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ER Doctors Fear Flu Crush

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New York Times Syndicate

By M.A.J. McKENNA And Andy Miller

Saturday, October 16, 2004

ATLANTA -- What will be the impact of the United States losing half its supply of flu vaccine?

Emergency room doctors predict a crush of flu cases that will overwhelm an already fragile system, forcing sick and elderly patients to lie on gurneys for hours, squeezing out others who need emergency care.

Alarmed at the possibilities, the American College of Emergency Physicians, a professional organization of 22,000 doctors meeting this weekend in San Francisco, plans on Monday to issue this warning: Unless ERs receive extra resources, flu patients will die.

"On any given night or day, in Atlanta and in major cities across the country, emergency departments are swamped with patients," said Dr.

Arthur Kellermann, professor and chairman of emergency medicine at Emory University School of Medicine. "Where will we find the hospital capacity to handle potentially hundreds of thousands of flu victims that will need at least evaluation and possibly hospital care?" The crisis that the ER doctors envision is a health care version of the perfect storm: a confluence of two trends, each challenging on its own, that together could produce "a disaster," according to Dr.

Matthew Carius of Norwalk Hospital in Connecticut, a past president of the emergency physicians' group.

The vaccine emergency is the first trend. Two weeks ago the federal government learned that British authorities, concerned about bacterial contamination, had impounded at least 46 million doses of flu vaccine headed to this country. That prevented delivery of almost 50 percent of this year's vaccine supply.

The Department of Health and Human Services has been unable to replace the lost doses from companies not licensed to sell their products in the United States. Instead, the Centers for Disease Control and Prevention sharply adjusted its vaccination target recommendations to include only those at highest risk, and moved to guarantee that they -- and health care workers -- get what vaccine is available.

Even with that rationing, some health officials fear the vaccine shortfall could cause a rise in the expected 36,000 flu-related deaths and more than 200,000 hospitalizations in the United States every year.

And those who are most seriously ill will probably enter the system through emergency departments, which are already severely stressed.

Since 1990, more than 1,000 ERs have closed nationwide, and hospitals, needing nurses and lacking funds, eliminated more than 200,000 inpatient beds, according to the American Hospital Association.

The closures have produced a crunch: Fewer ERs for patients to go to and, when patients arrive, fewer inpatient beds to receive them. The result: emergency departments that are already at maximum capacity, unable to absorb fresh waves of the sick.

"The glass can never get more than completely full," said Dr. David Talan of the University of California in Los Angeles, a city where four hospitals have filed plans to close their ERs. "But the more you pour into it, the more runs down the sides." Rerouting patients Nationwide, emergency patients suffering from flu pose particular problems. They may be among the estimated 45 million Americans without health insurance -- therefore likely to have postponed care, for fear of the cost, until they are extremely ill. In addition, flu is most serious in the elderly -- who are more likely to have other medical conditions.

In large cities, some ERs cope by going "on diversion," routing ambulances to another hospital nearby. In Atlanta, Kellermann said, at least one major hospital goes on diversion every day. But in rural Georgia, there may be no other hospitals nearby.

Brenda Josey is preparing for a higher-than-normal influx of patients at Wheeler County Hospital, a 25-bed rural hospital in Glenwood, where she is chief executive officer.

Typically, the hospital vaccinates 300 to 500 people at the facility, its five rural health clinics and nursing home, but hospital officials have not been able to obtain either flu shots or inhalable FluMist vaccine. About 6,000 people live in Wheeler County.

"If nursing home residents can't be vaccinated, then we'll likely have a full house at the hospital," Josey said. And if hospital workers don't receive their own flu shots, "it could get pretty critical," she said. "It could be catastrophic." In its preparation for flu season, the hospital is looking to hire extra registered nurses.

"If two nurses get sick now, we're in a world of hurt," Josey said.

"We're the first line of defense for many people in this area" who have serious respiratory or heart conditions.

"A bad flu could take them out," Josey said.

Children's Healthcare of Atlanta, which operates the two biggest children's hospitals in Atlanta, would take steps similar to those in the past to deal with a bad flu season, said Dr. Harold Simon, a pediatric emergency medicine physician at Children's.

"We actually got hit hard with flu the last two years,"' he said.

Last year, Children's Healthcare converted available space, including general outpatient areas, for patient care. Staffing was increased, and work hours were extended. Administrators who are nurses or physicians took care of patients as well.

"We do have the ability to expand capacity,"' Simon said. "'We may have to do the same thing this year."' During a heavy flu outbreak, some patients arriving at a hospital will have to wait to get a bed, said Dr. Robert Capparell, hospital epidemiologist for St. Joseph's Hospital of Atlanta.

"'It will be very difficult to receive help in a timely manner," he said. If St. Joseph's is inundated, the hospital may have to consider halting or cutting back on elective surgeries.

Emory University's hospitals would open unused beds, reassign on-call physicians, and, if necessary, invoke its bioterrorism/disaster plan, said Dr. Kate Heilpern, an associate professor of emergency medicine and assistant dean.

How bad will it be?

The urgent question is: How many Americans will contract flu? To anticipate the impact, ER administrators must account for two variables: the severity of the coming virus and the ethics of individuals.

If the flu season turns out to be light, illness and deaths could be lower than usual. The same could be true if Americans heed the CDC's plea that healthy people forgo the shot.

In the 2002-2003 flu season, the last for which the CDC has solid numbers, almost 21 million healthy people between 2 and 64 were vaccinated. If every one of them stepped back this year, their forgone doses -- which represent 37 percent of this year's 56 million available doses of vaccine -- could be used to protect those most in danger.

That could end up reducing deaths, because in an average year, only two-thirds of the elderly -- those at highest risk of dying -- get a flu shot. Those 21 million extra doses could provide enough vaccine to protect the remaining third, with some left over for other high-risk groups as well.

That does little to increase ER doctors' optimism. Even if the flu season turns out to be manageable, they say, the underlying problems will remain.

"There is no simple fix," Carius said. "We have to get back to devoting appropriate resources to the health care needs of this country." M.A.J. McKenna and Andy Miller writes for The Atlanta Journal-Constitution. E-mail: mmckenna@ajc.com; jamiller@ajc.com Editor Notes:Story Filed By Cox Newspapers For Use By Clients of the New York Times News Service



c.2004 Cox News Service

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