[Congressional Record (Bound Edition), Volume 147 (2001), Part 9]
[Senate]
[Pages 12060-12062]
[From the U.S. Government Publishing Office, www.gpo.gov]



                     THE CHALLENGE OF BIOTERRORISM

  Mr. AKAKA. Mr. President, I rise to address the threat of 
bioterrorism to our Nation's security.
  President Bush has asked Vice President Cheney to ``oversee the 
development of a coordinated national effort so that we may do the very 
best possible job of protecting our people from catastrophic harm.'' He 
also asked Joseph Allbaugh, Director of the Federal Emergency 
Management Agency, FEMA, to create an Office of National Preparedness 
to implement a national effort.
  On May 9, 2001, Attorney General Ashcroft testified before a Senate 
Appropriations subcommittee that the Department of Justice is the lead 
agency and in sole command of an incident while in the crisis 
management phase, even if consequence management activities, such as 
casualty care and evacuation, are occurring at the same time. Clearly, 
FEMA and the Department of Justice need to work together to shoulder 
the burden of responding to a large scale event. What is unclear, 
however, is how the Department of Justice will know that its crisis 
management skills are needed during a bioterrorism event.
  When will a growing cluster of disease be recognized as a terrorist 
attack? How do we differentiate between a few individuals with the flu 
and a flu-like epidemic perpetrated by terrorists? When will it be 
called a crisis? When will the FBI or Justice be called in to handle 
the newly declared ``crisis?'' In the case of a bioterrorist attack, 
the response will most likely be the same as if it was a naturally 
occurring epidemic. The key question is not ``how to respond to an 
attack'' but ``are we prepared to respond to any unusual biological 
event?''
  What would happen if a bioterrorist attack occurred today? It would 
not be preceded by a large explosion. Rather, over the course of a few 
days or a couple of weeks, people would start to get sick. They would 
go to hospitals, doctor's offices, and clinics. Hopefully, a physician 
in one hospital would notice similarities between two or three cases 
and contact the local public health officials. Maybe another physician 
would do the same and maybe, finally, the Center for Disease Control 
would be notified. So, the first responders would not be a Federal 
agency.
  Across the country, local law enforcement, fire, HAZ MAT and 
emergency medical personnel are doing a tremendous job preparing and 
training for terrorist attacks, and I commend their efforts. But, in 
the scenario I described, they would not be our first line of defense. 
Instead, the first responders for a biological event would be the 
physicians and nurses in our local hospitals and emergency rooms. We 
need to ensure that hospitals and medical professionals are prepared to 
deal with this threat. This is not the case today.
  This past November, emergency medical specialists, health care 
providers, hospital administrators, and bioweapon experts met at the 
Second National Symposium on Medical and Public Health Response to 
BioTerrorism. A representative of the American Hospital Association, 
Dr. James Bentley, spoke about the challenges hospitals are confronting 
and stated that ``we have driven over the past twenty years to reduce 
flexibility and safeguards.'' Flexibility and safeguards are exactly 
what is needed by a hospital to go from ``normal'' to ``surge'' 
operations. Surge operations do not require the extreme scenario of 
thousands of casualties from a bioweapon. Dr. Thom Mayer, chief of the 
emergency department at Inova Fairfax Hospital, was quoted in the 
Washington Post, on April 22, 2001, stating that 20 or 30 extra 
patients can throw an emergency department into full crisis mode.
  Dr. J.B. Orenstein, an emergency room physician, in a recent 
Washington Post op-ed, wrote about the ``State of Emergency'' the 
dedicated men and women working in our hospitals and clinics are 
already facing without the added worry of bioterrorism. Until a year 
ago, hospitals dealt with surges for only a few days or a week a year 
during the winter flu, cold and icy sidewalk season. Now, mini-surges 
occur in the spring, summer and fall due to decreasing numbers of 
emergency rooms, beds available in any hospital, and qualified nurses. 
On May 9, 2001, the Society for Academic Emergency Medicine convened a 
special meeting in Atlanta to discuss ``The Unraveling Safety Net.'' 
Are we, with all the planning and funding the Federal Government has 
done over the past few years to address terrorism, providing sufficient 
help for hospitals to prepare for bioevents?
  As Chairman of the Subcommittee on International Security, 
Proliferation and Federal Services, I am concerned that we are not 
addressing a fundamental problem. Would a biological event be a 
national security/law enforcement incident with public health concerns, 
or would it be a public health crisis with a law enforcement component? 
I hope that the effort led by Vice

