National report — While the H1N1 or swine flu virus pandemic hasn’t proven particularly deadly to date, sources say it should remind dermatologists to remain vigilant and prepared for myriad threats, from infectious agents to natural disasters, bioterrorism and power outages.
“The pandemic issue will impact all of us, regardless of where we’re located geographically,” says John W. McDaniel, president and CEO of Peak Performance Physicians, LLC, a New Orleans-based practice improvement consultancy.
“It’s probably a better wake-up call” for practices nationally than a hurricane, which would impact only coastal areas, he says.
The World Health Organization (WHO) declared the outbreak of H1N1 flu, a subtype of influenza A, a pandemic in June. The designation refers to the spread of the illness, not to its severity.
In a flu pandemic, “The threats to clinicians and patients are just about equal,” says Joseph Quimby, senior press officer for the Centers for Disease Control and Prevention (CDC), adding that the CDC offers complete planning advice for clinicians on its Web site ( http://www.cdc.gov/).
So far, “The response from the medical community has been very good,” he says. “We know from phone calls, medical associations and the number of hits on our Web site that people in the health field are leaning forward” to learn what they need to know.
“But that doesn’t mean there’s not room for improvement,” he adds.
Despite the wealth of disaster planning information available at federal, state and local levels, Mr. McDaniel says, “Very few practices actually engage in disaster planning.”
Practices at risk of natural disasters do, he says, “but natural disasters are only a small percentage of the disasters that occur in the United States.”
Hurricanes account for 10 percent of medical practice disruptions, he explains, while power outages cause 70 percent. Between these extremes lie disruptive breakdowns of computer and telecommunications equipment, Mr. McDaniel says.
Still, emergency plans have commonalities, whatever the nature of the event, experts say.
Owen J. Dahl, a practice management consultant in Houston, says whether disruption is anticipated due to bioterrorism, general terrorism, weather, a pandemic or another unexpected occurrence, “There are some basic principles everyone should consider.”
Use common sense
Precautions against a pandemic such as H1N1 mainly require use of common sense, sources say.
With the amount of traffic through dermatologists’ offices, says Erin Boh, M.D., Ph.D., “It’s an exposure issue more than anything.” She encourages colleagues to “do the things we should normally be doing to minimize the spread of infections.”
Dr. Boh, professor and chairman of dermatology, Tulane University, New Orleans, and Mr. Quimby specifically recommend making sure employees stay home when they’re ill.
“If all the staff are out,” Mr. Dahl says, “you’ve probably got to close the office. And somebody must be prepared to call patients to let them know.”
If many staff members stay home, adds Hugh M. Greenway, M.D., chairman of dermatologic surgery and CEO emeritus of Scripps Clinic in La Jolla, Calif., dermatologists should consider treating only high-priority dermatologic diseases, and rescheduling routine follow-ups.
Dr. Greenway is also a member of the American Academy of Dermatology’s disaster preparedness task force.
For patients who may present during a pandemic, experts recommend taking extra precautions.
Dr. Boh says, “We put signs up in our clinics and in the hospital: ‘If you have a cough, put a mask on.’ It’s a little bit (of) overkill, but it helps minimize the spread.”
Mr. Quimby adds that people can’t wash their hands — or use hand sanitizers, or cough into their sleeves, if needed — enough. Dr. Greenway also recommends staying at least five feet away from anyone who’s coughing.
Robert A. Weiss, M.D., president of the American Society for Dermatologic Surgery, says that in his practice, awareness of H1N1 has resulted in “hand sanitizers everywhere,” from check-in and checkout to each examination room.
Who’s to be treated?
Practitioners should decide beforehand whether to treat or turn away patients with pandemic symptoms, and whether to require that employees be vaccinated (and at whose cost), Mr. Dahl says.
Dr. Boh notes that dermatologists can offer the H1N1 vaccine — once it’s available — to patients at highest risk, such as those on immunosuppressive therapies. If the CDC’s priorities prevent this, she advises referring such patients to their primary care physicians.
Another concern is that patients with H1N1 often have other health issues.
Those patients “need to see a physician,” Mr. Quimby says. “We’re finding that more than 71 percent of people hospitalized with H1N1 have other underlying health conditions,” such as asthma.
Experts also advise maintaining awareness — but without obsessing.
“It’s important to stay informed” during an emergency, says Eve Lowenstein, M.D., Ph.D., chief of dermatology, Brookdale Hospital Medical Center, Brooklyn, N.Y., but unless it’s necessary to check for weather updates or breaking news, she says, monitoring media coverage 24/7 merely fuels panic.
