivity is so important because this is how it will work correctly.

Moderator: And a worker being exposed and potentially threatening him or herself - puts that person in peril and it disables the system from being able to take care of the victim in the first place.

Dr. Silber: That's both a personnel issue - about somebody going where they don't belong, and a systems issue about possibly not having a safe environment for the workers. It has to be approached from both levels.

Moderator: When we talk about those systems, what organizations or types of institutions are involved?

Dr. Gebbie: Well, we're talking about health care workers, and the fact is they're everywhere. It's easy to think of hospitals and public health departments, but there are people out in private practice gathered all across our communities. And we're talking here not only about physicians and nurses, but dentists and mental health workers, the whole range of people who are out there. Some of them work in community health centers and social outreach centers where there may be only one or two health providers. If you think of school nurses embedded in our schools across the country, and then a whole range in business and industry doing occupational health and safety. Our concern collectively is that all of these resources be well used and none of them wasted because they may be urgent to the response.

Dr. Silber: In addition, you know, they could be considered resources, but they're much fractionated. Theyre people outside of the health environment and non-hospital-based workers and physicians, clinicians -- theyre all over the place. Some actually feel an obligation to respond; others don't. You have to build them into the system using the ones who want to respond, given that their time is very precious. Theyre busy practitioners on the outside, so we really need to make an effort to make their training as efficient as possible - if they would like to participate.

Moderator: And these are difficult people to reach with that training, right?

Dr. Gebbie: They don't hold still. They also need a great deal of training about a lot of things because health care knowledge is always changing, and you need updates to stay on top of things. You need to use your precious time for training very carefully. If you're the manager of a system - a hospital for example - any time you release staff for training, that's lost income. So you have to be careful how you balance those pieces. Depending on the leadership of an organization, the supervisors and leaders, you find varying support for continuing education. Some people think it's your entire problem, "Well, you're a doctor - you should get the training you need." Others say, "You work for me and I want you to know and I want to build it in." Perhaps most important is the issue of competing time. If I'm running a cardiac intensive care unit --which means I have physicians and nurses and respiratory therapists and others all working there -- and I have only this much money for training this year and there are three new drugs that are great for intensive care, four new kinds of machines for improving respiratory functions and a new sequence of doing testing -- am I going to spend my training money on teaching them about Q fever and anthrax or am I going to make sure they are trained for what they will definitely see every day of every week?

Moderator: It's a direct healthcare issue, but also a billable hours' issue, because you're increasing your ability to return on your investment.

Dr. Gebbie: Sure, to get people successfully through your intensive care unit in a short time and get them to a less-expensive unit. It's easy from a purest health viewpoint to dismiss the money, but we run on that and have to take it into account.

Dr. Silber: Again, to incorporate all the people who aren't hospital-based - who want to respond - into a response environment, a lot of that will be reporting to the hospital. So the hospital not only has to train their own people for a successful response, but they have to train people who want to volunteer. That's very time-consuming, very difficult to coordinate and perform.

Dr. Gebbie: Yeah. If Dr. Jones usually comes on Monday mornings at 9 o'clock for quick rounds and maybe comes back twice a week, and the rest of the time is at her office, when do you train her? Where do you catch her for that?

Moderator: That's why once you've got them, using that time effectively is critical, right?

Dr. Gebbie: Absolutely critical. There are important things about training and retention time. Because just hearing something once doesn't mean you learn it, even if you think you have very high retention. We've done a little checking on what research says, that if you learn it once, if it's not reinforced within very few minutes with a reminder of "do you remember, we just talked about this", a day later a chance to repeat it, and then a month later, a chance to go back over it and repractice it, the odds are you're not going to retain it and use it. I can think of all those people who watched the CDC downlink on cutaneous and respiratory anthrax in 2001, and I'm willing to guess that a sizable percentage of them no longer retain the clinical details they heard. They might recognize the slide of cutaneous anthrax because its fairly distinctive, but its the whats next? It goes with the fact that much of this isn't perceived as being relevant or as having a reward structure to go through it, that you don't need to spend as much time on it because who cares. People are driving you to get through all your patient care today. They don't want to know that you can demonstrate five quick ways to evacuate an entire unit. All those things complicate the process.