[[Page 12061]]

President Cheney will address specifically this question and that the 
unique problems biological weapons present are not overlooked by any 
national plan to counter terrorism. I ask unanimous consent that the 
text of Dr. Orenstein's article be printed in the Record.
  There being no objection, the article was ordered to be printed in 
the Record, as follows:

               [From the Washington Post, April 22, 2001]

                           State of Emergency

                          (By J.B. Orenstein)

       It's a typical bad-day crowd in my ER: Here's a wheezing 
     baby who developed a blue spell in front of her panicked mom. 
     This 62-year-old gentleman came in with chest pain 36 hours 
     ago; his worrisome EKG and equivocal lab tests should have 
     put him inside for observation, but there's no room in the 
     ICU so he's been waiting here for 24 hours. This lady, razor 
     sharp at 89, suddenly started acting ``not right,'' so her 
     granddaughter brought her in; she's been in the triage area 
     for three hours, but can't get into treatment because chest-
     pain guy, blue baby and 18 other patients are parked in the 
     treatment beds while they wait to be admitted.
       Our communications nurse just told an approaching ambulance 
     to find someplace else to take its potentially critical 
     passenger because we had no place to put him. Not in the ER, 
     not in an ICU, not even in a plain old bed in a ward. The 
     official term for what's happening here is ``saturation,'' 
     but down in the pit this is known as buttlock.
       And it's happening too often, in more hospitals than ours. 
     On May 9, the society for Academic Emergency Medicine will 
     convene a special meeting in Atlanta on ``The Unraveling 
     Safety Net.'' The meeting was called in December because 
     panic buttons were being pushed in overcrowded ERs across the 
     country--Boston, St. Louis, Chicago, New York. It was a 
     medical version of the California power crisis, with our 
     rolling blackouts coming in the form of ambulance 
     ``diversions.''
       Up until a year or two ago, we faced this nerve-racking 
     logjam for only a few days or weeks in winter, when flue and 
     cold viruses turn into potentially fatal pneumonia, babies 
     fall prey to respiratory and intestional viruses, depression 
     fills the psych wards and slippery ice keeps the orthopedists 
     busy. But now we're seeing mini-surges in the spring, summer 
     and fall as well.
       When I started at Inova Fairfax Hospital in 1991, the ER 
     treated 55,000 patients in the course of the year. Last year 
     the number was 70,000. This is in keeping with the national 
     picture. In 1988, there were 81 million visits to U.S. 
     emergency rooms, according to the National Center for Health 
     Statistics. The number for 1998: 100.4 million. Meanwhile, 
     over the same decade, the number of emergency departments 
     fell from about 5,200 to just over 4,000. Their average 
     annual patient volume rose from 15,500 to 24,800--that's more 
     than 50 percent.
       In all of American medicine, the only place that federal 
     law guarantees Americans the right to a physician, 24-7, is 
     the emergency room. This is because of the 1986 ``anti-
     dumping'' law, the Emergency Medical Treatment and Labor Act, 
     known as EMTALA. ``[A]s enforced by the Health Care Finance 
     Administration and recently upheld by the U.S. Supreme Court, 
     EMTALA is a civil right extended to all U.S. residents,'' 
     Wesley Fields, chairman of the American College of Emergency 
     Physicians Safety Net Task Force, recently wrote. Crowded as 
     we are, if you walk in the door, you'll be treated whether 
     you can pay or not. Just get in line and take a number with 
     everyone else.
       I don't like this any more than my dissatisfied, frustrated 
     patients do. I tell them that it's like rush hour on I-66--
     too many bodies packed into a space built ages ago for a much 
     smaller population.
       But like most of life, the mess is more complicated than 
     that. One very important factor is the total number of beds 
     available in any hospital--particularly ICU beds. State and 
     local health agencies regulate the number of beds based on a 
     long list of factors: population, estimates of disease 
     prevalence, average lengths of stay. In the early 1990s, 
     conventional wisdom held that managed care would reduce the 
     occupancy rate. To a significant extent, that happened, and 
     in the mid-90's empty beds forced a number of underused 
     hospitals to close. In 1990, according to the American 
     Hospital Association, there were 927,000 staffed beds in 
     5,384 community hospitals in America. In 1999, the last year 
     for which there are complete numbers, 4,956 such hospitals 
     provided just over 829,000 beds. Meanwhile, the country's 
     population had grown by 10 percent.
       Many of those vanished beds might have been superfluous 
     anyway, due to a sweeping explosion in medical technology and 
     therapeutics. Ten years ago, a heart attack kept a patient in 
     the hospital for just under nine days; by 1998, these folks 
     were out the door in six. Stroke? The average length of stay 
     was down by a half: 10 days to five. Home nursing and IV 
     therapy freed countless patients from the confines of a 
     hospital bed. But the hospital closings were uneven. In 
     booming suburban areas such as Northern Virginia, money 
     poured into expanding both high-tech services and customer-
     friendly support at mega-hospitals like Inova Fairfax. But 
