Traumatized health care providers may need stress counseling in horrific aftermath of bioterror attack

A severe test for a mentally tough profession


In a finding that is likely relevant to many other states, a recent tabletop exercise in Columbus, OH, found that the health care system may be better prepared to deal with bioterrorism victims than the traumatized frontline providers who give them care.

The exercise was conducted by the Ohio Senior Interagency Coordinating Group in Columbus.

After running a scenario involving intentional release of pneumonic plague at a rock concert, emergency preparedness officials discovered there was little in place to address the mental health needs of doctors and nurses in the horrific aftermath. In the exercise, an attack with Yersinia pestis resulted in 332 fatalities, 720 hospitalizations, and 4,300 people who were examined and released.

"How do you handle all of the nurses and doctors who have seen many, many deaths, who have tried to decrease panic by remaining calm, and who have survived this huge confusion and turmoil?" asks Kay Ball, RN, MSA, CNOR, FAAN, a participant in the exercise and perioperative consultant and educator at K & D Medical in Lewis Center, OH. "What about their mental health? That is something that we found that we are weak in. We really have to develop that better."

The hypothetical event began Friday, March 15, when a popular regional band performed at Shawnee State University in Portsmouth, OH. Approximately 2,000 students and community members went to see the band, which is known for its use of smoke and visual enhancements, according to the scenario. 

"[The terrorists] aerosolized the agent in a fogging system and that is how it was spread throughout the building." says Darren Price, exercise training officer with the state of Ohio Emergency Management Agency in Columbus.

The players take their seats

The exercise had four groups of about nine people, each working at different tables as the events unfolded. The groups were health/medical, law enforcement, fire/emergency medical services, and government. An audience of about 150 people was on hand to observe and evaluate the exercise.

"The whole purpose was to determine our strengths and weaknesses through the disaster that happened," says Ball, who served as facilitator and discussion leader of the health/medical group. "The planning committee will meet and analyze what we learned from this, and then we will bring back everybody who participated."

The scenario was divided into three phases: incubation, response, and recovery. Each phase received about an hour of discussion at the tables, and all players received updated information at the same time. The scenario was necessarily arbitrary but designed to test the state’s resources at many levels, Price notes.

"Anytime, you are dealing with tabletop exercises there are a lot of assumptions and artificialities built in just to make it flow," he says. "We ask [participants] to bring their emergency operations procedures and plans, and to actually react based upon their plan."

While the exercise is still being analyzed, the mental health needs for medical providers became apparent in playing out the scenario. Part of the problem is the historic perception that health care workers must not succumb to the emotional toll of patient care, Ball says.

"Even in surgery today, if we lose a patient on the table, there is nothing really in place to talk about the trauma the practitioners are going through," she says. "We just think that we are these stalwart people and we can’t crumble under emotional strains. That was one of the [identified] weaknesses."

In contrast, firefighters and emergency medical service workers had a more thorough stress debriefing process than their hospital-based counterparts.

"Within the hospitals themselves we really don’t have the mental and spiritual health that we need," she says.

Moreover, the scenario projected widespread "psychological manifestations" in the affected area, with students withdrawing from school and residents reluctant to return to their homes. Bioterrorism response planners brainstormed about how to fight the problem, including bringing in celebrities and public officials to show it was safe to return to the stricken area.

The scenario included a short delay in determining the etiological agent, with chaos building before plague was confirmed as the infecting pathogen. Even with the new emphasis on bioterror education, that scenario is fairly realistic because so few clinicians have seen infections caused by the potential bioterrorism pathogens.

"The first problem was what kind of a bug was it?" Ball says. "Where do we send the cultures, and how fast can we get them back?

The scenario also had many students leaving on spring break. Given the anticipated exodus of people from the community — particularly into the neighboring states of Kentucky and West Virginia — there was no attempt to set up mass quarantine areas, Price says. Instead the national stockpile of antibiotics was called up and confirmed or suspect cases were treated and isolated.

"We looked at the issue of quarantine and determined it was not really feasible," he says. "You would have these large [quarantine] circles everywhere. We moved more toward isolation [of patients] at that point."

While identifying a weakness in mental health care, the planners found communications were strong between groups, there were no turf battles, and additional resources became available quickly.

"One of the strengths that we found was that we were able to get supplies in and to call in extra people," Ball says. "We were able to pull in lots of people very rapidly. We are learning how to work more with all of the other diverse factions."

Indeed, the exercise was set in a rural area so that resources would be taxed, reaching thresholds that would trigger state response, Price adds.

"We’re better prepared today than we were yesterday," he says.

Bioterror tips for running a tabletop

Planners of a recent bioterrorism tabletop exercise in Columbus, OH, offered the following tips for participants in the exercise:

  • The scenario is plausible, and events occur as they are presented.
  • There are no hidden agendas or trick questions.
  • All players receive information at the same time.
  • There is not a "textbook" solution. Varying viewpoints and possible disagreements are anticipated.
  • Respond based on your knowledge or current plans and capabilities.
  • Current agency or department policies and procedures should not limit discussion and development of key decisions.
  • The outcome is neither intended to set precedents or reflect an organization’s final position on specific issues.
  • Assume cooperation and support from other responders and agencies.
  • Speak up! Talk to your colleagues and ask questions. This is your chance to learn how other agencies in your community would respond in an emergency.