Dr. Silber: In addition, it's easier to do just-in-time training for different diseases, as was evidence in 2001. Everybody and their sister knew how to diagnose and treat anthrax within minutes. But to coordinate a system and practice a system where you now have diagnosed the illness and really have to respond - that's much more difficult.

Dr. Gebbie: The organizational support, the whole setup policies are those things that have to be in place for well-designed training, and can really vary by the kind of hazard you're thinking about and how people would respond to them. That's why taking what we call the all-hazards approach that continually teaches and redrills the system for any kind of emergency has more on-going day-to-day relevance for the response. As far as response than some of the training you can do for more the specialized agents, the biologic agents and so on, about which you will not practice very often, but for which you need to use the same system -- the very same system that you used for the natural hazard.

Moderator: We have a chart that tries to lay out some difficulties and responses to the preparation.

Dr. Gebbie: Right. I think it comes up now. To see that if you have done this training that has a very high probability of not just of being very easy to train, but to use the system will become sort of embedded in your bones, and you will then be able to take the just-in-time training and slide it into that systemic training much more readily.

Moderator: In other words, the factual set that fits your particular crisis and slides into the system and allows the response.

Dr. Silber: And the system, being an all-hazards approach, is basically the major framework. And then you have the nuances, depending on what the event is...

Moderator: You talked before about the importance of practice which allows you to meet the people you'll be interacting with during this emergency. And they all joke about exchanging business cards for the first time in the middle of a crisis which is not the optimal way to operate.

Dr. Gebbie: Absolutely not. That holds true for people who will be representing, say, your hospital with the central emergency management. They need to know who those folks downtown are. But for the people within the hospital to know who in the other departments they might need to work with but because it does require a shifting from every day systems to the more specialized emergency systems.

Moderator: Why is that? Everybody has a system that they operate in now.

Dr. Silber: There are a couple of reasons. First, one of the things that we were talking about - it's not really a person talking to a person, but a role talking to a role. An event can happen any time of day or night, and the people who are usually in that role may not be there so, somebody has to step in. It's very important in the structure that we have a single language that everybody can communicate with. When we talk about the systems, again, we're balancing what people do on a day-to-day basis and transitioning that to an emergency situation and that can be very, very drastic. As you can see from the slide here, on an every day basis, we have informal roles, some consensus decision-making - agency specific. Whereas, during an emergency, when we move toward the emergency, it becomes much more structured in order to be successful. It's command-and-control, very incident-specific. There are functional roles, interoperable. It's very important to move into those roles of an emergency very quickly. That's why people need to be trained and systems need to be built and monitored in advance.

Dr. Gebbie: Yes, and it moves gradually that way. You can see the arrow across the bottom. There are small-scale emergencies that don't require turning out everybody in the system. But if you start to think that way, you know which pieces to activate. There are some systems that are particularly critical in the face of an emergency - starting with the people, starting with the work force that they know. What to do, that they have met the important people. That you know not just that Dr. Silber is usually the Incident Commander, but here are the four other people that could take that role if Dr. Silber isn't there. So you've got your information systems. You know where to go to look up Q fever or anthrax or radiation exposure. You know the phone numbers to call or the buttons to push or do a mass fax to everybody, or so you can connect with the epidemiology people, that you know your lab operates within a laboratory network, that you have written it all out as a policy and evaluated it. You come back afterwards and say, "Now how did it go? Oh, we forgot to write that down." Or "We thought we would do it this way, but we'll do it another way." This makes the preparedness for response work well, so when you have to use it, it comes almost as second nature.

Dr. Silber: One of the major portions of this training in preparation to a real event is a communications issue. Having worked in the command center and emergency department, there's a real disconnect between different areas and you almost develop an animosity. The workers on the frontline are saying, "The people in the command center aren't really paying attention to us." And the people in the command center are saying, "The people in the emergency department aren't giving us information." So to have a system and to practice against and mitigate against this happening during the next drill or event will make the response much less anxiety-provoking and much more able to concentrate on the needs at hand.

Moderator: And of course the communication is not just inside the system, but to the public at large in most of these emergencies.

Dr. Silber: Exactly. There have always been rumors flashing around about the hospitals and department of health or others giving different reports. The goal here is a unified message to decrease chaos and confusion. Also frequently updated messages to the people who are working, so they feel they are connected to the bigger system.

