SCCM Resource Library-Worldwide Threats to Health Security: Critical Care Preparedness

Video Transcription

Good morning, everyone. Welcome to Worldwide Threats to Health Security. My name is Donna Armagnac. I'm a researcher at Baptist Health South Florida,  and I'm going to be the moderator for the talk. And these are our overall global objectives for this session. We have a panel of experts.  We're going to be speaking about contagions, infectious disease, influenza, the late coronavirus or the as of late coronavirus, how we can be prepared for these events,  worldwide tragedies, and how it affects our society and health care. Okay, this is our lineup of speakers. We have Dr. Tim Buckman, Dr. Adan Kumar, Dr. Mesh Adaji, Dr. He-Soo Jung,  and I'll be finishing up at the end. I'm going to introduce our first speaker, Dr. Timothy Buckman. I found this little shot of you. I don't know if you've seen this before.  As the thinking man. Yeah. Doesn't it look the same? Yeah, anyway, Dr. Buckman, most people are very knowledgeable about Dr. Buckman.  He's a strong figure in the Society of Critical Care, and he is the lead of intensive care at Emory University, as well as the chief editor for Critical Care Medicine Journal.  So, Dr. Buckman. Thanks, Donna. The last time I gave a talk for Donna, I actually was on the stage having shaking chills, ended up septic with meeting sepsis 3 criteria  in the hospital on IV antibiotics. Thanks so much. So, I'm going to chat a little bit about worldwide threats to health security in the context of 21st century viruses.  I have no disclosures relevant to the presentations. I do get invited for various lectures. Travel is paid. Honoraria goes to Emory. For identification only, I'm editor-in-chief  of a couple of journals. What I say today may not represent the opinions of the Society of the Journals. I also spend half-time working for the federal government  within the Division of Research, Innovation, and Ventures inside of BARDA, working for the Office of the Assistant Secretary for Preparedness and Response.  My opinions today do not represent those of the United States government or any agency. With that, here's the talk map. I'm going to go into a little bit of virology basics.  I'm going to give an overview of 21st century viral epidemics, talk a little bit about all hazards response frameworks, and then some lessons learned. So, let's get into it.  What's a virus? This is Peter Medawar. For anyone who's been in transplant immunology or is a transplant recipient, he was the gentleman  who made transplants safe with various medications by describing the immune response to foreign items. He wrote advice to a young scientist, and he wrote about viruses,  they're bad news wrapped in a protein. That was as far as the classification got until David Baltimore, who discovered reverse transcriptase  with Howard Temin, also won the Nobel Prize, gave us a classification of viral pathogens. He organized them according to their nucleic acids, which are shown in the top row there.  We're going to be focusing today on classes four and five because those are the major pathogens that we have dealt with in the 21st century.  All of those are single-stranded RNA viruses. Some of them come in as the plus strand, such as coronavirus. They have to be transcribed into the negative strand.  Some come freely as the negative strand, such as measles, Ebola, and influenza. But again, most of our talk is going to be focusing on these single-stranded RNA viruses.  Now, how many viral particles are there? There are about 10 to the 10th humans on Earth. Every liter of water in the ocean contains about that same number of viral particles.  How many liters of water are there in the ocean? About 10 to the 21. So there are a whole lot more viral particles than there are of us. Most are bacterial viruses.  Most are in the oceans. And in the oceans, microorganisms are about 90% of the biomass, and viruses kill about a fifth of that, 20% of it, each day.  They are there to maintain the ecological balance of different species, and in so doing, they are responsible for the oxygen you're breathing right now. So viruses aren't all bad,  but for your purposes, you can think of viruses as subcellular terminators. They are inanimate particles. They have no independent existence. They do one thing and one thing only.  They invade the host cell. They steal information in the form of DNA or RNA. They replicate, and then they go ahead, and they kill the host cell.  Now, a lot of the time, it's immediately, but they can integrate into the genome and park there and come out at inconvenient times, such as we see in shingles  or various oncogenic transformations. That's all they do. Let's talk about two centuries of viral epidemics. Over on the left, I have the rank order by death.  