Monday Morning Crisis Quarterback

Anyone who's ever had any kind of emergency training at all has heard some version of the same speech.  "Before you try to help," it goes, "make sure that you yourself can assist safely.  Do not become a casualty yourself."  In a Red Cross CPR class, this comes in the form of the reminder to "Check, Call, Care," that is, check to make sure it's safe before you do anything else.  In a lifesaving swim class, it takes the form of "Reach or throw, don't go," meaning don't get into the water if you can help the struggling swimmer any other way.  CISM has a similar principle, usually expressed along the lines of, "If the incident is personal for you, get someone else."

I bring this up because on Tuesday I was assisting with a response and became a casualty myself, although not, perhaps, in the way you would think.

Earlier this week, a family from Ann Arbor was involved in a major car accident in Virginia.  The mother, Theresa Supica, and one of the daughters, Samantha, were killed, and two other daughters are in the hospital.  The girl who was killed was a student at Slauson Middle School in Ann Arbor, where I am the training coordinator for the CISM teams.  Tuesday night, the team leader for that part of the district had organized a crisis management briefing and general get together for the middle school community as well as the associated elementary schools and the high school the sisters attend.  It was outside on a large patio in front of the middle school.  She asked me to attend as one of the supporting members of the team, which I was happy to do.

Tuesday was a pretty hot and humid day in Ann Arbor.  After work I went to a weight lifting class and, despite the air conditioning, we were all sweating profusely.  About three quarters of the way through the class I started to feel somewhat nauseous, so I sat out in the hallway (where it was a little cooler) for the end of class and felt much better.  I hopped in my car and headed towards Slauson, about 10 minutes away.

Half way there, my stomach started to feel icky again.  I realized I probably should stop driving, and that I wasn't going to be much use at the CMB.  My cell phone was dead, so I thought I'd get to Slauson and find someone I knew to call my husband to come get me.  I pulled into the parking lot, got out of the car, sat down in the grass near my car and, not seeing anyone I knew in the immediate vicinity, flagged down a stranger who was just arriving.

I don't know what I looked like at this point, but it can't have been good, because the woman immediately looked alarmed and said, "What's wrong?"  I asked her to call my husband, and she went to get her cell phone out of her car.  By the time she returned, I was vomiting in the grass, breathing very heavily and losing feeling in my hands.  The woman called 911.

At this point I was pretty much doing a face plant in the grass.  I could hear everyone and I knew what was going on, but I couldn't move and felt just ghastly.  I could hear the woman trying to give directions to where we were, estimating my age ("middle aged" -- I was a little disheartened) and asking if I'd ever had a stroke "before."  When the paramedics arrived and got me onto the stretcher, I was shocked to see that quite a crowd had gathered.  It hadn't occurred to me that I was causing such a ruckus.

To make what is already a long story a little shorter, after 5 hours in the ER and all sorts of tests, the only thing wrong with me was dehydration.  I should know better.  Apparently, however, I don't.  I was embarrassed to have caused such a scene. 

More than anything, however, I knew that I had caused a scene in a place where people did not need more drama.  A community reeling from the sudden death of one of its own does not need the image of a relatively young (OK, middle aged), relatively healthy person being wheeled into an ambulance.  They don't need to hear sirens.  They are working on believing that the world is a safe place once again, and my little episode underlined that maybe it isn't.

To the friends, neighbors, teachers and family of Samantha Supica, I send my heartfelt apologies.  I became a casualty myself.  You have my deepest sympathies and my sincerest regrets.  Thank you for helping me when I should have been helping you.

In August, 2002, a Chicago woman who was 8 months pregnant reported that her gynecologist had raped her.  Forensic evidence, including a rape kit, was gathered, but no comparison sample was ever taken from the doctor.  This wasn't the first allegation of sexual assault against this doctor nor, as it turns out, would it be the last.  His license was suspended for several months last year after four women made allegations.  On Thursday, the doctor was arrested in the 2002 case, almost 8 years after it happened, but less than two weeks after his DNA was finally tested against the rape kit.

Now, a few disclaimers.  I don't know the alleged victim or the alleged perpetrator in this case, and obviously I don't know what happened that day in 2002.  Everyone is presumed innocent until proven guilty, and that holds for this case as much as for any.  However, for the sake of argument, I'm going to presume that this crime occurred exactly as described and the doctor is guilty.  Again, I don't know if that's true, but let's imagine it is.