And the psychological trauma such coverage can create could exacerbate primary skin diseases, such as eczema and psoriasis, or drive patients into prurigo nodularis, she says.
Physicians who experienced 2005’s Hurricane Katrina and the subsequent flooding of the New Orleans area have much advice to offer from personal experience.
Tulane University’s emergency preparedness protocol now kicks in five days before the start of hurricane season, Dr. Boh says. The plan requires all staff, including residents, to register three alternate locations and a nonuniversity backup e-mail address at least 48 hours before evacuating.
When Katrina hit, “Our server went down, so we had no way to contact people,” she says. “So now, at the start of the season, everybody gets a printout and a flash drive with everybody’s contact information.”
Tulane also arranged for two off-site servers in different locations to back up its main server, she says.
Additionally, staff members can register their cell phone numbers with Tulane to receive text messages such as evacuation or “all clear” notifications, Dr. Boh says.
“Each department has a point person — in dermatology, it’s me — who stays at the hospital or elsewhere,” she says. “One of our residents has to stay back, as well — usually, the consult person.”
About 72 hours before landfall, a state-run system now being implemented will begin evacuating nursing home and hospice residents and the homebound, she says.
Dr. Boh says the dermatology department has secured alternate locations where residents can work if evacuation is lengthy. The department also has designated a backup team, housed in Baton Rouge, La., to relieve the skeleton crew (which then goes to Baton Rouge), if needed, she says.
“Residents can’t be on call for five consecutive days,” she says. This system worked well during 2008’s Hurricane Gustav, which missed New Orleans, but provided a valuable “dry run,” she says.
However, Dr. Boh says that during Katrina, the most important thing New Orleans area physicians needed — and still lack — was a quick path to long-term licensure in other states.
“We should have some sort of uniform general licensing process” that requires physicians to pay neighboring states’ fees only when they actually practice there, she says.
Possible bioterrorism attacks also should be on the radar when physicians draw up emergency plans, experts say.
According to Raymond J. Dattwyler, M.D., professor of medicine and microbiology/immunology and chief of the division of allergy/immunology and rheumatology, New York Medical College, Valhalla, N.Y., while most pandemic diseases have been eradicated in nature, dermatologists could still be involved in the case of outbreaks created by biological agents that cause cutaneous manifestations, particularly plague (Yersinia pestis).
“And we would only see that if there were a biological attack on the United States,” Dr. Dattwyler says.
The former Soviet Union’s vigorous bacteriological warfare program developed plague and smallpox into bioweapons, he says.
“Could anybody ever use those against us? Unfortunately, yes,” he says.
Smallpox doesn’t exist outside of laboratory samples, he says, but plague is endemic and easily obtainable worldwide.
Dr. Dattwyler says dermatologists should follow federal, state and medical society preparedness recommendations, and “make sure they have their smallpox vaccines up to date.”
For airborne agents, precautions include using N40 surgical masks, he says.
“We did get quite a few consults to rule out anthrax” and smallpox after the 9-11 attack, Dr. Lowenstein says.
If a bioterror attack should occur and patients swarm dermatology offices with serious concerns such as smallpox, she recommends giving these patients “fast-track” appointments to provide quick answers.
“You (also) must know whom to alert if you see one of the first sentinel cases,” she says.
Lending a hand
Dr. Dattwyler says dermatologists could volunteer to diagnose and treat disaster-afflicted patients.
Although there’s no effective plague vaccine, he says, bioweapons commonly involve an infectious disease process, “and the United States has stockpiled therapeutics for most of these agents.”
Whether bioterrorism-related or not, disasters teach medical practices “how local they really are,” Mr. McDaniel says.
“When the locality is severely impacted, closed or, in certain cases, quarantined, you’re out of business,” he says.
Dr. Greenway adds that during disasters, “Patients bypass their doctors’ offices and go directly to a hospital or emergency room,” so healthcare systems must be able to support those facilities.
For example, hospitals may set up tents to treat patient overflow.
“Hospitals probably will call on their hospital staff to help staff those,” he says. “Dermatologists and other specialists can serve many ways in various disaster programs.”
Above all, Mr. Dahl encourages physicians to adopt the attitude Dwight Eisenhower expressed toward battle plans. In actual battle, “The plans themselves are useless,” he says, “but the planning process is indispensable.”
Physicians can theorize and think they’ve created great emergency plans, “but the circumstances of a disaster will cause us to do things differently than we (had) planned,” Mr. Dahl says.
Disclosures: Drs. Boh, Dattwyler, Greenway, Lowenstein and Weiss report no relevant financial interests.
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