100 million from the Spanish flu, 1918 to 1920, all the way down to about a million as a global pandemic, 1968, 1969, the so-called Hong Kong flu. Look at the orders of magnitude  and compare that with the 20th century,  where our leading killer was H1N1 pandemic in 2009-2010. Ebola next in the 2013-2016 spread at 11,300. We have measles growing in the DRC, having killed more than 4,500 folks.  The current Ebola outbreak is now at 2,242, and as of last night,  COVID-19 caused by the novel coronavirus is at about 1669. So the current outbreak that we're dealing with is two orders of magnitude lower than the worst killer in this century  and many, many orders of magnitude beneath the Spanish flu. Let's talk about influenza for a moment, and it's all about species jumping.  It turns out that the way you make new influenza viruses is you park something that's a funnel, and in this case, avian viruses, all the bird flus,  ducks are great reservoirs for bird flus from a variety of species, and you put them into a mixing bowl, and it turns out the biology of pigs  is an ideal place to mix different viruses. Now, over on the right, I'm showing you what happens when there's a co-infection. This is not influenza. To get two viruses,  I had to show two different eukaryotic viruses, adeno-associated and herpes simplex. That's a single nucleus that you're looking at, and you're looking at the expression  of different parts of viral genomes hooked to different chromosomes. It's very easy for two different viruses to co-infect cells. Well, this is the influenza genome,  and this is why influenza is such a problem. Over on the left, you will see a bunch of double helices. It turns out that the influenza genome  contains RNA, but they're in separate segments, and attached to the top of each of those RNA pieces is the influenza polymerase. Each virus brings its own RNA polymerase  to make it easy for it to replicate, and on the way, tends to take out the host polymerase. Well, you get multiple influenza viruses, and now I'm talking about the right funneled  into a single source. You put them into the mixing environment, and all of a sudden, you have new viruses. So influenza is perfectly engineered  by the process of genomic reassortment to keep making new forms of influenza. And if we take a look at what happened during the Spanish flu,  this is from Bill Gates' Shattuck lecture in 2018. You can see that over the course of about six weeks, from a single index case in the United States,  it basically spread throughout the lower 48. Very fast, and killed worldwide about 100 million people in very short order. So when we fast forward to December the 10th of 2019,  my boss's boss's boss, Bob Cadweck, who's the Assistant Secretary for Preparedness and Response, wrote about preparing for the next pandemic, and he said, quite frankly,  we need to become better prepared to face the next pandemic. Make no mistake, it's not if there's another pandemic, it's when. And according to the study on pandemic,  it was influenza by the White House Counsel. It could claim the lives of about half a million people in the United States alone. Again, look at the date, December 10th.  Let me pause that for a moment. We'll talk a little bit about this particular organism, Ebola. And from a healthcare standpoint, what we learned during the Ebola epidemic  is that our US hospitals and contemporary ICUs are physically and socially engineered to expand access and, with our focus on family-centered care,  to encourage touch and interaction among the patient, family members, caregivers, and so forth. You can imagine how quickly something could spread in this environment.  That brought us to dealing with Ebola, and in 2014, the Emory Special Communicable Disease Unit took on three patients from the gray airplanes  and transported to Emory into this type of environment. Let's hear from someone who was involved in that epidemic. Oh, before I get there,  I'm not going to go through this in detail, but we learned an awful lot during Ebola about how to put things on, how to keep them on, and take them off.  The clinician that I am after my experience in this serious communicable diseases unit is very different than the clinician that entered this unit  the first time that I got to take care of Kent Brantley. I think that every time I'm rounding in the hospital, I'm always looking at the complexity of situations  that we are faced with. I think now I think that way about, what are we doing in everyday healthcare that puts ourselves at risk and puts our patients at risk,  and how do we identify that and then train around that? So this was the most recent wake-up call we had, only about 5 1⁄2 years ago now.  So let's move ahead to the current topic of interest, coronavirus. Coronaviruses are a bit different. The common cold is a coronavirus. The host, of course, is man.  