When most people hear the word "rape" they imagine someone jumping out of the bushes or a dark alley and accosting a woman.  They imagine a weapon of some kind.  They imagine that the perpetrator and the victim don't know each other.  In fact, however, the rapist and victim are strangers to each other in only about 1 in 4 rapes.

Rape, regardless of the circumstance or relationship, is traumatic.  Rape violates the victim's sense that the world is a safe place and that they are in control of and can protect their own bodies.  Rape by someone you know and trust adds the extra violation of the victim's belief that they can judge character and that they are loved and cared for by those closest to them.  In this instance, there is the additional factor that the victim was pregnant.  While violence against pregnant women is certainly a known phenomenon, most of us hold the belief that pregnant women are sacrosanct, particularly towards the end of the pregnancy.  Here, a woman was raped while pregnant, not just by someone she knew but by someone she trusted to help her pregnancy be safe.  Obviously, that trust was violated in the worst way.

People who have experienced or been exposed to trauma often experience a sense of unreality, both during and after the incident.  It's very common to hear people say, "This can't be happening" or "It isn't true."  What they are actually saying, though, is that the fact that it is true is too much for them to bear.  They can't process it.  The only thing that helps that is time spent living with the notion that it did happen, and opportunities to process what that means for them.  But in this case, as in too many cases of sexual assault, the people who were supposed to help this woman either didn't believe her or didn't care enough to follow up, or maybe they had some other motive. 

Whether the victim was actually told this didn't happen, she certainly got the message that it didn't matter.  That is an especially difficult message to receive, because it directly interferes with processing the original incident and coming to terms with it.  People already worry that they are crazy for how upset they are and how a critical incident affects them.  If they're told it didn't happen, while they still know it did they have entered another phase of the incident and their own disbelief -- not only was this woman raped, and she felt it couldn't be happening, she wasn't believed, which again must have felt unreal.  If she was told it didn't matter, that just reinforced how crazy she was already feeling.

Reading about this case, I was reminded of an exam I had during my own pregnancy with my son.  My doctor, who is male, and his physician's assistant, who is female, entered the room.  I made some wise-crack about the PA being my bodyguard, and my doctor said very seriously, "She's not here to protect you, she's here to protect me."  In fact, she was there to protect us both, and to attest that nothing inappropriate happened during the exam.  I can only vaguely imagine what it would be like to be assaulted under those circumstances.  I can't begin to fathom what it would do to me, after that, to not be believed.

Photo copyright istockphoto/jenjen42

Yesterday afternoon we had a perfect storm at my school.  The secretary was out sick.  The clerk is in China.  The lead teacher was out of the building.  The nurse and all of the special education staff were in a meeting.  One of the teacher's assistants, the one who works with our most medically fragile students, was picking up her ill child from another school.  I was in my office with my boss having my evaluation conference.  It's hard to imagine a worse time for a student to have a seizure in the lunch room.

In all likelihood, there were probably a total of 90 seconds between the start of the seizure and when I got there.  The nurse was 30 seconds behind me.  In this day and age, we were lucky she was even in the building -- she is only there one and a half days a week.  Had everyone been in their usual places, it might have shaved 30 seconds off the entire thing.  Those extra 30 seconds, of course, felt like an eternity to the lunchroom staff, and probably sounded like an eternity to the family when we spoke to them.

This child has a known seizure disorder and a written plan for what to do.  I won't say my adrenalin didn't kick in at all when I started heading for the lunch room, but I will say I wasn't scared.  We had a plan, the nurse was on her way, and I knew this child was susceptible to seizures.  Stuff happens.

Once the nurse had taken over, I looked around at the lunchroom staff and realized that my reaction was not the same as theirs.  The one who had first noticed the student seizing was beside herself wondering if she had done the right thing.  Another one told me her brother, who died a couple of years ago, had died during a seizure.  Most of them just were not at all convinced that this child was going to be ok.  They work at the school 2 hours a day.  They've never encountered this child having a seizure before, and it triggered all sorts of emotions for them, as you might expect.  Those of us who have seen this before felt much better than they did.

