A bird flu pandemic hit the University of Arizona Oct. 31.
But it wasn’t real.
Here’s the scenario: Increases in human-to-human transmission of the flu in Thailand led the World Health Organization to raise the pandemic alert to its highest level. Countries scrambled to stockpile the limited flu medication Tamiflu. People at the UA had to decide who to treat first and whether to put themselves at risk by treating patients.
Nearly 600 students from different majors participated in the exercise mimicking challenges professionals face during a large-scale health emergency.
Dr. Andreas Theodorou, chief medical officer of the University of Arizona Health Network, and Dr. Hal Strich, associate director of the university’s MD-MPH program, created the program.
Theodorou said a pandemic flu has been used as the simulated disease in past exercises because it is something that can actually happen. This year’s event coincided with the worst Ebola outbreak in history, making it especially meaningful for students.
“No longer is this theoretical,” Thedorou said. “Now there is a sense of urgency because people are reading it and seeing it every day.”
The exercise brought together students from medicine, nursing, pharmacy, social work, law and – for the first year – journalism, to explore logistical, social, ethical and legal problems that come up during disease outbreaks.
According to Theodorou, the UA is the only university in the country to run an exercise like this. However, Dr. Richard Carmona, the event’s “Incident Commander” and keynote speaker, said he gets requests from universities asking for assistance in recreating the pandemic exercise for their students. Students from Arizona State University, Northern Arizona University, Midwestern University and Southwest College of Naturopathic Medicine and Health Sciences took part in the UA program last week.
A UA graduate and the 17th surgeon general of the United States, Carmona spoke about his experience dealing with the aftermath of Hurricane Katrina and the terrorist attacks on Sept. 11.
“We started realizing that there is a whole host of challenges that we will be facing as a nation and in each community,” Carmona said. “All emergencies are local, that’s where they start. It doesn’t matter that the feds may ultimately come in.”
Carmona stressed that it is time to stop waiting to train people how to respond to emergency situations.
“Let’s start planning for these bad things, and let’s start with students,” Carmona said.
He emphasized the importance of working in multiple disciplinary teams to solve the challenges that communities and the nation face in the event of a pandemic.
“None of us can do it alone,” he said. “It’s all of us working together in a coordinated fashion.”
Participants learned there would be no right or wrong answer to the challenges, but that decisions would have to be made.
“The public is expecting perfection, that nothing slips through, but we’ll never have a perfect system,” Carmona said. Every decision is a balance of risk and benefit, he added.
And so the exercise began.
WHEN SUPPLIES RUN OUT, WHO GETS WHAT?
In the scenario, participants were told that limited medicine to treat patients was available. Students used nine criteria to make decisions: caregiver priority, critical infrastructure, first come first served, health care professionals service, longevity, pregnant women, prognosis for recovery, safety and security, and severity of illness.
“How can you tell the public that certain people will be treated over others?” asked public health senior Travis Connors. “And make them understand why?”
One student proposed treating the medical teams first.
“My first thought is to give it to, and this might be biased but, to the people who are providing the care, because we need them to provide care for more sick people,” said medical student Katelyn Rheault.
The teams had to decide what was more important to them: ensuring the safety of health care providers, saving the most people or keeping the city safe and running.
“I think it all depends on our goal, because our goal can be maintaining order. If that were the goal, then infrastructure would be up close to the top,” said pharmacy student Hoang Phan. “Or is our goal trying to treat as many people as we can?”
Personal bias was tested during the second exercise, when students were presented with 10 patients who needed treatment.
WHO GETS TREATED?
Students were given personal information about the patients, and had to apply the triage process they created to determine the best way to use the limited supply of medicine and who would get medicated and who would not.
“Somebody gets left out. No matter how you triage, there’s not enough to treat everybody,” Carmona said.
Despite having created a guideline for their assigned community, students struggled with evaluating the patients’ potential for recovery and had to evaluate factors including age, profession, arrival time and preexisting conditions, such as asthma, HIV or drug abuse.
WILLINGNESS TO TREAT
Theodorou asked students if they would be willing to treat a patient with Ebola.
“Yes, because being in public health, it’s my duty to uphold that standard of helping people out,” Connors said. “What kind of person would I be if I didn’t?”
Seventy five percent of the event’s participants agreed with Connors.
Theodorou asked students to remember that patients with other medical needs would be coming into the hospital.
“The reality is we have a lot of patients with a lot of different needs, and everybody needs care,” Theodorou said. “Those who volunteer (to treat patients with the flu) are part of the team, and those who don’t volunteer are part of the team and equally respected.”
LESSONS LEARNED
“Stopping an outbreak in infectious disease takes a group effort and more ideas than just one person calling the shots,” said public health senior Connors.
Chiaki Dedrick, a nursing student, said it was hard to find a way to treat patients equally and prioritize fairly despite any social stigma that may be associated with them. Students also struggled with the ethical and legal ramifications of putting patients in isolation but not giving them treatment.
“It’s really about taking away individual rights for the good of society,” Carmona said.
One pharmacy student remained adamant in her beliefs that uninsured patients and non-citizens should not receive treatment before others. A medical student in her group countered, saying health care professionals have a duty to help all in need.
This issue was raised again during a question and answer session with the professionals stationed at the emergency operation center.
Christopher Robertson, associate professor at the James E. Rogers College of Law, cited the Emergency Medical Treatment and Active Labor Act that requires any hospital that receives Medicare or Medicaid funds – which is virtually all of them – to take any patient and provide an initial assessment and stabilization of their condition without regard to even inquiring about their insurance status.
Lisa Driscoll, a second year medical student, said many difficult decisions had to be made during the exercise about prioritizing people’s lives.
“It opened my mind to political versus scientific and who should win – the politicians or the actual scientific evidence,” Driscoll said.
Carmona warned students against letting emotions – or politics – drive their decision-making.
“So emotion drives a lot of this and let’s face it, politics drives a lot of it in catastrophes as well,” Carmona said. “But you have to stick to the science. You can’t let emotion drive this.”
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Caitlin Schmidt, David McGlothlin, Gabby Ferreira, Stefani Quihuis, Luke Della and Justin Sayers contributed to this report.
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