SARS, MERS, and the novel coronavirus, I didn't change the name here, would have started in bats. Here it was the civet cat, here it was the camel.  We don't yet really understand the intermediate host here, but we do know, if we look at the genomic pattern, that it has some similarities to all of the coronaviruses listed here.  This is what we're facing today. It's not yet everyday healthcare in the Western world, but certainly in China, this is the sort of behavior we're seeing.  This is the West, of course. Here's the Diamond Princess docked off the coast of Japan. Here are people coming back from China into the United States,  and most recently, China has said, we don't have enough places to put people, so they are seizing hospitals and also hotels to fight the disease process to keep people quarantined.  Now, on February 1, 2020, the New York Times reported first that the viruses would travel only about six feet. It was unknown how long they live on surfaces.  They drew the comparison to measles, and they said they can travel up to 100 feet. So people felt pretty safe, but it certainly didn't explain this behavior of the Wuhan coronavirus  versus the spread of SARS two decades earlier. These data were taken to provide some kind of an estimate, at least of how far and how fast the virus could spread,  and the basic reproduction rate of the virus, so-called R-naught, was estimated from these data that ended on the 4th of this month, so ending about two weeks ago.  This was the spread of the virus in Hubei, and it was mapped to this exponential curve whose equation is shown here. That led to an R-naught of about 4.36. What does that mean?  The R-naught is the average number of people an infectious person will infect, assuming that the rest of the population is susceptible.  These dots here show the minimum to maximum estimate of R-naught. You will note here that flu here is about 4.5. So here's COVID-19, the virus that causes COVID-19.  It doesn't seem to be nearly as bad, if you will, compared to measles or chickenpox that are major killers today. Now, the problem with those estimates  is that they're based on sampling. Here are four patterns of spread. In each case, you have five different people who are detected as having the virus,  but depending on what's going undetected in the transmission profile, you may end up with very different estimates of R-naught. So that that initial estimate of 4.36,  it's a guess, no more. What we do know is that in our connected world, there's much greater opportunity to spread. Over here, again from the New York Times,  when SARS broke out, there were about a billion travelers. Passenger traffic in the world's airlines has increased by a factor of four over the past two decades.  This is the current worldwide air transportation map. And as we've learned, this virus can wander onto airplanes and wander off into populations at will.  I pulled this off the Johns Hopkins site this morning. Total confirmed cases was just under 70,000. Total deaths, really quite modest at about 1,670.  Obviously, all of that depends on the veracity of the data that's coming out of China. And at the moment, that's not clearly determined.  But the map shows you that by far the greatest concentration of the current infection is in China. Now, again going to Bill Gates' Shattuck lecture,  this is a simulation of what would happen if the Spanish flu was introduced to the world today. The estimates are that within about six months,  about 32 million people will have died. Now, that's based on a virus that has a significant severity and a significant amount of transmissibility.  But these are the best available working numbers. Which leads to why there has been developed an all-hazard approach to initial characterization of an unknown pathogen.  This review appeared in Nature Microbiology. I commend it to you. It appeared about this time last year. And they basically wrote the playbook for what's done  with a modern viral epidemic. Initially, there's detection. There's an attempt to identify the pathogen through nucleic acid sequencing.  There is next an attempt to provide a snapshot of who's gotten the virus and what types of wildlife they've been exposed to.  Because again, this is all based in new zoonotic diseases. The transmission chain is attempted to be identified. And then the spread is mapped and predicted.  Very much the playbook that's been followed over the past six weeks. How is this going to be treated? I'm going to mention only one medical countermeasure, the antiviral medication.  In this case, remdesivir. Remember I told you that these are both single-stranded RNA viruses. They carry their own RNA-dependent RNA polymerase,  the enzyme that copies the viral genome into the host for further replication. These polymerases, because they're there to go grab bits of nucleic acid,  they're kind of indiscriminate about what they incorporate into RNA. They're more than willing to make a few mistakes to get as much information as they can.  