I went back to my office and called the family.  Then I returned to my evaluation conference, and joked with my boss that there must be somewhere on that evaluation form to notate that in fact that had gone pretty well.

We spend a lot of time and energy preventing things from happening in schools, from shootings to fires to kids tripping over their shoelaces.  At the end of the day, however, you can't prevent everything.  And while we couldn't prevent this seizure, we could make sure we were ready, and we can go back and review how everything unfolded and tweak our procedures.  But even with these relatively "little" incidents, it's important to remember that, to someone on staff, this may not be little at all.  Someone's brother died.  Someone felt incompetent.  When it's over, it's important to support them, too, and review to see how you might have protected them from the trauma -- with a small "t."

There was a massive explosion at a Kleen Energy Services gas power plant under construction in Middletown, Connecticut at about 11 o'clock this morning.  Most recent reports suggest a gas leak may have been the cause, and that there were about 50 people working at the plant at the time.  Police officials said that this was a "mass casualty event."

If you don't do this sort of thing for a living, the term "mass casualty event" probably sounds pretty bad.  It probably sounds pretty bad if you do do this sort of thing for a living, too, but in a different way.  Most of us, when we hear "casualty" think "death," but of course that's incorrect.  Casualties include people who have been injured as well as people who have been killed.  A mass casualty event (MCE) is an incident that is of sufficient size that it will stress the first response and health-care system locally.  Different jurisdictions define how big something has to be to qualify as an MCE, and that also takes into account the capabilities of local responders.

Local hospitals in and around Middletown are reported to have activated their disaster plans.  On the face of it, this may sound odd.  We think of disasters as being earthquakes, tornadoes, floods and the like.  For the purposes of responding to them, however, there really isn't a big difference between a massive accident and a massive tornado.  If you work in the ER, you don't particularly care how all these people got hurt, but just that they did and how many of them there will be.  A disaster plan enables the hospital (or whoever) to plan for a situation that is going to tax their capacity.  It defines who does what when it's "all hands on deck."

Being injured in a mass casualty event as well as responding to one can have slightly different stressors.  The biggest difference that most people notice right away is the use of triage.  Responders have to choose who will get care first, and that means some people are going to have to wait.  If you are injured when your car hits a tree, for example, you are going to get the full attention of first responders.  If you are in a 50 car pileup, you will only get first attention if you are the most injured person that rescuers think has a chance of survival.  Anyone who has ever gone to the emergency room on a busy day has experienced triage.  You may be having the worst emergency of your life, but as long as someone else is having a worse one, you have to wait.

The triage involved in MCE's can become a predictable theme when responders and survivors work with crisis intervention personnel.  Survivors express the fear and frustration of being seriously injured and having first responders walk right by them without helping.  Responders report the horror of seeing multiple people in serious pain and having to leave them as they are rather than help.  There is nothing quite like having to step over a dying person without offering even comfort in order to save someone else.  These are choices none of us, even the highly trained, are used to making.

It will be a while before we know the full extent of the injuries at Kleen Energy.  That's also one of the hallmarks of an MCE -- helping comes before counting the people who need help.  As the dust begins to settle, this will be a big job for a CISM team, who will need to move in and help everyone recover from the difficult choices that had to be made today.

In the early 1980's, Rom Houben, a Belgian 20 year-old, was in a horrific car accident.  He was in a coma, and then diagnosed as being in a persistent vegetative state.  For 23 years, his family refused to accept his diagnosis and insisted he was conscious and aware of his surroundings.  Finally, with advances in brain scan technology, doctors were able to more thoroughly examine his brain and determine it was essentially normal.  Over time, they were able to help him communicate using a single finger and a keypad. 

Houben wasn't in a vegetative state at all, but rather suffering from "locked-in syndrome," a state where he was able to hear and feel and understand, but unable to move or speak.  The medical journal article that detailed his story estimates that up to 43% of people diagnosed as being in a vegetative state are actually conscious.

I'm sure this case will be the subject of much political debate.  The news coverage is rife with mentions of Terri Schiavo, the Florida woman whose husband's battle to remove her feeding tube made its way all the way to the United States Congress.  I acknoweldge that this case raises ethical questions, and I also acknowledge that I am completely unqualified to discuss them.

