A Day At The Races

After passing crowds of people patiently lined-up in front of the building and noting the "Racetrack" sign which told me I was in the right place, I parked and then reported for assignment at 7:30 AM. We were told (and the deputy sheriffs and security people with whom I shared the lunch table verified) that the lines to receive the H1N1 flu vaccine had begin to form at 1 AM on a cold fall night.  Even the Santa Clara County Fairgrounds Exhibition Hall was cold and I wondered how well my stiff fingers would accomplish the job ahead and how I would stay warm in my cotton and Dacron tan public health uniform. My worries proved unnecessary.

It was clear that the Santa Clara County Public Health Staff had paid lots of attention to vital organizational details and logistics. Vaccinators (like me) wore distinctive orange jackets and logistics people, security, administrators, greeters, guides and translators each had distinctive garb. The enormous hall had serpentine Disney World-like crowd handling lanes. Tables and chairs lined each side of the hall and at each table were three vaccinators, supplies of syringes and vaccine and alcohol swabs and adhesive bandages and cotton balls and every other item which we would need to do our jobs throughout the day.  After a quick breakfast and a few organizational instruction meetings (i.e. - "don't get dehydrated," "drink water," be sure to take your 10 minute breaks," and be sure to stop for lunch") we set out for our tables.

The introductions at our table were brief. I worked with two paramedics who throughout the day did not waste words, motion, vaccine or supplies. At 9:30 AM when our first patients appeared, one of the paramedics had pre-filled syringes with vaccine and we were ready to go. We worked steadily throughout the day.

Each time we had an empty chair, we signaled a volunteer who directed individuals, and families, to us. Mothers, fathers, grandparents, young and older children of all character and description presented for H1N1 vaccine. They seemed well-informed (thanks to the people who were assigned to work the lines to provide information to the potential vaccine recipients) and almost always came with the paperwork which assured us that their vaccination experience would not involve unnecessary risks. The noise level was high because of screaming children, but because of the educational effort directed to the potential vaccine recipients, they were well-informed and relatively relaxed, which was reflected in most of their kids' simply accepting the injection or the nasal flu vaccine.

The hours passed quickly, Our stocks of vaccine dwindled. And the last vaccine recipients were cared-for. Unlike the iffy world of horse-racing, there no question about the benefit received by thousands of people whom we vaccinated, some of whom might otherwise be sickened or die from H1N1 influenza.

Public health prevention is better than trying to treat the complications of a preventable disease.

We're From The Government & We're Here To Help You

This is not a good time for hospital emergency room or intensive care unit director physicians in your communities. If a more severe mutated form of H1N1 ("swine") influenza or a more lethal influenza such as H5N1 (avian) appears, one of these physicians may have to make decisions for which he or she is not likely to be professionally prepared, for which there are  no community accepted ethical standards, and which may leave the decider professionally liable for misconduct and exposed to personal financial ruin.

Quietly and without significant current public input or current public ethical discussion , national, state and local public health authorities have assumed the responsibility to order the take-over of public, private and non-profit hospitals, and determining the priorities to be applied when providing life-saving treatments during a national health emergency which swamps the system. As described in The New York Times, 10/25/2009 "Week in Review" section at page 3, the dilemma of "Choosing Who Gets the Breath of Life" and other serious issues of life-saving facility availability will be resolved by government-prescribed triage rules, rather than the rules which govern today's allocation of health care.  Who among this blog's readers knows what those triage rules are? Who gave appointed officials the authority to dictate this approach to medical decision-making?

Who among my readers knows which patients will be allowed to continue to receive respirator support and which patients will have that support terminated for the benefit of another person? Who among my readers knows which patients will have dialysis terminated so that another person can have access to the dialysis machine? Who among my readers knows whether, under the triage rules, some older citizens will be removed from life-saving support to benefit those who are younger, what the rules will be on allocation of support among various races, ethnicities, religions, social groups, economic status groups, political members, citizenship groups or occupational groups?

Decisions will have to be made. But having them made by appointed bureaucrats without vigorous current public input  and without active current discussion of the ethical issues is inappropriate.  The public has the right to participate in this discussion and those with experience and expertise in analyzing and formulating ethical choices and decisions should be heard.

After all, this is America.

H1N1 Influenza - Conflicting Concerns Unclear Plans

Ten days ago, I spent several hours at an excellent Santa Clara County Public Health Department Emergency Medical Services for Medical Volunteers for Disaster Response. I won't tell you about my snazzy new federally-compliant government identification card or about the uniforms we're going to get. What I will tell you is the tone of concern that permeated the discussion of the Swine Flu pandemic. We were told that medical personnel who actually take care of patients will be high priority recipients of the H1N1 vaccine (two injections to a series - approximately 5 weeks to full immunity). Pregnant women, school children, and young people up to age 24 (perhaps to age 30) will also lead the list of those targeted for the vaccine series, along with migrant workers.  Significant plans for non-hospital care of influenza patients in staffed centers for those who are sick (but not critical) are in the works, where they will be able to receive hydration and respiratory therapy.  I asked whether the Medical Volunteers would receive the vaccine, since we would potentially be the staff for the centers and would need two injections and five weeks to build protective immunity, but was informed that no decision had yet been reached on that issue. We talked about Tamiflu and learned that when the commercial doses run out, there will be reserves of public health reserves to draw upon (but asked my self whether the influenza will be Tamiflu resistant by that time). The public will be advised not to go to their physicians' offices or hospital emergency departments for routine influenza care, but to be in contact with health care providers for illness that has life-threatening characteristics (high fever, dehydration, severe shortness of breath).

Incidentally the H1N1 vaccine, in my county, will be made available to the usual medical provider sources, but public announcements of vaccine availability and administration will be limited.

To my surprise, Thomas Frieden, head of the CDC provided a more reassuring picture concerning the severity of the expected US epidemic in an interview today (CDC-Frieden: or Click on Title Above for Linkage).

My suggestion to high risk people is that they contact their health care providers about the availability of the H1N1 vaccine from them.  While children in schools, young adults in colleges, and pregnant females are likely to have ready access to the vaccine, I don't know what the picture will be for those now healthy age 30 - 65 individuals.  When plans solidify, I will pass the information on to you