This afternoon, the Rochester New York area experienced a foreshadowing of what medical care might be like during a pandemic. It wasn’t pretty.
Rochester and Monroe County are in the grips of influenza. The local hospitals are overflowing with folks complaining of cough, fatigue, aches and pains and for many elderly, confusion and disorientation.
As the demand builds at each hospital’s emergency department, they go from “green” to “yellow” to “red”. By law they cannot refuse a patient, and even when red the patients keep coming.
Ambulance crews had their usual wait times grow, and grow again, until some crews were waiting at triage for four hours. Each crew waiting at the hospital meant that an ambulance was not available to take another call.
About 2:30 pm I was called in to the East Rochester Ambulance base by our captain. At the time of the call, ER had the only staffed ambulance on the east side of Monroe County, with over a dozen ambulances from volunteer agencies tied up on calls and no ambulances available from either commercial ambulance service.
Shortly after my arrival, I was dispatched by the county, with my driver, to Penfield Ambulance to cover their district and that of West Webster. All four of the ambulances that would normally cover those two areas were tied up.
We were finally released about 6 pm, as ambulances came back into service from the hospitals. It had been slightly busier than normal today and that added patient load would normally have been covered by mutual aid from corps not overloaded and the two commercial agencies. Between the crowds at the hospitals and the busier call volume, EMS services became very scarce for about three hours.
People expect that if they don’t feel well, they will be able to go to the hospital, by ambulance. On a day like today, it is easy to see how this expectation will affect medical care when a real crunch, a pandemic, happens.
What would the next step have been? The logjam was the emergency departments. How can they assess and treat patients faster? Having done this for a dozen years, I could sympathize with a desire to tell many of the patients to go home and come back when they’re sicker. Feeling lousy isn’t fatal, nor is a runny nose or a cough or a cut finger or feeling depressed.
The emergency departments locally are new or nearly new. And the demand has already outgrown the supply. Patients wait, sometimes for a day, to get admitted to a real hospital bed from the E/D.
Quasi governmental agencies determine the number of in-patient beds, and E/D beds, and they keep closing hospitals and removing beds in an effort to keep health care costs down. Since they also control the revenue streams for the hospitals, it’s a real mess. Demand is always greater than supply. The hospital must stay open, without staff or beds for all its patients and it cannot add either without a long fight with an unelected governmental agency or agencies.
For three hours today, if you lived in the wealthiest suburbs of Rochester, your emergency care was dependent upon the fates and whatever ambulance within twenty miles was available. If you got to a hospital, you would have waited hours before being seen by a doctor.
And this was just a taste of things to come.
16 responses so far ↓
1 Chuck Pelto // Mar 11, 2008 at
RE: Lousy Service During a Influenza Epidemic….
….is not going to be the same thing as NO SERVICE during a Pandemic.
In the first place, there WILL be ‘lock-down’, better known by the euphemism of ’social distancing’. Or so I understand our plans here.
In the second place, special ‘emergency facilities’ will be established…or should be….to accommodate suspected pandemic illness vs ‘routine’ emergency service needs. Something to do with ‘triage’. [Note: In the military we, amongst the grunts, referred to triage as 'give a doctor a gun'.]
In the third place, after a while, in a truly bad pandemic, nobody in their right mind is going to want to go anywhere NEAR a facility where half the people are coughing up a lung and most of them are going to die.
The real challenges are going to be in terms of long-term preparedness and self-application of medical care for non-pandemic situations; fractures, bad cuts, burns, etc. If you do not have a life-threatening situation, you’re not going to go to a place where you’ll likely get one.
Most people are not prepared for this possibility. Nor has the commercial sector adequately prepared for it. Case in point, how are people who live in tiny apartments going to get food in a two-to-three month ’social distancing’ situation? Let alone pay bills for electricity, water, heat, phone, etc., if they can’t go to work.
There are ways to deal with most of these things, but people have not been well informed on what they are. This could lead to panic situations that would not be conducive to maintaining public order. And, in my honest opinion, therein lies the REAL potential for disaster.
Regards,
Chuck(le)
[Chance favors the prepared mind. -- Louis Pasteur, the Father of Microbiology]
[Editor: Chuck, I agree with everything. If I had a quibble, it would be about the decision making process which would establish the alternate sites. When does it kick in? What exactly triggers it? And, shouldn't the hospitals be allowed to protect themselves from being flooded with patients they cannot possibly handle?]
2 Trusted.MD Network // Mar 11, 2008 at
“Foreshadowing of what medical care might be like during a pandemic”…
Ugly. (via Instapundit)…
3 ronbo // Mar 11, 2008 at
… or feeling depressed.