This story also raises questions for the families of those diagnosed as being in persistent vegetative states.  On the one hand, accepting the reality of their loved one's situation is important, regardless of what people decide to do about it.  Holding out unrealistic hope can trap people in the common trauma reaction of feeling like the situation isn't real.  On the other hand, if this study is accurate, about 4 times out of 10, it truly isn't real.

This story is very encouraging to those left behind by traumatic accident victims in vegetative states.  I truly hope that as many of them can be "unlocked" as this story predicts.  I just worry about the 6 out of 10 situations or more where this research will prevent survivors from accepting reality.

Deaths of children due to Novel Influenza A H1N1 rose 20% in just the last week.  So far 114 children have died.  That's what Bloomberg is reporting this afternoon, following the weekly update on the CDC website.  Bloomberg's coverage then continues with this penetrating commentary from Irwin Redlener, the director of the National Center for Disaster Preparedness at Columbia University:

This is very unsettling news for parents, particularly when coupled with the shortage of the vaccine. The situation is much more fluid and uncertain than the government expected and than the public is comfortable with.

So, let's face it.  A lot of us very naturally look to the news to tell us how scared we should be.  If something makes the news, we figure we should pay attention to it.  If it's bad, we figure we should worry about it.  In the case of something like a pandemic, the news is our major source of information.  So a 20% rise in pediatric deaths in one week scares us, and now we have an expert telling us that this is unsettling news, so we feel, well, unsettled.

Bloomberg, as the press often does, is violating the Quarterback's 5th commandment of H1N1 communication:

Thou shalt put thy information in appropriate context so that thy public may understand the dangers they face with relation to other dangers, and not overreact to thy numbers.

The fact of the matter is that nowhere do we have a sense of comparison between the number of pediatric deaths from H1N1 and other causes of death for children.  We don't know how many children have H1N1 in the first place, so we don't know what the chances of any given sick child dying might be.  We don't know how many children tend to die from seasonal flu, nor how many of these children were medically fragile and likely to die from something else if they hadn't contracted the flu.

The death of any child is a tragedy.  The highly publicized death of a child is scary to parents.  But the naked number "114" has no meaning whatsoever.  And the statistic "20% in one week" is unbelievably misleading -- I certainly didn't think the number was going to be in the low three digits when I saw that.

Which brings me around to Professor Redlener, who really ought to know better.  Not only does he tell us to be scared without any context at all (although, to be fair, he might have given context that was edited out), but he then goes on to tell us that this is much "more fluid and uncertain" than predicted.  That is patently false.  Back in August, the President's Council of Advisors predicted between 30,000 and 90,000 deaths from H1N1, which translates to between 5,400 and 16,200 pediatrict deaths.  We've had 114.  I would say that if we are more uncertain than we thought we would be, it's because the big shoes have yet to drop, not because there have been so many deaths.

Reporters are trying to sell newspapers, and fear sells papers.  An honest headline this week like, "Yep, Still Lots of Swine Flu" would not sell papers, so that's not what Bloomberg picked up.  They need to remember that hysteria is a lot more contagious than any flu can ever be.

Here in Washtenaw County, Michigan, we've been told for months that there is going to be H1N1 vaccine for everyone who needs it. In my school district, three clinics were scheduled to vaccinate anyone who wanted it at the three biggest high schools in town during the first two weeks in November. Similar clinics were scheduled at a variety of school sights around the county.

Then a couple of weeks ago, the word went out that actually, not everyone was going to be able to get vaccinated. In fact, these clinics would now be limited to health care workers, pregnant women, caregivers of children under 6 months, children from 6 months through 4 years old, and children ages 5 through 18 with underlying health conditions. One of our district's three clinics was canceled.

Clinics were set to begin this past Tuesday. In the days leading up to the first clinic, the word went out that only 1,000 people would be vaccinated at the clinic on Tuesday. The idea, apparently, was to spread the vaccine around to the various locations. What was not shared was how many doses of vaccine were dedicated to all the clinics put together, just that it wasn't nearly as much as originally hoped, but more was trickling in.

Monday's clinic, at our local Intermediate School District, was slated to run from 2:30 - 9:00 PM. The first person lined up at 9:30 AM. People parked 1/4 of a mile or more away from the building to get in line. By 5:00, the clinic was closed. My son was among the many people in the designated groups who planned (or whose parents planned) to get vaccinated that day who didn't even bother to get out of their cars.