Moderator: What do we get from having well-planned and well-executed exercises?

Dr. Gebbie: We have already started talking about it. I can think back to when we first starting the kind of resuscitation we now do in hospitals, which is now almost second nature, because every doctor and nurse learned it when they were students. They fall into a routine and know how to do it. That's what we're aiming for at a system level with emergencies. That you hear the word "emergency" and very efficiently we use only the resources we need, but all the resources we need so that if a hospital knows its clear assignment of roles, all routine housekeeping stops, and the housekeepers become runners with the exception of a small, trained unit -- and you don't have to look for them later on. You have the communication channels - you know this is the magic phone number from the emergency department to the command center. It's your number and only yours and you can get things done. And you have a way to resolve conflict. So when the outside person comes charging in to say, "I'm a pulmonary specialist and I can solve all your problems," there's a way to say "Thank you. We have a nice room for you to sit in. Wait a bit and we'll be able to incorporate your knowledge."

Dr. Silber: That's the micro level. At the macro level - when we run drills and have to prepare, which is the agency in charge? If it's an interstate event, then what happens? Which governor -- who do they talk to? In drills, I think it was Dark Winter a number of years ago, they found all these issues came to the forefront and need to be addressed in advance. Otherwise, there will be inconsistent messages and people won't know what to do and that adds to the chaos, confusion and the ability to respond appropriately.

Dr. Gebbie: Some of that will happen anyway. We can't control what governors will fight about during an emergency. But if the health system falls into place together, they'll do what they need to do to protect the people in their jurisdiction or hospital. Let that fight go on without feeling compelled to get into the middle of it - just to go forward. That's why we have the kinds of response systems we have - which are bigger than hospitals and bigger than health departments. And that's the overall national incident response system.

Moderator: Right, the incident command and response system, right?

Dr. Gebbie: Exactly. The formal declaration for the country is as a whole that we do have this national network that expects every organization and every jurisdiction to master what the Incident Command System is and how it works. And that becomes the governing, if you will, macro-system, within which we have the systems for person-to-person communication for those who need to talk. If I'm going to hand a patient over - this is who I talk to. Why we have the increasingly effective laboratory network of knowing which kind of specimens go to which laboratory, with a chain of custody and all of those things. And then the wonderful Regional Alert Response Networks... I live in New York City, am on the network, and routinely get nice little emails that tell me what - as a health professional - I need to be watching for. All of those systems come together to make it work, and we need them desperately.

Moderator: What happens when someone doesn't work within one of these systems?

Dr. Silber: I think we have already discussed freelancers where people go to a scene when they should be in the emergency department. People are counted on to perform a role within the command structure and they don't do it - which leaves a gap. An example I actually find amusing is how we're training in chemical drills over and over again, and one of our hospital administrators would always show up to the emergency department and we'd kill her every drill. It took four drills for her to realize you do not belong here. You're a vital cog in the Incident Command Center and that's where you should be.

Moderator: You're not helping here.

Dr. Silber: Youve become a casualty and now we have to take care of you.

Dr. Gebbie: That's a problem. With uncoordinated resources, you get people who add a burden to the system instead of a benefit. You get uncertainty because others say, "Who is this? Why are they here? What am I supposed to do with this person?" They divert people from what theyre supposed to be doing. Theyre often uninformed - operating from what they heard on the radio - and it disrupts the whole team.

Moderator: Sometimes if the administrator shows up, people start deferring to her or him, which is totally inappropriate for the command structure going on in the emergency.

Dr. Gebbie: Exactly. I have worked with a situation where the director of the agency named an incident commander and then sat next to the incident commander all day. Who do you talk to? What do you expect? If you have named one, get out of the way and let that person do their job.

Dr. Silber: That's at the upper level. If you have people responding, going somewhere that they're unauthorized or don't have expertise in because they think it's the right thing to do or might be fun - they're getting in the way, causing confusion and really not helping the situation.

Dr. Gebbie: Yes. And it's perhaps particularly important for those people who do have real technical expertise. We do have people in our country who, by virtue of their past military experience or laboratory work or sheer brilliance in a particular area really are the experts. But what we need those people to do is not to say "Im the expert" and wait to pop up and use it, but to come into the system and make sure the hospital they work with or the health department in whose jurisdiction they live know theyre there and can plan for, "Okay, if we have this kind of event, you're who I call. Here's where I want you to go and how you're going to help me." That will make all the difference to really know the rules of where you fit in.

