By Avram Goldstein
Washington Post Staff Writer
Monday, July 14, 2003; Page B01
Bioterrorism experts are developing a
do-it-yourself triage system in an attempt to prevent
panicky crowds from overwhelming Washington area
hospital emergency rooms during an epidemic or terror
attack.
The idea is to get the public to use a
sophisticated electronic questionnaire that would get an
instant medical risk assessment and to help persuade
those who seem not to be at risk to stay away and give
medical professionals time to focus on patients who are.
After the computer leads someone through the
questions, either online or over the telephone, the
patient would be advised according to what the symptoms
seem to be. The options the system might offer include:
stay home in voluntary quarantine, go to a designated
site for follow-up care, move to an isolation facility
or just relax.
The system could be updated with localized
information about the hazard and the nearest appropriate
medical help, said one of its developers, Georgetown
University biodefense coordinator Michael D. McDonald.
Programmed correctly, it could be used to respond to
severe acute respiratory syndrome, smallpox, nerve
agents, radiological hazards and unforeseen diseases or
emergencies.
The project is being coordinated by McDonald and
Harvard psychiatrist Stephen E. Locke. They have secured
no formal funding commitments, but Georgetown officials
are conducting meetings that include discussions of the
concept with public health officials.
Proponents say the electronic assessments would
ease pressure on hospitals while protecting the
so-called "worried well" from gathering where they would
be in close quarters with people who actually had been
exposed to pathogens or chemical agents.
Some experts, though, question whether the
screening tool might give bad advice, and they said they
doubt many people would seek or accept electronic advice
when they are fearful. Others said they worry the system
might inadvertently discourage some sick people from
seeking help that they need.
Most local public health officials and
bioterrorism experts are not familiar with the program,
but several said anything that might limit a post-event
surge of people to hospitals would be welcome. "If it
doesn't cost much and keeps anybody away from the ER,
it's worthwhile," said Arlington County Health Director
Susan Allan.
"Many patients we saw in our emergency room during
the anthrax attacks would not have needed to come in for
care if they could have had simple questions answered,"
said the director of a large emergency room who spoke on
the condition of anonymity. "You could lop 20 or 30
percent off the top."
"It's a very exciting and potentially valuable
tool," said Michael S.A. Richardson, the D.C. Health
Department's chief medical officer. "It gives the public
a way to access important information in a crisis so
they can act appropriately . . . The physical facilities
are not going to be able always to handle large amounts
of people efficiently. Large groups of people should not
be out on the streets."
Richardson wants the District to anchor the
Washington region testing of the software, and triage
system leaders at Georgetown and Harvard say they plan
to make the national capital area a "test bed" for the
project, along with Pittsburgh and Massachusetts.
Another group is working on a similar concept in Los
Angeles, they said.
But McDonald and Locke said that some experts have
doubts. "Somebody is scared to death, and you suggest
going to the computer and starting to answer questions,"
said Ken Alibek, a former Soviet bioweapons expert who
defected and now is a biodefense specialist at George
Mason University. "Some people would do it, but the
great majority wouldn't be able to do it. The major
engine is fear."
Concern about the "surge capacity" of health care
facilities has sharpened since the anthrax attacks of
2001, when about 20,000 people in the region were given
preventive antibiotics, mostly by public health
agencies.
Thousands of others went to doctors and emergency
rooms complaining of symptoms. Few turned out to be at
risk of contracting anthrax. The rest, McDonald said,
were somatizing -- experiencing physical symptoms caused
solely by psychological distress. Experts say physical
ailments rooted in the mind account for up to half of
office visits to primary care doctors.
"Even in normal times, somatization is the leading
reason why people seek care from a doctor," said Locke,
who also is president of the American Psychosomatics
Society. "People go to doctors with physical complaints
in which careful evaluation fails to reveal an organic
cause from one-third to one-half of the time."
In a major outbreak, stress-related symptoms could
run wild, causing huge lines and flooding facilities
with people who do not need to be there, McDonald and
Locke say.
"Conservatively, the somatizers will likely
outnumber those actually exposed by 5 to 10 times,"
according to a report on the screening tool by Harvard
researchers supervised by Locke. "However, it is
conceivable that this number may in fact be much
larger."
Georges C. Benjamin, executive director of the
American Public Health Association and former Maryland
health secretary, said he knows telephone triage
protocols can be effective because he used to write them
for private health plans.
"You absolutely can sort people into high-risk and
low-risk groups," he said. "The research needs to be
done to figure out what you do with people who are
giving you exactly the symptoms they read about or saw
on television . . . And you have to make sure that you
identify people who are both somatizing and [also]
sick."
SARS, smallpox, chemical agents, radiological
bombs or an entirely new "engineered agent" -- a
combination of deadly pathogens -- could trigger a far
more intense public response than anthrax did, according
to experts working on the triage project.
"When you put a lot of people under stress, you
suddenly have a huge surge in demand of people needing
help determining whether their symptoms are due to
stress or exposure," Locke said.
Models of the questionnaire ask for personal and
contact information, take the patient through
descriptions of symptoms, inquire whether the patient
often somatizes and ask about the patient's attitudes
about health care and life.
Dan Hanfling, director of emergency management and
disaster medicine for Inova Health System, said of the
anthrax scare that brought large numbers of the
uninfected people to emergency rooms, "That opens a
window of experience on what we are likely to face in
the next event." He added, "We need to preserve the
ability to deliver acute health care. This will have
hiccups, but I think it's a great step in the right
direction."
Some say they think the system needs extensive
testing. "I think the concept would be fine, but I see
all kinds of possible problems," said Philip S.
Brachman, an Emory University epidemiology professor who
spent 32 years at the Centers for Disease Control and
Prevention in Atlanta. "It has to be field-tested very
carefully in a random way with good controls by an
independent group."
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