So that this particular drug, which is shown here, they're ramping up mass production in China. It's really quite simple. Here's the prodrug. And that prodrug gets hydrolyzed  into a triphosphate, which is really just a cyanide moiety attached to garden-variety ATP. That's all it is. It's ATP with a slightly different shape  gets incorporated by the viral polymerase. Fortunately, our host polymerases say, no, we're not going to take this one. And that's how it works. Why six months on that simulation?  Because typically there's a six-month interval from an influenza vaccine strain selection to actually getting it out into the public. This is the current timeline.  This is how the annual United States vaccine supply is generated. Again, about a six-month interval from the point at which it's selected to the point at which the vaccine  becomes available in your local drugstore. That's obviously not fast enough. So the government agency I have the privilege of working for,  BARDA, has been involved in many countermeasure productions. Since 2007, there have been 54 FDA approvals, licensures, and clearances. If you read up in this region,  you'll see a lot devoted to Zika. There is a great deal of activity at BARDA going on today seeking input for countermeasures against this novel coronavirus.  And it's safe to say we will be seeing new production going on of novel countermeasures in the near future. So there are some lessons learned from all of this.  The first is, as Perelman wrote in the New England Journal a couple of weeks ago, another decade, another coronavirus. We had SARS in the early years of this century.  We had MERS about a decade ago. It's very clear that even after this current one is over, another one will happen. There will be a global response,  and it will eventually be controlled. The problem is, is that healthcare workers who are involved in this are going to become infected, and some of them are likely to perish.  This happened in SARS. It's happened in MERS. And it's clearly happening with COVID-19. So we are rightly concerned with the exotic and the novel. Here is the current Ebola outbreak  as it is occurring in the DRC. However, the greater risks are more familiar. And I remind you that the Spanish flu was the second deadliest plague in history  and wiped out 3% of the world's population within about a year. What is the worst-case scenario here in the United States? So far, we've been able to contain it.  But I think this virus is probably with us beyond this season or beyond this year, and I think eventually the virus will find a foothold  and we will get community-based transmission. And you can start to think of it in a sense like seasonal flu. The only difference is we don't understand this virus.  That is the director of the CDC, Robert Redfield, earlier last week. So I leave you with a question. What are your institutional plans? What are your personal plans  when your hospital's emergency department calls you to see patients who have a sudden onset, rapidly worsening respiratory illness? Thank you. Thank you.  Our next speaker is Dr. Anand Kumar, who's going to be speaking on anti-infectives. Oh, and this is the picture I found of you. I was back during the H1N1 epidemic.  Thank you for the invitation. I'm speaking a little bit off the viral topic today. I'm going to start with this slide, and I'm going to start with it because  mostly you're going to hear about pandemics today and, you know, black swan events, which are rare and unexpected. I think those are a lot like tsunamis.  They're big, they're huge, they come and hit you, but then they fade away. I think what we're going to talk about is more like rising oceans related to climate change.  I know we shouldn't mention climate change in Florida. I think that's verboten, but essentially look what happens to Florida with the slow rise of the seas with climate change.  Either way, though, you're going under, right? So once upon a time, 1928 to be exact, there was a great scientist, and by the way,  for those of you who tell your children these stories, you can just cross off scientist and say hero. So a great hero named Fleming discovered the miracle of antibiotics.  And that was around 1928, actually, and thereafter you know that we hit this period where we were in the golden age of antibiotics. We had penicillins and aminoglycosides  and tetracyclines and this, that, and the other, and that golden age has persisted right through to the last couple of decades. But Fleming was quite prescient.  He actually said something that was very interesting. He said that microbes can be educated to resist penicillin and a host of penicillin-fast organisms is bred out.  