Until depression turns into suicide. Do you really think it’s fair to lump depression in with a runny nose or a cut finger? Any psychiatrist (or even primary care doc) would want a seriously depressed patient to go to the ER. Would that patient be triaged to the top of the list? Of course not, but at least he would be where he couldn’t hurt himself, and that’s the important thing.
Otherwise, very enlightening - and troubling - post.
[Editor: I agree to a point. I have also seen such patients leave the hospital before my paperwork is done. That is depressing.
The appearance, in this area at least, is that many docs turf their problems to the hospital. So do the police. After you have taken the "out of control" six year old in as a mental hygiene arrest, you do start to wonder. The E/D facilities for mental problems are even more limited than those for medical. I have waited an hour for an intake for a patient, and that was when they were not terribly busy.]
4 Chuck Pelto // Mar 11, 2008 at
RE: The ‘Trigger’
“If I had a quibble, it would be about the decision making process which would establish the alternate sites. When does it kick in?
What exactly triggers it?” ” — Chuck Simmins
Well….
…here is where I and the ‘authorities’ differ in ‘opinion’.
The ‘trigger’ should have been last June when I sat in on a Public Health Department county-wide assembly to discuss this matter.
[Note: I was told to shut down all my recording devices and erase everything I had recorded up to that point. Otherwise, I suspect, I'd have been 'ejected'. This despite my 10+ years of work in emergency management from the (Army) installation and state—as in State ARea Command (STARC)—levels.]
The ‘trigger’ for preparation was realization—at that meeting—that most agencies were unprepared. In everything I heard after each break-out session, I heard of lot of “we should” as opposed to the more satisfying “we are prepared to” statements. Such things do not give me the proverbial ‘warm and fuzzy’ feeling that all is well planned.
As for the ‘trigger’ for the actual incident….when you hear about people in Asia dropping like flies…THAT should be the ‘trigger’ to gird up your loins.
The way I see it, from my education in microbiology—emphasis on pathogens and epidemiology—I figure it will start there, where people and birds and pigs all are crunched together; probability of .8.
However, the way the so-called ‘main stream media’ behave regarding politics, e.g., Spitzer IS a ‘Democrat’, but you won’t hear that on NBC and such, we’ll likely not pick up on such information from them until it is too late. Too much potential for ‘panic’. [Note: Indeed, a rep from a nearby television station said pretty much that during the course of the meeting.
However, I suggest that a bit of panic now by the overly sensitive is better than a whole lot of panic by just about everyone, when it's too late to do anything.]
Better keep an eye on the web for such matters.
“And, shouldn’t the hospitals be allowed to protect themselves from being flooded with patients they cannot possibly handle?” — Chuck Simmins
Yes. They should be able to protect themselves. Indeed. It will be essential. But unless the general population is educated and prepared, there’s very little chance that they could withstand the wave of people seeking aid.
That’s one reason why the need for education is so damned important.
Without the panic-mitigating preparedness, people are going to act as they are described by the Tommy Lee Jones character in MIB, i.e., badly.
And there are not enough police and national guardsmen to go around. Especially if they behave like one PD officer intimated in that meeting I attended, i.e., “We’re going to hold up with our families in a designated compound.” [Note: This is exactly the way people in responsible positions in the 14th Century behaved when the Black Death marched across Europe.] Lotta good that’ll do for hospitals and such.
So….what are you going to do?
I recommend taking up the Boy Scout motto….Be Prepared! But then again, I was one of them and still am of that mind-set.
From the perspective of a dedicated emergency service provider; (1) make sure your family has adequate supplies for one year, better two-three, as they’re talking about ‘waves’ of the disease—whatever it may be—sweeping across the land, with two-to-three month ’social distancing’ applied to each wave, (2) be prepared to administer significant medical aid to your immediate family and neighbors [neighborhoods will be what prevails, if they can get their 'act' together], (3) get the materials to protect yourself as you perform your professional duties, (4) make sure your ‘house’ is ‘in order’ [gotta Will?] and (5) if/when it happens, make your peace with God.
Hope that helps…..
Regards,
Chuck(le)
[Everyone dies. It’s just a matter of when, how and—most importantly—why.
5 Chuck Pelto // Mar 11, 2008 at
P.S. Someone REALLY should put together an OPLAN on how to (1) be prepared and (2) protect oneself, ones family and ones community in such a situation.
[Editor: In my experience, public health officials are far more worried about teen pregnancy, guns in the home and buying shiny new toys with Federal funds. This truly minor sequence of events shows just how unprepared we are for epidemics, never mind pandemics.]
6 CHenry // Mar 11, 2008 at
It seems so civilized and orderly. I fear it won’t work out quite like that.