Dr. Silber: Also on that slide - you know if you have the expertise, but don't know where to go or who to report to, what good is your expertise?

Dr. Gebbie: That's where you end up on CNN saying, "I know a lot about this, but nobody asked me." Because nobody knew where you were when you started.

Moderator: You don't want the cavalry riding over the hill, but you want the experts there from the beginning. Now, who should focus on the details of the symptoms and who should practice the foundational systems work?

Dr. Gebbie: Everybody needs a bit of both. The answer depends on where you are, what you do within the day-to-day world. Some good examples are the people who really need the detailed clinical training.

Dr. Silber: I think the emergency responders, the people on the front line - they don't have to live and die by these symptoms. But they need to have a high index of suspicion, because these might be the people who pick up a new event. Again, it is a balance. I think everybody should have a baseline, as well. One reason to have a baseline on symptomatology - it will decrease your anxiety. You feel more comfortable knowing there's a response plan behind it. Given time is such a premium; the first responders need to concentrate on a systems approach - where they should go. But they also need a little background, because the just-in-time treatment of symptoms is more effective than just-in-time systems. So it's sorting out what you really need to know from what's nice to know and thinking through where you are. If you primarily work within a hospital, not the emergency department - you're back a layer; then the system is probably far more important to you than the symptoms. If you work in a solo office in the community where you get a lot of random "Gee, I don't feel good" phone calls, then you probably need a pretty good 50/50, because you might be at least detecting the odd. You then need to know where to go with it, who to talk to and what to do next.

Moderator: What do we keep in mind about training these individuals on symptoms?

Dr. Silber: Well, one, that just-in-time training is very easy, but also something you would like a background on first. The clinicians are the people who will be recognizing these symptoms. They should see slides about them. They like to see slides about them. It keeps them interested in what's going on. It might make them feel it's more important to learn the system behind it. It can be practiced independently on a need-to-know basis. A lot of people want to know more if they have the time to learn more. But I think it's very important, like I said during the anthrax event in 2001, to realize you don't have to know everything about everything right away when it comes to symptoms. There's lots of just-in-time training and it's very effective.

Dr. Gebbie: It was a matter of days before we had huge downloaded broadcasts from the CDC and all kinds of direct training there. Advanced training can be very, very useful for some people. People who work in laboratories absolutely need to know all of these agents, where to find the techniques, to know their laboratory has the right kind of reagents. They really need very detailed training. There are also some key central hubs. Aside from any emergency department, major resource hospitals like this state have set up regional resource hospitals and everybody expects them to really have a lot of expertise. We have our local health departments, the CDC, the state department of health, the larger local health departments that have a great deal of expertise. And they review all kinds of materials to make sure nothing got missed. Then there's the last group on the slide here. We know there are people who just want to know. Good for them.

Dr. Silber: Exactly, good for them.

Moderator: As long as you can plug them in effectively when the time comes for them to respond.

Dr. Silber: As long as they're not learning all of these symptoms and treatment at the exclusion of how they would respond in an incident in the system.

Dr. Gebbie: And at the exclusion of being able to take care of the kind of ordinary things that cross their path every day.

Dr. Silber: I wouldn't want to go to every doctor who diagnosed every rash as smallpox.

Dr. Gebbie: No! There are people, who are not just highly motivated learners, but people who I joke are disaster-prone; who get a real adrenaline rush out of being able to respond. Some have chosen to work in emergency departments where they get some of this every day. But there are other real opportunities for those who enjoy being really connected in their community with the ability to respond - the Disaster Medical Assistance Teams (DMAT) organized across the country, and there are several from New York State. They are always looking for additional people because when they are activated, it means leaving your job for several days at a time or several weeks at a time, and they need a wide range of resources to do that well. The nice thing about those teams is they are part of a system and they practice and drill their assigned roles and equipment. So they can function and really work together as a team. Every DMAT in the country ended up in Katrina and Rita. There are international response agencies. The international situation is just as crazy as the domestic one. I have a friend in the area who says, "Folks show up thinking they're going to get to do brain surgery under a palm tree after a tsunami." The answer is no... Locally now there are Medical Reserve Corps that are being created all across the country for practitioners to volunteer with a local hospital or health department to be called upon for local kinds of events. And lastly, the Military Reserve is always looking for health professionals to be part of those response units, as well. So there are lots of chances if you like doing this kind of thing.