In such cases, the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with a penicillin-resistant organism.  I hope this evil can be averted. So he knew what was coming. And in fact, if you look at the sequence of events as it relates to antimicrobials over the 20th century,  it has always been one of introduce the drug, resistance develops. And that's held pretty much right through. If you look at the last two,  daptomycin introduced in 2003, resistance in 2004, ceftazavobactin released 2015, same year you've got resistant pathogens coming up.  So we have a real substantial resistance problem. And it's along the lines of what Dr. Buckman said. A lot of it's driven by travel, in fact, at least the dissemination of it.  Now when we talk about multidrug resistance, it's worth kind of just defining the term. Basically, a multidrug-resistant organism is one that's non-susceptible to at least  one agent of the three major antimicrobial categories. Whereas a pan-drug-resistant strain is resistant to all known antimicrobials. And of course, an extensively drug-resistant one  is intermediate to that. So we all know what the problem is as far as how you drive resistance, right? My wife's an allergist, and I keep telling her,  what are you doing with all these antibiotics? Because people come in and they go, I got the sniffles or whatever, or I got a wheeze. They all want antibiotics.  So getting to this issue, it's actually very precise in terms of how these resistances developed. Like if you look at gram-negative pathogens, it's not well known, but in fact,  penicillin, when it was introduced, most gram-negatives were susceptible to it. In fact, Staph aureus was susceptible to it.  In my career, I've only ever seen one Staph aureus specimen that was still susceptible to penicillin. It was a guy who had chronic osteo from the Second World War.  He actually got his Staph aureus infection before penicillin was widespread. But once it was introduced in the night, we found resistance developed quite quickly.  So you had susceptible gram-negatives becoming resistant. You introduced ampicillin and aminopenicillins. Next thing you know, you've got resistant E. coli developing  through a bunch of different mechanisms. You add cephalosporins and fluoroquinolones in the 1980s and 90s. You start getting resistance there.  And then in the 2000s, we have carbapenems being introduced. Lo and behold, a couple of years later, you have NDM. You have porin defects. You have metallobeta-lactamases.  You have resistance again. Now, what drives this resistance? As we said, it's use of antibiotics. But more than that, in fact, it's the total consumption of antibiotics.  You could actually show this on an institutional level. This is an institutional study. So if you look at carbapenem resistance in this particular institution,  you can see that the use of the carbapenem is closely followed by an increased incidence, increased selection of organisms that are resistant. And if you go out further here,  you see that as the use falls, so too does the level of resistance in the hospital. And again here, increased use again, increased incidence of resistance, always following.  You can apply that, by the way, to the individual. You can apply it on an institutional level. You can apply it on a national level. And in fact, you can apply it to a global level.  This is a study by a colleague of mine that was published, I believe, last five years ago. And you can see the countries that have the greatest use of antibiotics  invariably have the highest level of resistance. Now, you can't show causality just with that, but there have been lots of studies that have been done that actually show causality  between basically the tonnage of antibiotics distributed and the development of resistance or the selection of resistant strains. What's the problem with antimicrobial resistance?  Well, primarily, it's not that getting the wrong drug initially kills you. It's that it delays getting the right drug. So if you look, for example, in this study,  where you look at fluoroquinolone-resistant strains and fluoroquinolone-susceptible strains, you can see that only about 10% of people get appropriate antimicrobials within 24 hours  if they're resistant, but more like 55% if they're sensitive. What's the impact of resistance on outcomes? How many times... how many lives do we save?  How many times do we have to get it right to save one life? Basically, inappropriate antibiotics give you a 3.4%... a 3.4 times risk of increase in risk of death.  This is just kind of all comers. I did a study myself where we looked at in septic shock, and in that particular case, there was a five-fold increase in mortality.  