     some smaller hospitals, like Jefferson Hospital in Loudoun 
     County, found their beds chronically empty and had to close. 
     (The planned shutdown of D.C. General's inpatient facility is 
     a result of forces pushing in the opposite direction, 
     resulting in too many unused beds.)
       When hospitals close, it puts more pressure on those that 
     survive. At Inova Fairfax, occupancy averaged a jam-packed 92 
     percent over the past year. Thom Mayer, chief of our 
     emergency department, put it this way: ``The inpatient 
     population is so high so regularly that a mere 20 or 30 extra 
     patients throws us back into full crisis mode.'' And that can 
     happen during one shift in a busy emergency room.
       Beyond the number of beds, just how many are available at 
     any given time often comes down to two letters: RN. A 
     hospitalized patient needs a doctor for just a few minutes 
     each day, but nursing care must be available around the 
     clock. But, like hospital beds, fully qualified nurses have 
     been disappearing fast, too. A widely cited study from 
     Vanderbilt University, published last year in the Journal of 
     the American Medical Association, pointed to some ominous 
     trends. A key finding: The average age of nurses is rising. 
     The number of nurses under the age of 30 fell from 419,000 in 
     1983 to 246,000 in 1998; by the end of this decade, the study 
     said, 40 percent of working nurses will be older than 50. 
     Retirement will create an estimated shortfall of half a 
     million nurses in the year 2020. The clear reason: A decline 
     in the number of high school girls who go to college intent 
     on becoming nurses. ``Women, who traditionally comprise the 
     majority of nursing personnel, are finding other career 
     options that are less physically demanding, more emotionally 
     rewarding and come with a higher rate of pay,'' Brandon 
     Melton, representing the American Hospital Association, told 
     a Senate subcommittee earlier this year. And men aren't 
     making up for the shortfall.
       My wife, a savvy, experienced nurse, last did floor work 
     more than 10 years ago, and though conditions were tough 
     enough then, she recoils at what she would face if she went 
     back now: More and sicker patients on an exponentially higher 
     number of meds; less time getting to know the person who is 
     the patient, and therefore less opportunity to catch early 
     signs of deterioration; widespread use of ``health techs''--
     people who take vital signs and dispense pills but have no 
     training for more meaningful interaction. No wonder students 
     at nursing schools dread the first few years following 
     graduation, because before they can get to the challenging, 
     rewarding places to work, such as ERs or ICUs, they have to 
     get experience on inpatient wards.
       It's crowding in those ICUs that puts the worst pressure on 
     the ER. In the highly sophisticated environment of the ICU, a 
     patient's heart rate or blood pressure can be fine-tuned with 
     a shift of an IV drip. A phalanx of monitors register any 
     number of physiological trends to answer the question, ``Is 
     this person getting better or worse?'' When a patient 
     requires this moment-by-moment scrutiny and all ICU beds are 
     filled, the only place with roughly equal capacity--the only 
     place we can perform the same level of care--is the ER. This 
     ties up our nurses and blocks the bed from the next guy 
     waiting to get in.
       And chances are, that next guy is in pretty bad shape. Most 
     people who come to the ER these days have higher ``acuity'' 
     than a decade ago--that is, they're sicker. There's been no 
     easy way to quantify this change, but, like tornado victims, 
     ER does know what we've been big with. We spend more time 
     trying to get a borderline patient ``tuned up'' enough to go 
     home rather than be admitted to a busy, barely staffed 
     hospital floor. We arrange home delivery of nebulizer 
     machines for asthma patients. We check out the patient 
     discharged yesterday after surgery who is back today, feeling 
     weak, wondering if he's really well enough to be home. I kind 
     of miss the good old days when a 10-hour shift meant a string 
     of straightforward technical procedures--like reducing a 
     dislocated shoulder or sewing a complex laceration. These 
     days, it seems more time is spent tracking down a patient's 
     three or four specialists--the oncologist, the psychiatrist, 
     the infectious disease guy--or negotiating with the intake 
     person to authorize a bed or transfer the patient to a 
     hospital that accepts his insurance.
       Whine, whine, whine. I started writing this as a letter of 
     apology to all the miserable, aggravated patients who wonder 
     why they have had to wait so many hours to see me, and here I 
     am complaining about my own problems. I'll try to get back on 
     track, because the worst is still ahead. And the worst by far 
     is ambulance diversion.
       It happened a lot over this past winter. In Boston--hardly 
     a hospital-deprived town--the Globe reported that 27 area ERs 
     went ``on diversion'' for a total of 631 hours in November, 
     677 hours in December and more than 1,000 hours in January. 
     And it was worse in Northern Virginia: In January, the area's 
     13 ERs placed themselves on diversion for more than 4,000 
     hours. Evenly divided, and it most assuredly was not, that 
     would be every ER refusing ambulances for 10 hours