That was Monday. By this morning, all of the school-based clinics had been canceled, and the convocation center at a local university is the location for a new, "mass vaccination clinic" for the same high risk groups next week. It suddenly seemed like a better idea to try to do as many people as possible all at once rather than have people go from clinic to clinic, hoping to be in line early enough to get their shot.

While the shortage of H1N1 vaccine may not have been predictable, scenes like this one certainly were. Anyone who's ever tried to get tickets for a popular rock concert can tell you what happens when you publicize that there is only a certain amount of something that people really want and that it will become available on a certain day, at a certain time, in a certain place. Its a wonder the Health Department didn't give out wrist bands ahead of time -- they might consider that in the future.

Back in July I predicted what a shortage of vaccine, or a prioritization of who can be vaccinated, or a rationing of health care during the pandemic, might do to people psychologically and how it might cause people to act. I'm not expecting that the powers that be read this blog, but if I can figure it out, so can they. Planning clinics based on the idea that you can vaccinate a certain number of people per clinic over a certain number of clinics over a certain number of days is all well and good, but you have to take into consideration how many people will want to be vaccinated each day. Around here, the Health Department seemed genuinely shocked by the notion that significantly more than 1,000 patients showed up for a 1,000 patient clinic.

This really shouldn't be that hard. You select which groups can be vaccinated based on which groups you think you can vaccinate without turning anyone away. You set up a mass clinic with lots of parking, and you publicize that everyone in those groups who wants to will be vaccinated. You allow people to make appointments, or get wrist bands, or something to spread out the crowds. And you hold the clinic until everyone who is entitled has had their shot. When more vaccine becomes available, you do it again. And you stop being shocked that the public's priorities and ideas about how to proceed do not include the convenience of the Health Department. That ship sailed a long time ago.

Several months ago, I blogged about what I thought was going to happen when people who are used to getting what they want in health care were told that they couldn't get the H1N1 vaccine right away. That scenario completely failed to recognize the possibility that people actually wouldn't want the vaccine at all. It turns out that both are true. About half of the population does not intend to be vaccinated, and the other half is facing something of a shortage, at least in the short run.

Here in Washtenaw County, Michigan, the supply of vaccine is coming in slower than planned. This means that scheduled H1N1 vaccination clinics are being postponed or scaled back. My school district had intended to hold 3 clinics during the first 2 weeks of November and vaccinate anyone who wanted it. Today we got the word that one of those clinics was canceled and the other two would only vaccinate high priority subgroups.

This was, in almost all respects, a possibility I was prepared to deal with. I was not prepared, however, to deal with perhaps the hardest crisis communication audience I ever have to face: my daughter. My daughter is 11 and healthy. Her brother is 4. That means that he is a high priority for H1N1 vaccine, and she is in the next tier down. This means that, at the beginning of November, instead of the whole family going to the clinic for our vaccinations, we will just take my son.

My daughter has a mom who does crisis and crisis communication for a living. She's used to talking about some pretty heavy things around the dinner table, and to weighing some difficult ethical topics. She gets why my son gets the vaccine and she doesn't, at least intellectually. And yet, it's hard enough when your baby brother gets all the attention and the presents and gets away with everything and everyone says he's cute (at least that's how it seems sometimes). Now he is a higher priority for healthcare. This is a form of sibling rivalry few of us have experienced.

I am telling myself that I'm OK with not getting the vaccine right away, and with waiting to get it for my daughter. I also know we have two students at school who have secondary infections following presumed cases of H1N1. They are very sick, and they've been out for a long time. I know the numbers and the odds -- I write about them incessantly. But those two kids are much more real than all the numbers in the world, and I identify them much more with my own daughter. I'd be lying if I said I didn't want an extra dose, just for her.

My daughter tells me it wasn't a year ago, it was a year less 11 days, but to me it was exactly a year ago, because it was the day before Rosh Hashanah. My secretary walked right into a meeting in my office -- something she never does -- and told me that my daughter was on her way and had hurt her wrist. I walked into the main portion of the office and peeked out the window at my 10 year-old, whose cries I could already hear. I could see her walking with a friend, her arm poking out of her sweater with her wrist looking curved in all sorts of places that wrists are not supposed to curve. It was obviously broken. She had fallen off the monkey bars on the playground and landed on her arm. As it turned out, her arm was broken in the wrist and above the elbow. She required surgery that night and two days in the hospital, with me sleeping on the couch beside her.