You went from 10% mortality to 50% mortality just if you gave the wrong antibiotic at the first dose, even if you corrected it thereafter. Basically, for every five patients  given appropriate therapy, you'll get one more survivor. Where is the problem that we're seeing now? Well, if you look at ESBL producing E. coli by country,  this is in the first half of the decade, you can see that there are some places, India and Bolivia in particular, that have 80% to 100% resistance. 80% to 100%.  United States, on the other hand, 10% to 20% ballpark. But whether it's going up or down, I'll show you, but certainly it's progressing here.  What about carbapenemase-resistant klebsiella pneumonia, a KPC we call them? Where is that? These are even more difficult to treat because you don't have carbapenems to treat it.  And again, hotspots, India, Guatemala, Nicaragua, well, these two in the west, Greece in the eastern side, Greece and India in particular.  So again, we're seeing there 50% to 60% incidence of carbapenemase resistance there. And if you think that's bad enough, we're actually seeing plasmid-mediated colistin resistance.  So if you start seeing plasmid-mediated colistin resistance, you're getting to pan resistant strains of various gram negatives, and those are just starting to be seen.  The CDC and the World Health Organization have actually defined what are urgent threats and what are serious threats and those that are of less magnitude.  But the urgent threats, basically, carbapenem-resistant acinetobacter, Candida auris, which is a new Candida species, at least recognized clinically in just in the last five years.  Clostridioides difficile, used to be called Clostridium difficile, and carbapenem-resistant enterobacteriaceae, CRE. Now, there are other threats.  The ones that are underlined are the ones that are particularly relevant to intensivists. You guys are familiar with a lot of those, so I'm not going to belabor it,  but I will go through a couple of them and just show you what's going on with them. So, this is carbapenem-resistant acinetobacter. This is U.S. data.  You can see, in terms of the resistance level, it's actually falling across all the different groups of antimicrobials, so 98% to 89%, 80% to 75%. So, that's good news there.  The percent of acinetobacter that are resistant is falling, and the number of cases of acinetobacter is falling as well. So, that's one of those good news stories.  On the other hand, carbapenem-resistant enterobacteriaceae, those are relatively stable, maybe increasing a little bit. ESBL-producing enterobacteriaceae,  clearly increasing over the last five years, so that's bad news. Drug-resistant hospitalized candida infections, generally those are actually going down.  Now, those are the candida, sorry, candida, the usual candida, candida albicans, candida glabrata, candida parasilosis, et cetera. Not talking about candida auris there.  Most of these cases are albicans and glabrata, as I mentioned. Those are actually showing the increased resistance but decreasing frequency.  So, good news, bad news, and in this particular case, what's mostly happening is that we're selecting out the variants that are resistant.  So, for example, candida glabrata is increasing in frequency relative to candida albicans because it tends to be more resistant to the azoles, which we commonly use.  Candida auris is another candida species that has come to our clinical attention in the last four or five years. We're seeing scattered cases across the United States,  increasing quite rapidly. Problem with this is that it is completely resistant to virtually all the known antifungals, all the ones that are clinically available.  This was interesting. Unlike KPC and, for example, ESBL, which developed in certain places and then spread. So, for example, the carbapenem-resistant  New Delhi beta-lactamase, that obviously came from India. I think the KPCs, which is another variant of that, came from Israel. And then rapid travel around the world,  air travel, as Dr. Buckman was discussing, basically disseminated that through the rest of the world. How much of a problem is antimicrobial resistance?  It's really interesting if you look at it from an economics point of view. Now, you know, we're physicians, so we don't really look at economics that much.  But I will say, when you look at the numbers, it's quite startling. This is the impact on GDP globally during the 2008 financial collapse. So, it basically dropped the GDP  by about 4% or so, plus minus. Now, a low AMR scenario, a low antimicrobial resistance scenario, you get about 1%. But in a high AMR scenario, you're talking about 4.5%, 5%, 6%.  And the really interesting thing there is we're talking about $100 trillion US dollars by 1950.  