As new threats arise from Al-Shabaab, and ISIS
encourages attacks by isolated radical volunteers at specified targets throughout the Western world, media outlets and political pundits are recommending all sorts of mitigation measures: everything from heightened security measures to increasing vigilance by the public to counter-publicity. Unfortunately, no matter what we do to prevent this tragic violence, it is likely to erupt in some anticipated or unlikely venue and challenge us to respond to the ravages of bombs, bullets or toxins and to minimize the death and disability that almost inevitably results. As so many prior events have shown us, the emergency departments (EDs) in our communities, urban and rural,
are key to this response and critical to minimizing the impact of terrorism on both our citizens and our national psyche.
The
Boston Marathon bombing gave us a taste of how this could play out when the resources are adequate to the task, the ED and hospital
multi-casualty response systems are well organized and surge capacity is sufficient to meet the demand. As a result, deaths and disability were minimized in ways that exceeded the expectations of even the most experienced disaster response experts, and all of America was both relieved and justifiably proud of Boston’s rescue, ED and hospital reaction teams’ ability to meet this challenge.
At least for a few days.
Since then, whenever you hear the defense experts and the reporters and the retired CIA consultants talk about preparing for the next terrorism strike, you rarely hear anything about the need to reinforce the capabilities of our ED safety net. No question that an ounce of prevention is worth a pound of cure, but if we just focus on prevention, our assumptions about the availability of the pound of cure may end up resulting in finger-pointing and great disappointment.
Thus far, we have been fortunate. With just a few highly publicized exceptions, EDs and hospitals have done a great (and
sometimes heroic) job responding to these multiple casualty incidents. Fortunately, most of these exceptions did not involve a large number of patients with poor outcomes. Imagine what may happen in a terrorism attack with 50 victims, when an ED is tasked with responding in a community where two nearby EDs and hospitals have closed? Imagine an ED that is already overwhelmed and understaffed, with a shrinking on-call specialty roster, where too many highly qualified emergency physicians have been replaced by PAs and NPs in response to the financial stress of having to cover the influx of under- and uninsured patients that were inherited when the other hospitals closed down. How many victims who could have survived may die or suffer avoidable disabilities? Ten, even 20? The
cacophony of criticism that fell on the ED and hospital in Dallas for missing a single case of Ebola would be nothing compared to the second-guessing and puffed-up outrage that would likely be leveled at these providers. The failure of local, state and federal agencies and legislative bodies to respond to the threatened closure of adjacent EDs and hospitals — and the concerns of local providers about the impact of these closures on the remaining ED — would be long forgotten.
It is not just ED closures, however, that threaten our response to terrorism. As some have pointed out, many of the EDs that are impacted by adjacent hospital closures have opened additional treatment areas and increased staffing in response. Yet the danger of putting all your eggs in one basket in a war zone is a not just a lesson for generals. Furthermore, the problem of inadequate surge capacity and resource constriction is a function of the overall financial viability of the emergency care safety net.
Claims that Obamacare, with its reduction in the uninsured, have mitigated or eliminated these problems are widespread and utterly wrong. It is the less obvious but progressive decline in the ED safety net, exacerbated by steadily increasing patient loads, higher acuity, expanding demands on ED staff to limit admissions and obviate readmissions, and depleted on-call specialist rosters that undermine an ED’s surge capacity and limit the staff’s ability to coordinate a response to a wave of terrorism victims or victims of any multi-casualty disaster. The list of politicians, regulators and agencies that have ignored the strains on this safety net is long, and the potential consequences grave.
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