Moderator: But again, you don't want people to go too far with this, right?

Dr. Silber: No. If you overcompensate on symptoms training, it can be a mistake from a macro and micro level. If you're an individual practitioner and continue to harp on learning this, there's a chance you're not using your time efficiently. When an event happens, because you may have so much knowledge, then, you may want to overstep your responsibility within the system. And also on the macro level, it's easier to train people toward symptoms because it's just something that's more inherent in training. And we need to get people who are training on the macro-level also to pay more attention to systems training than symptoms training.

Dr. Gebbie: Yes, and to look at the systems at all levels. How to connect every town with every other town within a state; within each town how to connect the hospitals, police, and fire. Again, this is going on now, but then within the health sector, how to connect the hospitals, the health department and all those individual offices and clinics, and so on across town. There are ways to think about that for any kind of emergency. We're up here in a blizzard belt. Parts of New York are in hurricane alley. We have heat waves in the summer. All of those provide opportunities to practice single parts of this whole system. And, to be very honest, not only practice it in events, but meet some regulatory requirements. Hospitals now have to do this. Health departments are now starting to expect it as a matter of routine, so why not use it all the time, learn it well, make it an ingrained part of your activity.

Moderator: So these are the take-home messages: that there are all kinds of events, large and small, natural, man-made, that applies to the systems piece.

Dr. Silber: Thats important, because people think all these Incident Command or training exercises are all related only to bioterrorism or chemical terrorism, but there are every day events: chemical spills, large fires, explosions. If you train in an all-hazards approach and train for what the hazard vulnerability is in your area, if something else happens beyond a natural disaster or explosion or maybe a terrorist attempt, you'll be prepared for it.

Dr. Gebbie: And for the clinicians, the injuries caused by a terrorist explosion or coincidental traffic-related explosion are still the same injuries. The system to make sure those people get to the hospital and get treated is still the same system. There are some other things about evidence and public anxiety that need to be dealt with, but at a very basic level, the same system falls into play.

Dr. Silber: Also, the injury patterns may not be all that important for the secondary responders. Their goal is - I need to get where I need to because I am a resource that can be utilized in a number of ways. And I need to get there, find out where they need to deploy me and I can use my expertise in that area.

Moderator: We touched on the importance of exercises before, but I want you to address that. These are important, but also time-consuming and costly.

Dr. Gebbie: They are. That's a concern. Again, emergency departments, fire departments do practice all the time, either practice or just keep responding to events; that's their life. We know that classroom isn't sufficient for somebody to say, "Stop doing what Im doing. Minimize the number of people coming into my office. Get ready to close down and go to the hospital and help out." Or whatever it is they're supposed to do. And if you haven't actually done it, the first time you have to do it is going to be awkward. If the first time you have to do it is in the middle of a huge emergency where they need all the people at the hospital, it's going to be difficult. So we really encourage folks to find ways to engage this wide range of clinicians in the process. So they have had at least a little bit of practice, not just a classroom event, before something happens.

Moderator: The NIMS system is something that many people in the field, and Im sure our audience today is aware of. How do we incorporate that into our training at the local level?

Dr. Gebbie: Well, everything we have been saying is, in fact, derived out of NIMS. NIMS is more a philosophy than a system. Its the principles behind the commitment we have made nationally to use an Incident Command System when there is an event. As you can see, there's a direction that everybody must complete the training. But what level of training and how many hours they need to spend on it? If you're going to be the person who represents your hospital at the city planning desk, then you really need to know a lot about NIMS and a lot about the whole broad national connectivity, because you've got to make sure your hospital connects.

Moderator: Right.

Dr. Silber: But if you're the actual responder for your institution, it's important that you know that there is some overall structural system, so that you can have confidence that there are things going on at a higher level. But you really need to know your individual role at your individual institution, so that your response will be successful at your level.

Dr. Gebbie: Yeah, being able to recite Presidential directives about NIMS doesn't work if you're standing in the driveway saying "Where do I go?" And that's one of our concerns - making sure this comes home to where a person fits within the local system.

