Practice Without Precedent
Johns Hopkins Community Physicians view terrorism as a matter of primary concern.
For nearly 45 minutes, internist Gregory Kelly knelt in a hallway between exam rooms, working with two nurses and every asset they could lay hands on to stabilize the two men who'd suddenly become their patients. One man's femoral artery had been pierced. The other man, who'd collapsed moments after making it to the second floor of Johns Hopkins at White Marsh, wasn't responding to basic life support. Both were plastered with dirt--from an explosion, said the man with the jagged piece of lumber in his thigh, on "The Avenue" near White Marsh Mall.
In the lobby one floor below, meanwhile, Kelly's colleague Arthur Schroeder and another nurse crouched beside a man having seizures. On the pavement outside, internist Richard Gross hunched over a third unconscious victim-a man impaled twice by sticks extending through his leg and his side. Behind the building, Doralise Aponte, a certified medical assistant, hosed down one man with a broken wrist and another demanding to know what had happened to his 9-year-old son.
Word was that the nearby detonation had been a "dirty" bomb--a device made of conventional explosives laced with radioactive material--and everyone at the Hopkins community medical center was following its disaster plan. One person had shut down the air conditioning, others had cordoned off areas they feared could be radiologically contaminated. The medical staff worried about how seriously their new patients were injured and how quickly their supplies were dwindling. Still, they believed, all they had to do was hold on until the emergency medical services people arrived. After all, these were doctors' offices, not an emergency department.
Gregory Kelly, battling to keep one of his patients alive, took the news the hardest.
Even though three Baltimore County Fire Department ambulances pulled up 30 minutes after the first injured patients arrived, the EMS personnel aboard said area hospitals were already overwhelmed. Furthermore, their priority-one patients were those who still hadn't been triaged at the mall. Everyone being treated at Johns Hopkins at White Marsh, regardless of their injuries, would have to continue being treated there-whether staff felt up to the task or not.
"It was frightening to think I would be taking care of this fellow long-term," admits Kelly. "We aren't set up to be invasive, nor are we trained to be invasive. It becomes a case of what can you do, of stabilizing with what you have. But I feel better now, because I know what would be expected of me if a disaster of this magnitude were really to happen."
And that, of course, was the point of the elaborate drill.
When Susan Crocetti came up with the idea of staging disasters at Johns Hopkins Community Physicians practice sites, she didn't know she'd be moving the organization into uncharted territory. But in the wake of the attacks on the World Trade Center and the Pentagon last September, what she did know was that, with 24 primary care practices in 18 locations around the state, Hopkins Community Physicians had work to do.
"Two and half days after 9/11," says Crocetti, JHCP director of performance improvement and risk management, "it dawned on me that we're in the loop with terrorism. All the focus was on emergency departments and emergency medical services, but one of the lessons from New York was that people ran from the event into anyplace that looked like health care. We don't have the same trained personnel and equipment as a hospital, yet we can't just throw up our hands and say, There's nothing we can do. We had to develop a plan for staff to respond."
Furthermore, the anthrax infections that began surfacing last October confirmed what Crocetti already suspected: A biological attack would be covert, and the first to see victims would probably be the family doctor. (Among the worried well who were seen at various JHCP sites last fall, in fact, was a patient who worked at one of the places where anthrax spores were found.) The anthrax cases also raised the specter of even more diabolical attacks: smallpox, bubonic plague, chemical or nuclear weapons.
"We felt the safety of the country could rest on our ability to catch something early," says Crocetti. "I remember a friend saying to me, Oh, you work for Hopkins. Don't they have it all figured out? Of course we got general guidelines from the experts, but we had to take the big picture and translate it to the grass-roots level. How would we actually put the plan into practice in our facilities, the way they're laid out, with the equipment we have? If we got a smallpox patient, maybe the National Guard or the CDC would be there eventually, but how do you get to that point?"
An hour before they descend on Johns Hopkins at White Marsh, 14 "patients" gather in the conference room of a nearby building. In real life the couriers, mechanics and supply managers who physically maintain all the Johns Hopkins Community Physicians sites, by now they're something of a troupe. For a few, this would be their first disaster, but most were veterans who'd already enacted a smallpox exposure at Johnson Medical Center in Baltimore, another dirty bomb incident at Odenton-Meade Health Center in Anne Arundel County, and a building collapse at Cranberry Station Health Center in Westminster.
Bantering is inevitable as they admire each other's props, "wounds" and theatrical blood. "I feel nauseous," jokes courier Timothy Gerlach, holding a cup filled with an evil-looking soup mixture. Scripted to play the head-injured man, he'll toss the concoction on the ground when the time is right to simulate vomit.
