Public Participation in Disaster Response: Prospects and Myths

1. Public Participation in Disaster Response: Prospects and Myths Griffin Trotter, M.D., Ph.D. Professor Department of Health Care Ethics Saint Louis University

2. Public Role In Disasters • Often mechanisms for appropriating the help of citizens and public groups (e.g., news media, service groups, school systems, etc.) are given sparse attention in disaster planning. • These groups often excluded from disaster exercises also • A Few Important Functions of the General Public in Disaster Response (emphasis today will be on pandemics) • Pre-Disaster Deliberation • Ancillary Medical Activities • Self-Triage, Self-Quarantine, Self-Decontamination, Self- Treatment • Search and Rescue • Evacuation

3. Pre-Disaster Deliberation • Good disaster policies and procedures are based on good reasons. In democracies, public values and ethical reasoning are a function of public deliberation. • Examples where public input is crucial • Triage (drug, vaccine, ventilator), Isolation and quarantine procedures, Takings, Conscription • Technique: Deliberative Polling

4. Ancillary Medical Activities • Manual ventilation • Copenhagen 1952, polio • New Orleans 2005, hurricane • Dead body transport and storage • Logistics and transporting supplies • Patient transport and toilet • Changing dressings • Administering routine pharmaceuticals

5. Self-Care • Self Triage • Deciding when to report to a SAC • Self Quarantine • Toronto v Hong Kong, SARS • Self Treatment • Extension of current policies • Self Decontamination • Personal decontamination kits • Showering at home

6. Search and Rescue • Currently most disaster protocols provide for professional search and rescue, assuming that virtually all casualties will be recovered in this manner. • The likelihood that this will happen approaches zero • Overall, about 80% of search and rescue in disasters is performed by untrained civilians

7. Self-Decontamination • Feasibility depends on contaminating agent • Personal decontamination kits • Insufficiency of current decontamination protocols

8. Myths that Prevent Optimal Public Participation • Panic Myth • Personnel Shortage Myth • Surge Capacity Myth • New Ethics Myth • Onsite Triage Myth

9. Panic Myth • Regarded by disaster researchers (e.g., Dynes, Quarantelli) to be among the most ubiquitous and wrongheaded myths in all of disaster planning • Causes reluctance to include citizens in disaster response, and overuse of coercion • Concept of Panic • Example of Misplaced Fears about Panic • 9/11 Aerospace Defense • Exotic Threats • Remedies • Education and Training • More balanced News Media

10. Personnel Shortage Myth • The Rule in Disasters: Personnel overload is far more likely to be a problem than personnel shortages. This reality is typically disguised in disaster drills. • The Problem: Situating personnel where they are needed; matching them up with the needed resources • Part of the Solution: Utilizing those who are already properly situated

11. Hospital Surge Capacity Myth • Hospital Surge Capacity is frequently the cornerstone of local disaster preparedness • Often this is based on the myth that hospitals can and should function as the primary treatment centers during disasters (and related myths, such as the belief that most casualties will arrive by EMS, already decontaminated) • To the contrary: Planners should focus on Secondary Assessment Centers

12. Hospital Surge Capacity Myth Continued • Ventilator Surge Capacity expansion is also too heavily relied upon. In a major pandemic, for instance, casualties will greatly outnumber ventilators. • Need to Rethink Ventilator Triage (next slide)

13. Example of Dynamic Norm: Ventilator Triage • Allocation of Ventilators often characterized as a “life or death decision” – but that is usually not the case • Ventilator Triage: Two problems likely to pertain: • Too few ventilators in the universe • Too few ventilators at treatment site (only thing that matters) • When there are insufficient ventilators at treatment site: • Construct protocols that use alternate forms of ventilation (bagging as in Katrina 2005, Copenhagen 1952, many others) • Construct secondary triage (priority) plan for determining priorities for allocating ventilators and bags (likelihood of survival (SOFA – PaO2, Platelet ct, Bili, Creatinine, MAP, GCS), years of life gained by survival, projected duration on ventilator, projected other resources needed to achieve survival, etc.) • Secondary protocols may need adjustment every few hours • Train and utilize unskilled volunteers, minimally injured, observers (e.g., at bagging) • Withdrawing versus withholding – arguably no difference (possible exceptions… chronic ventilator pts., preexisting pts.)

14. HHS PANDEMIC PLANNING ASSUMPTIONS From Toner and Waldhorn, 2006 Moderate scenario (1968-like)Severe scenario (1918-like) 90 million sick 90 million sick 45 million need med care 45 million need med care 865,000 hospitalizations 9.9 million hospitalizations 129,000 needing ICU 1.5 million needing ICU 65,000 ventilators 743,000 ventilators 209,000 deaths 1.9 million deaths Compare to Current U.S. Capacities (according to FluSurge 2.0) 750,00 non-ICU beds 90,000 ICU beds 105,000 Ventilators

15. New Ethics Myth • It is frequently claimed that fundamental ethical principles change in disasters; such that the overarching ethical principle becomes “do the greatest good for the greatest number,” or something similar • This claim is simply false. To the contrary, there is a change in circumstances during disasters that effects a change in equilibrium between middle and lower level ethical norms – more emphasis on immediate security and safety; less on liberty and privacy. • Hence, there is a practice paradigm shift away from ordinary clinical medicine to a rescue paradigm • Other ethical values do not fall off the map – Those who assume they do are likely to commit illicit acts against the public.

16. What are the Higher Level Ethical Principles that Dictate a Transition to the Rescue Paradigm? • They are not circumscribed by a single complete and comprehensive ethical theory (utilitarianism, Kantianism, communitarianism, etc.), because no one theory is embraced by the population at large • They coalesce around democratic political processes: To articulate GOOD REASONS for an intervention, one must first obtain some sort of PUBLIC JUSTIFICATION through democratic processes (e.g., an agreement that the proliferation of a lethal, transmissible contagion may justify involuntary confinement of the innocent) • Expertise in science or ethics contribute nothing to such determinations – a consensus of clinicians about a triage protocol, for instance, has no legitimate meaning unless it can be linked to public values. • The higher the level of organization (e.g., federal government rather than city government), the thinner, less comprehensive and less determinate public value systems will be • Under normal conditions, the various ways that differing persons prioritize competing values makes it difficult to construct one-size-fits-all ethical guidelines • This problem is mitigated somewhat in disasters, because of the coalescence of interest in survival

17. Rescue Paradigm Misapplied:Marcia Welby’s Failure to Respect the Prerogative to Refuse Treatment • Tularemia outbreak in Dover… • Welby’s decision on isolation justified by maxim to maximize survival • But this decision is based on a strict consequentialist approach that diverges from the public values invoked in the emergency powers act • All physicians are beholden to public values • State sponsorship of training • Dependence of public philanthropy • State sponsored monopoly on the practice of medicine • General civic duty • What about the Hippocratic Oath and Beneficence?

18. Onsite Triage Myth: Final Example:Nerve Agent Attack • Sarin release at shopping mall • Typical Protocol: • Secure Hot Zone, S&R to Warm zone, Treat Immediates, Decontaminate using classic HAZMAT corridor techniques, Further stabilization, Transport for Definitive Rx • Teaching Points • This decontamination scheme has 0% chance of working – (a) 80% or more casualties will self-evacuate prior to securing boundaries, (b) corridor techniques are too time consuming and difficult, and are not necessary under any reasonable “sufficiency of care” model for nerve vapor exposure, (c) all roads will lead to the nearest ED, (d) ED will be overwhelmed and unable to decontaminate all comers • Tokyo • Personal Decontamination Kits and Non-Congregation • Educating and Informng the Lay Public