Moderator: You need to know there's a system and you can have confidence in it, but your role is not to discuss the founding Fathers--

Dr. Silber: Youre not going to be calling the governor. Youll talk to your supervisor.

Dr. Gebbie: I reviewed some materials that were being prepared and did a lot of scratches and edits when it suggested that the individual nurse in the hospital might be the one who called the FBI. No, I don't think so. If the nurse is suspicious it is a crime, there are ways to deal with that. And that's what the nurse needs to learn. But you don't want 15 people each calling several different places because they saw it on a NIMS chart.

Dr. Silber: And if time is precious, you want to train them on what theyll most likely do, not what the exact wording of a Presidential directive is.

Moderator: You want to know the nurse can communicate the information to somebody who has the FBI number.

Dr. Gebbie: Exactly, and somebody who can filter for what the FBI needs. Thats what a good emergency system will do.

Moderator: What does it look like, in your mind?

Dr. Gebbie: From a clinicians' point of view, it respects clinical judgment. It has built in it a way to get access to the clinical expertise that you need that's laid out so clearly that the doc who only comes to the hospital once a month knows "If they asked me to come, this person can tell me what I need to know." And you have built into the system an update capacity. You have a unit, the clinical just-in-time training unit, and are respectful of the fact that people will remember some of the stuff, not treat them as ninnies. But you provide the updates in a way that they can quickly put it into use.

Moderator: You mentioned earlier that systems training is complex, time-consuming, has personality conflicts. How do you convince other people to take on the challenge?

Dr. Gebbie: It takes some advocacy and leadership. It takes people who can grasp this balancing game and these pieces to stand up and describe it. And to also be very clear in the exercises they do how these two pieces have come together. And to lay out, yes, it's true, that person made a clinical judgment error, but lets look behind. Did we give them what they needed? Did we provide them what they needed to have? Did they own what was going on so they could see how the people come together here to make it work? If the evaluation is kept secret-- we don't want to let on that somebody did badly, youve added to the problem rather than learning from the event. Also, since most practitioners are not obligated to respond - if you want people to respond, you have to make them perceive that it's important they respond; that they are an integral cog in the response system and that the environment they respond to is also safe. It also has to be interesting because they won't come to non-interesting training even if they want to respond.

Dr. Gebbie: Yes. So when training clinicians, you have to get enough clinical detail in there that you can see it applies to them. You just go on and on about management roles and they'll say they chose not to be managers - they want to be clinicians.

Moderator: So you need to focus on the things they need to know and do for their role.

Dr. Gebbie: Be honest with them: "We're going to go over this today. We don't expect that you would be able to independently manage a patient with this disease tomorrow or six weeks from now, but you would have the basics so if we needed to turn to you, we could get there."

Moderator: Let me remind viewers we'll take your questions in a few minutes: 800-452-0062. You may send written questions by fax to 518-426-0696. I have a couple already by fax I'll get to in a moment. First let me ask you, you obviously don't work in isolation in preparing people for this. Can you talk a little bit about some of the associations which are focusing on training?

Dr. Gebbie: Well, we are one example of the nationwide network of training resources that have been developed in the last few years. The New York State Consortium for Emergency Preparedness Continuing Education involves several universities across the state, expertise from hospitals, from health departments, working with a wide range of professionals. We're very grateful that we have this kind of support here, as do most states. To give you another example of what we have available within that, we have a specific set of courses that were designed for this secondary set of responders. Not the emergency room, not the EMTs but the doctors and nurses in the hospital who would be called on to make it work in a bad event. Again, we show you this one as one example of the kind of thing that's available across the country in many formats and we would encourage folks to take advantage of those out there.

Moderator: And people viewing have these slides so they can pick up the website themselves. Now, we're ready to take your calls. The toll-free number is again 800-452-0662. The fax number is 518-426-0696. Let me go to a couple of these fax questions that came in. Here's one from Iowa. How can we support the development and practicing of emergency response systems like ICS at the higher policy level, both nationally and within an institution? In other words, get the leadership involved?