The civilian ambulance service won’t be the limiting step, the limiting step will be the hospital itself. As early cases are admitted, and the epidemic is identified, critical care beds will fill quickly in community hospitals. Eventually there won’t be enough beds available to support ordinary surgical activity as postoperative beds will be taken by critically-ill influenza victims. Trauma support will go on standby at many hospitals with longer diversions. When ambulances fail to provide sufficient support, private conveyances will bring the sick to hospitals, with no coordination with other prehospital services and where the ED facilities will already be unable to accommodate them and where there will not be enough beds to accept them within the hospital. As some patients are released from critical care, stepped down or more likely expiring, there will be a triage within the hospital for critical care beds. Doctors will be forced to choose which of the sickest get the next ICU bed or ventilator. These decisions may not be accepted peacefully.
Outside the hospital, things will get more desperate. As more sick arrive, with anxious family, unmet demands for service will deteriorate into disorder. Hospital security will become a problem. Police services, already taxed by other threats of disorder and the new requirements to enforce quarantine law, may not be able to adequately respond. Other resources–likely state national guard forces–will have to be called upon to assume police and public order duties that the police can no longer handle. Entering the hospital may require passing a national guard cordon to a secure triage station. More patients will be sent directly home–increasingly by force–rather than be allowed to enter the hospital where they risk infecting other patients and hospital staff. Elective surgeries would be postponed indefinitely. As many patients as possible would be transferred home or to any available nursing facilities. Except for the direst of emergencies, the hospitals would generally have ceased to perform ordinary day-to-day services. And that is assuming the staff themselves don’t become ill, in which case things would become worse.
Whole areas where outbreaks are reported could become quarantined, not just households, but whole communities. Air travel could be suspended. Highway and rail travel could also be suspended or controlled, restricted to vital food, fuel and medical supplies, and enforced by national guard and martial law.
If travel is restricted, controls will also be necessary to ration essential but limited supplies of fuel and food. This will require an extraordinary effort of self control by all members of the community if the requirements are to be met without collapse of civil order. Money may become in short supply and there will have to be diligent efforts to prevent black marketing and smuggling at the fringe of the civil society. Mass feeding stations, a response typical of many civil disaster scenarios would present a problem as a potential locus of transmission of disease. In all likelihood, an effort to support individuals and families in place would have to replace all forms of mass-services. This will require a contingent of able-bodied persons willing to perform delivery and warden duties in local neighborhoods. An effective network utilizing all available forms of wired and wireless communication methods will be necessary to sustain these efforts.
[Editor: a good projection of the effects of a pandemic. Yesterday's events should have resulted in a triage area in the parking lot, heated, staffed and with the ability to turf patients who did not need hospital care. They way things actually work is that the triage nurses disappear from their posts for a half hour or more. See, the hospital knows that once the triage nurse sees the patient, the hospital has a responsibility. If there are a dozen ambulance crews in triage but no nurse, it's the ambulance crews' problem. If you have ever seen a crew doing CPR while waiting for a triage nurse...]
7 Chuck Pelto // Mar 11, 2008 at
TO: All
RE: The Root Cause ‘Problem’
In my personal opinion….
….the cause of all the concern over health care services in a pandemic, or ever DAILY, situation is the hammer-lock the AMA/Medical-Industry has on health care in the first place.
Yeah. Lots of people like to point fingers as health insurance, but, tell me…..
….why does a liter-bag of physiological saline solution cost over $200?
People got upset about the US Air Force’s $600 hammer in the 1980s. But at least the Air Force got to use the hammer more than once.
And what does this have to do with the ‘price of’ medical care in the US today? Let alone this topic?
Only that because of the monopoly the AMA works to its financial advantage will be a serious problem in the face of any future pandemic—bird flu or otherwise.
There won’t be enough medical support to support the society….
Regards,
Chuck(le)
[One can serve either righteousness or mammon. -- Some Wag, around 2000 years ago]
[Editor: Chuck, any hammerlock exists because the government has chosen to allow it. A hospital has its size dictated to it by the government, its prices, its policies and its costs.
The AMA itself is a dino, a majority of MD's do not belong. And most MD's are so scared of lawsuits that they treat sniffles like the Black Plague.]
8 Chuck Pelto // Mar 11, 2008 at
TO: Chuck Simmins, et al.
RE: Hammerlocks, Anyone?
“….any hammerlock exists because the government has chosen to allow it.” — Chuck Simmins
True. Or…maybe…because the government, like most people, still labor under the illusion that hospitals are operated by charitable organizations.
“A hospital has its size dictated to it by the government, its prices, its policies and its costs.” — Chuck Simmins
Interesting idea, that.
Tell me. How is it that I see the hospital across the street from me is unconstrained by your concept? Indeed, it’s CEO says his reason d’etre is to increase the corporate bottom line.
This sounds like it is anathema to the concept of providing the best possible medical support to the surrounding community.