We're talking about, at that point, $10 trillion per year. So, you're going to take $10 trillion out of the economy that you might be using for other things, including healthcare,  if we don't get this resistance problem under control. What about deaths, though? We are most interested in deaths. Right now, AMR accounts for about 700,000 deaths globally.  By 2050, it's estimated to be about 10 million deaths,  Comparatively to cancer, it'll actually be more of a cause of death than cancer, which is projected to be about 8 million or so. And you can see the other conditions across here.  Where are those deaths going to occur? Well, we've got pretty advanced medical systems in the United States, Canada, most of Western Europe.  So, we're going to see maybe 300,000 plus minus deaths per year. But on the other hand, Asia and Africa, approximately 4 million deaths per year from AMR by 2050.  Now, you might be asking, well, you know what? We've controlled this problem with antibiotics and we're still seeing new antibiotics every year. What's the problem?  We can just give antibiotics. Well, in fact, if you look kind of at the surface, we're doing pretty well in terms of this issue. You can see just in the last decade,  there's at least 8, if not 10 now, 12 antibiotics that have been produced and licensed and are available in some place in the advanced world, United States or Europe.  The problem is that there have been no novel antibiotics in the last 30 years or so. The last antibiotic that was, well, maybe with the exception of fidaxomicin.  Fidaxomicin might be the only new antimicrobial, and it's not a big one in terms of its utility, might be the only new antimicrobial that's been developed in the last 30 years.  When I mean new, I mean novel, something that has no cross resistance to anything else, basically an entirely separate mechanism. You can see that the peak was in the 1950s,  going down by the 1980s down to two novel groups and then basically flat since then. Now, if we're going to contain antimicrobial resistance, how are we going to do it?  Well, I mean, frankly, we could have talks going for hours on how you do it, but basically you have to have interventions on the human and animal level both,  and then you have to look at antimicrobial drug utilization. But all of these are kind of external to what we do. So I'm going to just say that they exist.  There's lots of things, you know, some of the containment that Dr. Buckman was talking about actually also applies here. But we have control of something else.  We have control of the antimicrobials and what's going on in the hospital. So what's critical is you've got to use the drugs that you have right.  You want to use the correct drug at the right time, first off, so selection is important. It's really important for us in particular  that we want to dose appropriately to the circumstances. The big one that we tend to get wrong is we tend to underdose because the volume of distribution in critically ill people  can be up by a substantial factor. The whole human body, 100 kilo person, has about 20 litres of volume, extracellular volume. How difficult is it to increase that?  So when you give somebody saline, for example, basically you often give them 10 litres of saline, 5 litres of saline. So you can increase the extracellular space  by a factor of about 50% quite easily. And if you give standard doses, you can substantially underdose. That's something you have to worry about.  You have to be careful about timing. If you give the antimicrobial too early, you may be treating unnecessarily because you don't actually have the diagnosis you were worried about.  On the flip side, you treat too late, what happens is if they survive, that they have a prolonged hospital and ICU course,  and I guarantee you they get lots of antimicrobials during that course. And then you want to use the best dosing strategy available. So, for example, PK optimization in particular,  beta-lactams, the new surviving sepsis, probably going to say extended infusion is a better way to use them.  But there are all sorts of things along those lines that you can improve. Again, another talk. Stewardship, incredibly important. Won't get into the details here,  but I can tell you that virtually every study that's looked at the importance of stewardship programs actually shows a benefit in terms of reducing the amount of resistance  in the hospital situation. And in fact, somebody asked me once, well, isn't that shutting the barn door after the horses have bolted?  Some of the horses are still in the barn, so it's still useful. And then we have some interesting, novel non-antimicrobial approaches to the AMR problems.  Vaccines, you have both direct and indirect protection. Indirect protection, you inoculate for influenza, and you have decreased risk of MRSA pneumonia.  Antibody therapy is being developed for things like C. diff and bacterial pneumonia. Bacteriophages are a novel approach to kill bacterial pathogens. Fecal microbial transplants,  basically stool transplant, seems to be very effective for some things. And replacing your flora with probiotics and such is another potential approach.  