Was this a critical incident? Hard to say. A critical incident is one which has the capacity to overwhelm your usual coping skills. This was certainly more obviously a trauma for my daughter than for me, but at the same time it was more emotionally distressing to me than it was to her. She wasn't scared so much as she was wanting the pain to stop. I was scared for her and coping with the violation of my belief that I could protect my children from harm.

The first clue that this incident overwhelmed my coping skills comes when we compare this incident to one that happened a couple of weeks earlier. Another child came in from the playground having fallen from a swing, his arm also obviously broken. While the office manager called the father, I worked with other staff to carefully immobilize the arm so dad could safely take the child to the hospital. When my own daughter was the victim, however, I simply grabbed my purse and ushered her to the car. I didn't assess the injury, I didn't splint it, and I left my keys on my desk inside. When the ER resident put her x-rays up for me to see I was horrified, both because of how graphic the elbow break was and because it was clear that I should not have driven her myself, and certainly not without immobilizing the injury.

Another hint that this was traumatic for me is the vivid sensory memories it holds. I can play it in my mind like a slideshow: the sight of her wrist . . . the sound of her begging me to touch her fingers in the car because she couldn't feel them . . . the feeling of lifting her into the wheelchair . . . the scene of them cutting off her sweater . . . the sight of the x-rays . . . the sound of her teacher on the phone saying, "if I could have flown across the playground, I would have caught her" . . . the smile on the doctor's face after surgery . . . the taste of the dinner my friend brought me . . . the sight of the "relaxation station" the hospital placed by her bed with gentle lights shining in the darkness.

If you ask my daughter about that day, she talks about it fairly calmly. If you ask me, I shudder visibly. It was worse for her physically, but for me emotionally. It's a good reminder that the people most impacted are not always who you might think, that sometimes trauma isn't Trauma, and also . . . be careful on the monkey bars.

May all the Quarterbackers out there be inscribed for a sweet, healthy, happy and trauma-free New Year.

The New York Times is reporting today about efforts in New York City to better manage another outbreak of H1N1 "swine" flu. Not surprisingly, ER's were pretty flooded by the "worried well" in April and May, so they are trying to beef up their triage system outside of the hospitals. They are also instituting new communications plans.

This is all welcome news to me and my readers. I have posted twice about the need for better communication and attention to the panic side of the pandemic (see Flu Preparedness: Body AND Mind and The 2009 Flu Pandemic). It looks like New York is thinking in the right directions, and that's all good.

What is surprising, however, is the numbers being cited. Conventional wisdom, based on biological terror attacks such as the Aum Shinrikyo sarin gas attack in the Tokyo Subway System, holds that anywhere from 80-95% (with 80% being the most commonly cited number) of people seeking medical attention in a public health emergency are either the "worried well" or at best do not need to be hospitalized. However, based on the Times' numbers, on the worst days of the outbreak in May, 40-50 people were hospitalized while an average of more than 1,400 people were seen in the Emergency Room for "flu like symptoms." That means that the "worried well" and the not very sick accounted for about 96.5% of those going to the ER.

For those of us who have prepped for disaster with the so-called "80-20 rule" (80% of people will be worried well, while 20% will be actually ill), this is a sobering statistic. What it means is that we have vastly underprepared for people's level of panic about this disease, and the triage plans that even the most prepared jurisdictions have might not be enough.

Unless, of course, we get better at communicating and more directive about who should do what. Telling people that the symptoms include "fever," for example, is not going to be enough. Public Health authorities are going to need to say,

If you do not have a fever higher than X [and I leave it to them to determine what X is] you do not have the flu. Do not come to the triage center.

Note how I phrased this. It will not be enough to say not to come to the triage center. They need to say why. Doing so will increase credibility and make people listen more. It won't be perfect, but it might tamp things down to that 80-20 ratio. Because if it's going to be 96-4 and we have a major outbreak, our health system is in deep trouble.