“The AMA itself is a dino, a majority of MD’s do not belong.” — Chuck Simmins
It’s a very active and powerful ‘dino’, if you see it in the legislatures, as i have.
As for whether or not MDs belong to it….show me your statistics and sources.
“And most MD’s are so scared of lawsuits that they treat sniffles like the Black Plague.” — Chuck Simmins
Maybe if there were a tad more ‘competition’, instead of the current monopoly, they might treat ’sniffles’ appropriately.
Just a thought……
Regards,
Chuck(le)
[All professions are a conspiracy against the laity.”
9 Chuck Pelto // Mar 11, 2008 at
P.S. The ‘Follow-On’ Thought….
….is that the current state of ‘affairs’—government, medical industry, whathaveyou—is NOT prepared for a pandemic. And, in my honest opinion—based on years of planning for disaster—it NEVER will be, in it’s current money-grubbing modus operandi.
So. Whether now?
If you’re serious about being prepared….forget getting help from hospitals; as their professionals—based on historical evidence—will flee from anyone who has a contagious disease they think they may contract.
If you doubt this, please read Barbara Tuchmann’s classic treatise on what happened during the Black Death; A Distant Mirror: The Calamitous 14th Century.
Dry. But informative…..
10 Sue // Mar 11, 2008 at
How about we begin to prepare the “patients” now, this minute and every minute for the next 10 years. What in the hell happened to “common sense”, street smarts and just plain knowledge? Why does everyone appear to be stupid about everything! Good lord, what has America done to Americans? What has the liberal ideology of victimization created in the past 50 years?
Welcome to the future, it is plain ugly.
11 Bruce Long // Mar 11, 2008 at
Relevant to this discussion I think.
I read (Samizdata blog?) recently the government in Britain mandated all patients to the ER must by law be seen by a doctor within four hours of arrival. The NHS has met this new mandate. It really wasn’t that hard to arrange. Hospital security simply turns away all arrivals unless the ER is ready. The sick and injured wait in the in ambulances or private cars for several hours before the “official” four hour clock starts. ….
12 Skip // Mar 12, 2008 at
“What in the hell happened to ‘common sense’” - Sue
THAT right there is a major player in all that ails society as a whole. Bring common sense back along with personal responsibility and many of the fears of “preperation” for a pandemic could be alleviated.
Thank you Sue for keeping me company in wondering where it all went.
13 kurt9 // Mar 12, 2008 at
The last place you want to go during the plague is a hospital. After all, hospitals are full of sick people. You do not want to be near other sick people during the plague. Its best to stock up on vitamins and supplements (my favorites are CoQ10 and Resveratrol) and any anti-virals that you can get. Also, lots of Vitamin C is good for warding off the viruses. Then you hack it out during the plague.
After the plague is when the fun begins. Since I am an automation engineer, there will be lots and lots of contract work for me automating all of the mines and factories because half of the work force is gone. No one will ever tell me or anyone else that “you’re not qualified”. Also, plagues lead to golden ages. You see, by killing half to three-quarters the population, plagues efficiently destroy social rigidities and bureaucracy that kept Europe in the dark ages. People were free to innovate and create. This is how the “guild” system went away in Europe and the renaissance came about. It almost makes you want that plague to happen.
So, cheer up everyone. There is a silver lining to the plague.
14 Chuck Pelto // Mar 13, 2008 at
TO: Bruce Long
RE: The 60-Second Rule at Wendy’s Drive-Thru
“I read (Samizdata blog?) recently the government in Britain mandated all patients to the ER must by law be seen by a doctor within four hours of arrival.” — Bruce Long
Big deal…..
It won’t happen if there are not enough doctors in the system. And, based on my observation, the AMA’s lock on supply would preclude that, if they thought it was in the best interest of their ‘bottom line’.
The ‘work-around’ you describe—security turns back the ambulances—seems like a superb approach to skating around the ‘law’.
Regards,
Chuck(le)
15 Chuck Pelto // Mar 13, 2008 at
TO: Kurt9
RE: Well….
“So, cheer up everyone. There is a silver lining to the plague.” — Kurt9
….one way or another….if….
….you’re a REAL christian.
Regards,
Chuck(le)
[We preach the Lord. The pay is lousy, but the retirement benefits are Out of This World.]
16 Bithead // Mar 14, 2008 at
Chuck;
You’ll be interested to know that they had a Death due to the flu… in Buffalo, a few days ago…ECMC, I think. 4 years old, the kid was.
Dunno about you, sounds fairly serious to me….
[Eric, this year isn't especially dangerous for kids. There was a year, oh, three or four years ago, that was unusually bad. We're above epidemic levels for deaths in the total population but not a great deal above. It's the worst year in several but no where near pandemic levels. Most of the increase is a type A and a Type B that were not in the vaccine for this year.]