In most disasters, the hospitalist’s medical practice will be a departure from the details of daily practice. “Because the majority of hospitalists have internal medicine as their background … they tend to be very detail oriented, which is really their strength,” says Dr. Cantrill. “But in a case like this, they may not have that luxury.”
Another major consideration and “probably the stickiest one,” is altering your standards of care in terms of providing efficiency care or austere care as opposed to what you normally consider appropriate medical care.
What hospitalists will do in any disaster depends on the event—natural, biological, chemical, or use of weaponry—and how your metropolitan or rural area is set up. If it is a biological or bioterrorist event, the pathogen involved may make a difference. Although anthrax is not contagious, for instance, in the event of a large-scale airborne anthrax attack, the need for ventilators will quickly overwhelm resources.2 “That’s one of our largest areas of vulnerability,” says Dr. Cantrill, “whether we’re talking influenza or pneumonic plague, it still is an important factor: How many people can I support?”
The issue of limited ventilators may not be completely soluble, he explains. In ordinary circumstances hospitals can get, say, ventilators from a strategic national stockpile from which equipment can be flown out within 12 hours. Yet if an influenza pandemic breaks out, then the entire country may be involved, rendering that plan inoperable. And even if you have extra ventilators, do you have extra respiratory techs to administer them?
Dr. Cantrill’s institution, with a grant received from HRSA, offers a two-hour course to train people with some medical knowledge to be respiratory assistants who can manage ventilated patients in an emergency.
Injuries may increase exponentially in the case of a disaster. Other needs include vaccinations, treatment for dehydration, serious heat- and cold-related illness, or threats from floodwater (i.e., water laced with toxic chemicals, human waste, fire ants, rats, and snakes).3
Kate Rathbun, MD, MPH, family physician in Baton Rouge, La., is certified in disaster management and knows well the problems that can arise in providing medical care in such an event.4 When Hurricane Katrina hit in 2005, everyone in range of the winds, rain, and destruction, “hunkered down to weather the storm.” The day after the storm, Dr. Rathbun joined other providers and administrators, opened their clinic, and readied themselves to treat trauma and lacerations. It soon became obvious that their biggest health issue was the inability of the displaced to manage their chronic diseases. (Baton Rouge’s normal population of 600,000 exceeded a million within days.)
In cases of diabetes, cardiac disease, HIV infection, or tuberculosis, for example, being without medications might mean lethal disease exacerbations.3 In many cases, patients have no prior history documentation on presentation, and with computers often shut down the provider is faced with prescribing for or actually putting a stock of medications into patients’ hands.
Additional concerns pertain to those who cannot receive hemodialysis or seizure prophylaxis; or disrupted care for those with special needs such as hospice patients, the mentally and physically disabled, the elderly, and individuals in detox programs.
When Dr. Rathbun and her coworkers put a couple of nurses on the phones to handle incoming requests for drugs, she gave them some standards: If it’s for chronic disease medications, prescribe a 30-day supply and three refills (to ensure that 30 days later they would not once again be inundated with calls). When patients requested narcotics or scheduled drugs, they were told they would have to be seen by a provider.