"Before we're on, it's fun," says Jen McCarty, an administrative secretary who also had a role in the smallpox drill. "During the drill, though, we get serious because we want to make the medical staff feel like it's really real. We ad lib, and we're very persistent."
Each actor gets a card describing a basic persona-contagious patient, waiting-room patient--and a brief statement of what to do, such as, "Twenty minutes into the exercise, tell a staff member you're diabetic and need to eat something." By getting into their characters and improvising as they go, the players raise realistic-and unexpected-issues.
"They're really impressive," says Rebecca Kritzler, senior director of clinical operations and performance improvement, who's collaborated with Susan Crocetti, corporate services director Trish Sadowski and staff development coordinator Joan Kramer to write and stage the scenarios. "Some get angry and start yelling. They bring up a lot of things we wouldn't have thought of, like a person who suddenly needs a cigarette, or a parent who insists on leaving to pick up a child, or patients who request masks and gloves for themselves."
Clinical and office staff do know ahead of time that a drill will occur (either before or after hours so as not to disrupt real patient care), but they have no idea what the premise is or how it will be presented. Still, says Crocetti, "It's not about testing them. It's about having them help us figure out what we're missing."
Before 9/11, Johns Hopkins Community Physicians had a three-page disaster plan, geared more toward tornadoes than terrorism. By late last fall, the plan's length more than tripled as the management team assembled reams of new information-lists of symptoms to look for, scripts on what to do and who to call. That alone provided some comfort and semblance of control. Yet reading, even memorizing, a to-do list isn't the same as living it.
"Before our drill," says Odenton-Meade clinical supervisor Antoinette Bourne, "we went over our disaster plan-the doctors who would be triaging with a nurse, the person who would transport patients, the people who are assigned to flashlights. During the drill, one after another, patients were showing up, looking like they were really cut and burned. Plus, we were getting some who supposedly had appointments. One said, I wanna see a doctor and I wanna see one now. We were getting IV poles, ordering stuff, sending patients to X-ray. The adrenaline was really high. Joan Kramer was timing us in certain areas, like how long it took us to triage. That was good. It lets you really know your strengths and where you need to improve. The best part was afterwards, hearing everyone's comments. If we're gonna get that many patients, we definitely need more supplies."
There was a list of other things they hadn't considered as well. Staff knew to decontaminate radiologically exposed patients on grass, which can be dug up and disposed of later, rather than on pavement, which would send the water directly to a storm drain. But only when they went through the motions did they realize that it was a McDonald's across the street that had a long-enough hose. They needed a way to label the bags containing hosed-down patients' clothes, which were considered criminal evidence. To minimize contamination, they needed an outside team, an inside team and one person to act as a go-between. And they needed to designate one person to take down people's names.
"You only learn the pieces by going through it," says Kramer, who makes up what's happening in each scene (the phones are out, the computers go down, there's an hysterical staff member in the supply room). "There's a lot we hadn't thought about."
Such as, do you need to post a guard outside a bathroom so no one turns on an exhaust fan that could spread contagion? That one came out of the smallpox drill.
After each drill, there's a debriefing where staff can go over what they've learned. "At first, everyone's all tense because they've tried hard to do their best," says Kramer. "It gives them a chance to laugh and give feedback. During one of the sessions, one of the actors said, You know, when that nurse explained things to me, I felt better."
Instead of being frightened by the holes they've uncovered, virtually everyone who's participated says the exercises bolster confidence. After each debriefing, the information gets incorporated in the overall disaster plan and is shared with each site.
"The drills promote teamwork, they empower people," says Barbara Cook, JHCP acting president and vice president of medical affairs. "Leadership skills come out of the woodwork. People just rise to the occasion-the same thing we saw again and again in New York."
And it's not only insiders who've taken notice. During the smallpox drill, staff made real phone calls to external agencies--the FBI, the Hopkins Access Line and the Centers for Disease Control and Prevention. "The CDC told us, Yours is the first call we've ever gotten from anyone saying they were doing this," says Becky Kritzler.
"You are light years, light years, ahead of other facilities," Baltimore County EMS Captain Richard Brooks told the stunned White Marsh group at their July 23 debriefing. "You are looking at weapons of mass destruction where others are only just now beginning to think about them."
Welcome as such accolades are, they also bother Crocetti.
"It's ironic," she says, "to congratulate ourselves when we're in this situation of even having to talk about patients with radioactive dust on them. I'd like to see every doctor's office have some plan, because that just extends the reach of help, no matter where you are. If every primary care practice was prepared, what a network, what a set of feelers. This is what we can do, in our own way, to contribute to the security of our country."
- Mary Ann Ayd