- The Washington Times - Tuesday, September 17, 2002

Tommy Thompson, secretary of Health and Human Services, recently assured Americans they are much safer from a bioterrorism attack than they were a year ago, saying that training of hospital emergency responders is the "centerpiece" of his efforts.

His intentions are well-placed, and emergency physicians are dedicated to the safety of our patients and to being prepared for medical emergencies. However, the nation still does not have a training program for emergency physicians and nurses to detect and treat biologic agents. This is especially troubling when, as we witnessed on September 11 and during the anthrax attacks last fall, the place people most likely will go after a biologic, chemical or nuclear attack is a local emergency department.

Billions of federal dollars have been spent to improve the nation's response to terrorism, including creation of a new department to coordinate activities. Yet, not one dollar has been designated by the federal government for a program to train emergency physicians and nurses to detect and treat biologic agents.

This is because there are serious flaws in our understanding of what is needed to effectively respond to medical emergencies from biologic agents. Part of the problem may be that many of the nation's policy-makers still do not recognize the role of emergency physicians and nurses in disasters.

Clearly, emergency physicians and nurses have joined prehospital providers as first responders, especially in biologic attacks. This was demonstrated when nine of the 11 recent inhalation anthrax patients became seriously ill and drove themselves bypassing EMS or other first responders to an emergency department where they were diagnosed and treated.

Quick detection and treatment as well as quarantine of patients infected with highly contagious agents such as smallpox clearly will be essential to preventing mass casualties. Yet most emergency physicians and nurses are not currently trained to detect and treat biologic agents or even to protect themselves. Bioterrorism training has not been incorporated into the curriculum for medical students and residents, and the nation's 35,000 emergency physicians are not receiving regular training through their annual continuing medical education courses.

To save lives in a bioterrorist attack, emergency physicians and nurses must be trained to detect, triage and treat biologic agents, including those that are weaponized and act differently from those occurring in nature. The difference between life and death for the recent victims of inhalation anthrax was the length of time between the onset of symptoms and the diagnosis and treatment. In other words, it was dependent on the knowledge and training of their local emergency medical staff.

Before the events of September 11, an expert task force of the American College of Emergency Physicians had identified the core content of a national training program to detect and respond to nuclear, chemical and biologic agents, under a grant from the U.S. Department of Health and Human Services (DHHS). The second and third phases of the grant development of course materials and its implementation still need to be funded.

Another critical gap is the lack of a national, real-time disease surveillance system. It is imperative the country have a surveillance system that links emergency departments across regions with state public health departments and nationally with the Centers for Disease Control and Prevention to serve as an early warning system for biologic, chemical and nuclear agents. Congress mentioned this in the legislation enacted in June, but no funding has been provided yet.

Lastly and most importantly, little has been done to expand the capacity of the nation's emergency departments to handle sudden increases of large numbers of patients from mass casualty events. Our nation's emergency departments are already overcrowded, and little has been done to reconcile this problem with the recognized need for surge capacity to handle mass casualties during a terrorist event. More than 1,000 emergency departments have closed in the past 10 years, and the number of emergency patients has increased dramatically to more than 108 million in 2000, up from 89 million in 1992.

Emergency physicians and nurses are essential to ensuring that hospitals and communities are prepared for disasters and that the nation is prepared to respond to terrorism. They need to have primary roles in the medical aspects of disaster planning, emergency medical management, and patient care. And before our nation's policy-makers proceed further, the critical gaps in emergency department training, surveillance, and surge capacity must be filled.

Dr. Michael L. Carius is president of the American College of Emergency Physicians.

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