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Mr. Chairman, members of the subcommittee, my name is Kathryn Brinsfield, MD, MPH. I am the Director of Research, Training, and Quality Improvement for Boston Emergency Medical Services, a practicing Emergency Medicine physician, and the Deputy Medical Commander of the National Disaster Medical Systems International Medical and Surgical Response Team- East. I would like to thank you for inviting me here to speak on this topic.
On March 20, 1995, Sarin was released in the Tokyo Subway system. The incident started at 7:55 am; the last patient was treated before noon.
On September 11, 2001, the terrorist events at the World Trade Center killed over 6,000 and injured fewer than 2,000. The last live victim was rescued within thirty-six hours.
All disasters are local.
Terrorist disaster response is a local response.
Federal programs have helped prepare localities for dealing with these disasters but there is still more to do.
Ensure that significant funding goes directly to localities so we can have the flexibility to plan our response based on our unique needs
Enable local health and public safety agencies to work together with hospitals to coordinate a response
Coordinate among agencies at the federal level to ensure unified interagency guidance, materials and funding.
Follow-up Domestic Preparedness training with concrete information and lessons learned based planning guides.
From floods to fires to bombings, the initial minutes and hours of a disaster largely determine the number of victims that will survive. While federal response provides important relief in the forms of specialized experience, credentialed personnel and supplies, the ability of a locality to rescue, treat, transport and provide definitive care to its own citizens weighs the balance between life and death.
This holds true for bioterrorism, although in nontraditional ways. Treatment and stabilization of a terrorist event is dependent on recognition that an event is underway, and recognition is dependent on the ability of local responders and the local public health office.
In Boston, we are lucky to have a strong Public Health Commission, with Cabinet level input into the operations of the city, and strong funding and support. This has allowed our local CDC office to take the lead in organizing a citywide hospital volume surveillance system, which has two years running detected the onset of influenza in the state prior to laboratory isolation. If this type of system can detect influenza, it should be able to detect the flu like illness that may be a harbinger of bioterrorism. In addition, we have been able to develop a consortium of Boston hospital based infectious disease and emergency medicine providers, poison control center representative, and zoo veterinarian, who meet quarterly, and have the ability to share information and alerts over the Internet. Our recent exposure to the West Nile Virus proved that Incident Command training for public health professionals pays off, and that the Public Health Director can act as Incident Command with Police, Fire and other city agencies participating in a Unified Command Structure.
Many localities are not so lucky, and rely on antiquated information systems, scarce personnel, and minimal recognition from the public safety agencies.
In bioterrorism, the ability to respond is dependent on the education and equipment of the prehospital personnel and hospital providers.
In Boston, we are also fortunate to have an emergency medical service with strong city support. This has allowed us to train all of our Emergency Medical Technicians and Paramedics to the hazardous materials operations level and domestic preparedness EMS- technician level. Even though the training materials, and sometimes the training, are provided free to agencies, training costs are not. We are also fortunate to have respiratory protective equipment provided. Annually recurring training and fit testing costs supported by the city are close to a half million dollars a year for our small agency alone. In an anthrax exposure for 1000 people, assuming the National Pharmaceutical Stockpile arrives and can be unloaded in seventy-two hours, the cost of antibiotics that must be on hand in a city to immediately treat exposed victims is 25,000 dollars. In Boston, we are lucky to have funding through the HHS Office of Emergency Preparedness MMRS program. We are also fortunate to have the support of the local hospital pharmacies, who have agreed to rotate this stock of antibiotics for us, so that they do not out-date, wasting our investment if no event happened in two years time. However, training and fit testing costs are renewable and supported by federal funding; while these costs may be small compared to a federal budget, they are large costs for local agencies.
We are also fortunate to have a strong Conference of Boston Teaching Hospitals, which has a long history of working together to improve health care in the city. This organization supports a hospital disaster committee and hospital EMS committee. These relationships proved invaluable over the last five years, in pulling hospitals and physicians into the terrorism planning process through EMS. In addition, we applaud the local hospital CEOs, who have been long sighted enough to recognize the importance of this issue, and provided funds for the construction of decontamination areas and staff training in the emergency departments.
Many private and hospital based EMS agencies do not have the funding or support to receive the necessary training or equipment, or to stockpile the necessary antibiotics. Many hospitals do not work in this type of collaborative environment, and are not able to participate in citywide planning. Few physicians receive any training in bioterrorism. Emergency Department and hospital overcrowding is a very real issue that will only be exacerbated in an event of any magnitude. Future preparedness funding should take these things into account.
In Boston, we consider ourselves fortunate to have been one of the initial cities trained under the Domestic Preparedness program. Although not perfect, the DP program did several things well.
First, it required all city public safety agencies to sit at the table, and submit a unified training and equipment plan before the training would be scheduled. Second, it trained the personnel locally, allowing city workers to brainstorm at the breaks and in the sessions, and meet people they may be working with in the event of a disaster. Third, it provided an adequate awareness training of terrorism. Finally, it allowed instructors and students to share information, and gain knowledge of many other cities plans.
Unfortunately, the program failed by its stand-alone nature, and its sometimes foster child status among the various federal agencies who, at one time or another, have been responsible for its implementation. New programs need strong, clear federal leadership that reflects interagency cooperation at the national level.
Domestic Preparedness was an awareness level program, and should have been followed by more concrete information and coordinated planning guides. Every locality is different, but every locality can learn some lesson from each other. Planning guides were produced separately by various agencies, and no other effort took into account the need for fire, police, and emergency medical personnel to collaborate on a single city plan.
At the time the program was started, the importance of bioterrorism, and the delayed manner in which it would appear was not appreciated. We now realize that in a bioterrorist incident, the Emergency Department and Medical Clinic providers are truly the first responders. In the initial DP bioterrorism tabletop exercise, cities were encouraged to do an anthrax hoax letter drill, testing the fire department HAZMAT response, but ignoring the hospitals and public health system. In March of 1999 in Boston, we went against the tide and held a tabletop with seven hospitals, all public safety agencies, and several state and federal agencies participating that tested our ability to respond to a Pneumonic Plague event.
As the events of September 11th have unfolded, many who were previously skeptical are now requesting training. Lets not lose this opportunity. Based on the Boston experience, I recommend that
New programs should include a lessons learned format, with concrete references and examples to help localities plan.
·New programs should be planned to include hospitals in addition to city public health and safety agencies
Standardized, funded training and protective equipment should be provided for hospital based, public health, EMS, police and fire personnel.
Monies should be tied to a universal, citywide approach to the disaster. This would require several federal agencies to either work together or outside their usual funding schemes. I believe this consolidation on the federal level is critical to avoid a splintering of response on the local level.
In closing, I share with the committee that I was proud and honored to be a member of the Massachusetts 1 Disaster Medical Assistance Team that responded to the World Trade Center. Although as a health care provider it was frustrating to have so few live victims to treat, our mission to treat the rescuers was rewarding and awe-inspiring.
Nonetheless, I will be very happy if I never again find myself working across the street from 6000 dead. It is clear there is only so much the medical response community can do in an event of this size. My thoughts and hopes are with the law enforcement agencies that can prevent these tragedies
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