[[Page 12062]]

     every day. Almost half the time, back in that icy January, if 
     you needed an ambulance to get to an ER you were SOL: 
     severely out of luck.
       The American College of Emergency Physicians is certainly 
     concerned about the problem: Last October, an advisory panel 
     proposed guidelines for ambulance diversion, blaming ``a 
     shortage of health care providers, lack of hospital-based 
     resources and ongoing hospital and ED [emergency department] 
     closures.'' But it's easy to get the feeling that others at 
     the national level aren't taking it seriously. At a public 
     health conference in November, at the beginning of the 
     critical winter season, U.S. Surgeon General David Satcher 
     was quoted as recommending that people be ``educated'' not to 
     go the emergency room unless they really need to. Dennis 
     O'Leary, head of the Joint Commission on Accreditation of 
     Healthcare Organizations, a critical monitoring group, was 
     quoted as saying: ``Quite frankly, this problem waxes and 
     wanes . . . but without anything tangibly happening it 
     resolves itself . . . The system will somehow muddle 
     through.''
       They're right: I muddle through each shift worrying about 
     patients trapped in the waiting room or ambulances that can't 
     discharge their passengers at our door. I mutter humble 
     apologies to private docs outraged that the patients they 
     sent in specifically for urgent treatment--pain control, 
     antibiotics, whatever--cool their heels for hours on end. I 
     go home exhausted and aggravated with myself after 10 hours 
     of juggling alternatives so as not to put a patient into a 
     scarce bed--telling people to try a ``stronger'' antibiotic, 
     ratchet up the home respiratory treatments, take a few extra 
     tabs of pain reliever each day, and always be sure to follow 
     up with your own doctor tomorrow. I wonder which patients are 
     going to be back in another ER the next day because I missed 
     their real problems or insisted on an ineffective patch.
       Doctors and nurses have a bottom line that ultimately 
     distinguishes us from other professions: quality patient 
     care. When we can't provide this, we have failed. Our 
     hospital administrators and department chiefs assume that 
     excellent patient care is a non-negotiable minimum standard. 
     But every winter, and increasingly at other times, the crash 
     of the system is the quite capitulation to these accumulated 
     pressures. When forced to maneuver so many sick patients 
     through an overwhelmed system, I just don't know if I'm doing 
     a good job any more. As a result, I often find myself phoning 
     the patient the next day, checking in: ``Everything okay 
     today?''
       Many of the region's hospitals have received, or are 
     negotiating for, approval for more beds. Where more nurses 
     will come from is another problem. Anthony Disser, the chief 
     executive nurse at Fairfax, says the intrinsic value of 
     nursing is already luring a certain number of burned-out 
     software writers or disappointed entrepreneurs for a second 
     career. Yeah, I guess we are muddling through, after all.
       I look forward to that ``Unraveling Safety Net'' meeting in 
     Atlanta in three weeks, where I expect to be transfixed, like 
     the audiences at ``Hannibal,'' by the horror stories and dire 
     statistics of other ER docs and public health researchers. 
     Maybe they've been coming up with some solutions. If they 
     have, I hope they haven't been waiting till May to share them 
     with the rest of us.

                          ____________________