In recent years, emergency medicine physicians and our partners in emergency management have participated in bird flu and pandemic flu preparations with local governmental officials. Yet we never allowed ourselves to entertain the reality of a true pandemic resulting in tens of thousands of American deaths, nor did we imagine the unpleasant task of deciding which patients required EMS transport and hospitalization. We did not consider the reality of our children being unable to attend school; empty grocery shelves and closed gas stations; or the possibility of us or our families becoming ill. These potential realities struck home on April 24, 2009, when the city of San Antonio's emergency manager called and said, "We need to talk. Have you ever heard of H1N1?"
The discovery of H1N1 infection in five people in California and two teenage boys in Schertz, TX (a city bordering San Antonio), led to weeks of meetings and behind-the-scenes discussions. There were unending conference calls, school closure decisions, suggestions of social distancing, and hospital employee and visitor surveillance for flulike symptoms, all topped with media frenzy and general fear and uncertainty throughout the public. We scrambled to find our pandemic flu plans and dust them off--only to realize we were not thoroughly ready.
Our challenge: Apply the plans, smooth any wrinkles and get fully ready--fast.
In San Antonio and the region served by the Southwest Texas Regional Advisory Council (STRAC), public health officials faced tough decisions daily as they led the response to this new threat. Difficult choices included decisions about closing schools and banning public gatherings; when and how to distribute antivirals to uninsured and low-income patients; identification of those needing H1N1 testing; what to do when the region ran out of viral testing medium; and so on, with countless new decisions daily. City and regional hospitals wrestled with concerns of overloading already-stressed emergency departments. EDs grappled with the worried well and patients sent by private physicians for testing. They anticipated the challenge of unfunded patients who needed antiviral medication. Hospitals dealt with their own employee populations: when to begin employee and visitor screening, identifying employees needing prophylaxis, and more issues compounding daily.
We in the EMS community encountered the same and other issues. We had unique problems caused by the novel flu strain--a strain with uncertain morbidity and mortality. As medical directors responsible for the prehospital care of the citizens of San Antonio and well-being of more than 1,600 emergency providers in San Antonio and Bexar County, our list of questions grew hourly. How do we keep medics and firefighters safe and healthy? What standard precautions should they use? Should precautions include personal protective equipment for every patient encounter? What is considered exposed and at-risk? When should EMS personnel be placed on antivirals for prophylaxis, and how will it be funded? Will we treat their families too? How do we educate medics and firefighters and instill the gravity of the situation’s potential and the importance of wearing PPE, without causing panic?
We knew we may face difficult ethical choices too: choices like, who will and won't be given transport to the hospital if the system becomes overwhelmed? Who will be given respiratory treatments, such as nebulized albuterol or intubation, if the risk of exposure to medics becomes too great with these procedures? Who may not receive an ambulance when they call 9-1-1? These potential decisions were enough to make most medical directors uneasy. In the end, we did what we do best: We planned and developed protocols for such foreseeable issues. Mitigation plays a central role in preparing for the next event. The following are a few of the lessons we learned.