Dr. Gebbie: Well, we joke within the system that where it says Dr. Silber chairs the Emergency Preparedness Committee, they ought to make a system rule that no hospital administrator can be assigned a role within the system unless they have taken the course. We haven't gotten very far with that. It will take a collective community message to people in leadership roles that just being a good leader in ordinary times doesn't automatically make you an emergency leader. Maybe we need to engage them in a couple of drills so theyll stumble - that's one way they learn.

Dr. Silber: I agree with you.

Moderator: Do you think there's a commitment to the systems training at the national policy level?

Dr. Gebbie: There certainly is a lot of verbiage about it, and the commitment to NIMS has come very clearly to "ICS has to happen." The gap would appear to be that people at the national level are paying more attention to what we're teaching at the local level than practicing their own roles.

Moderator: I see.

Dr. Gebbie: Its easy to get into that trap when you're responsible for a training program. I think we all need to look upward at the folks that are funding and say, "Have you practiced lately? What are you doing?" Ask them the pop-quiz questions of what they would do if an emergency started.

Moderator: We saw the glaring spotlight during Katrina of the importance of everyone understanding roles. And the communications issues that were also a big mess. Here's a question from Vermont: How do you evaluate the readiness of a system and how do you measure its level of preparedness? And then what that system needs to focus on to get ready, to get better prepared?

Dr. Gebbie: The only way you can evaluate it is to try it. That's where the drills and exercises become very important. I think people forget to break the drills and exercises down into manageable components. You can practice the pieces of an emergency response much more efficiently than you can practice - imagine your whole city blew up and what you were going to do about it. So a hospital can practice their turnout drill. How do we get everybody here within 20 minutes? Just practice that. As soon as they're there, send them home again. Don't keep them for four hours.

Dr. Silber: Region-wide communications drills. Communication is always the number one issue in a response. A communications drill, a distribution drill of patients, you know, and how many patients would you be able to handle today? So everybody at the higher level can see where people might go. And at the institutional level, they may see what they may need to receive so they can prepare for those contingencies. Mostly you would want to prepare for contingencies that you can manage first before you start ramping it up. So smaller drills or tabletop drills, in general, just to get the logistics down. And then, you know actual focused drills on certain aspects with patients or just focus drills within the hospital... Then you can go to the bigger drill with the bigger search capacity.

Dr. Gebbie: And then the feedback has to go back to everybody. I mentioned this earlier. It doesn't do any good to do it and have an evaluator write down "Half the people didn't show up and half the people went to the wrong room." But if that doesn't get back to all those people. "You went to the wrong room, so next time do it this way..."

Dr. Silber: Thats interesting, because theres a new joint commission requirement for hospitals - that there's a critique of the drill and then a correction of the problems for the next drill. And that has to be documented. So that actually puts the institutions a little more at risk - that they should be doing the critique and then the correction.

Dr. Gebbie: Yeah, and actually in our trainings, we try to alert people by saying "If you hear somebody say, "that's what went wrong the last time," then you know you didn't do the right thing in between the two drills.

Moderator: A couple of questions just came in, one from Missouri for Dr. Silber. How do you resolve some of the conflicts that occur when you're laying out your Incident Command System or structure and how do you get all those people to play nice and come to the drill? We have about half a minute for you to answer that, Im sorry.

Dr. Silber: The simple thing is you have to put everybody in a room first and run the drill. And you will find that people will think they have an area of expertise, but they don't have an area of expertise and they're better focused doing something else. Usually people will gravitate after a little bit of ego fighting. They'll gravitate to the right position. Logistics is logistics and thats usually facilities, and organization is best run by nursing and medical by medical. People will fall into the right categories. You might have to have some -- you know not well-run drills originally, but eventually it will smooth itself out.

Moderator: Thank you both very much for the very informative hour. It went by rather quickly. I think our audience got a lot out of it. I want to thank all of you out there for tuning in. I'm afraid that's all the time we have today. We would like to ask you all to take a moment to fill out your evaluation online. Your feedback is very important in developing our programs in the future. This program will be available via web streaming within a week. Please check our website for details. We hope you'll join us next month for Ethical Hazards in Pandemic Flu Planning and Response with Dr. Harvey Kayman from the University of South Carolina Center for Public Health Preparedness. I'm Peter Slocum and we'll see you next time on the University at Albany Center for Public Health Preparedness Grand Round series. Thank you.