Antibacterial and immune response, augmenting peptides, and antivirulence factor products. Do I have a couple of minutes? Okay. So, I'm just to the last couple of slides.  So, these are the antibiotics that have been authorized in the last two years. And there's a decent number of them. Two of them, in fact, are novel agents, entirely novel agents.  This one, the beta-lactamase inhibitor is a boronate. This one, lafloxamilin, this is a group that's entirely novel. Although, this one was actually developed in the 1950s.  It's now turned into a clinical product. So, eight new products. The problem is, most of these drugs are being developed by small biopharma. And just in the last year, two of them,  Melinta and Ekeagin, they went bankrupt. This was picked up, though, fortunately, by Cipla, this product. And then, this one here, this company, Tetraphase, has been cutting back.  They're under some financial stress. So, the small companies that actually develop these products, not doing that well. So, not all of these, although they're approved,  not all of them may catch, may be produced. Fortunately, there are more drugs in the pipeline. 32 antibiotics in the pipeline. Again, there is a problem with that.  At least half of them are just a beta-lactam, beta-lactamase inhibitor combination. It's just a variant of stuff that we already have. And that could be a significant issue.  There's about 250 or so products that are in preclinical development that may be useful. I'm going to just focus on the biological antibacterials in development.  These are actually quite cool. There's a bunch of, like I said, anti-staph aureus, immunoglobulin, phage endolysin, basically a phage product, et cetera.  You can see all these very novel kind of drugs that are being developed, and hopefully some of them will come to fruition. And I did mention vaccines before.  You know, if the 50s, 60s, and 70s was the golden age for antibiotics, right now is the golden age for vaccines. We have more vaccines being produced now than we ever had  before, and we are actually developing vaccines for gram negative sepsis, potentially for staph aureus, and for a variety of other pathogens. So, the question at the beginning was,  are we winning the battle but losing the war? And here's my thoughts on this. I think that if this is a battle, then I think we in this room, physicians,  healthcare workers, can actually potentially win that battle with help, a little bit of help. But if it's a war, well, a war you need government support.  And I think right now that's lacking a bit. There was one nice act that kind of spurred some antimicrobial  development and discovery and development. That was the GAIN Act. Most recently, the DISARM Act has been introduced but not advanced, and this would reimburse hospitals via Medicaid  for novel and critically important antimicrobials. That could be a really important thing. It's really interesting to me. We'll spend $100,000 for an obscure anti-cancer drug that,  you know, is a limited application, which has, you know, borderline, you know, 8% improvement in survival, for example. But when we're talking about antibiotics,  which will give you a 50 or 60% improvement in survival, we bulk at a cost of anything more than, you know, $1,000, $2,000, right? And that gives you, like I said,  60% improvement in survival probability. So my last thought is AMR is coming. It is a big problem, but it's only one problem. So thank you.  Well, this is going to be Dr. Ermesh. Oh, here we are. He works at Johns Hopkins Center for Health Security, and he's been in the throes of not just the coronavirus issues  that are as of late, but many types of viruses that are going on right now. And he's going to talk to us a little bit about how not just the coronavirus issues that are as of late,  but many types of viruses and how we had to respond to them. Thank you for the invitation to speak here at SCCM and thank you for coming to hear this talk.  Like she said, I work for the Center for Health Security, which is a public health think tank that works on  infectious disease emergencies, pandemic preparedness, biosecurity, bioterrorism. I'm both an infectious disease and critical care physician as well.  There's my Twitter handle if you'd like to follow me. But what I'm going to do in this talk is try to put this coronavirus into context because you've heard a lot  about it and I'm really going to try and drill down into what it means and why this was so important.  So what I want to do in this talk is to get you to understand the history of coronavirus infections,  both pre-SARS and post-SARS, because that's a real inflection point with coronaviruses. Talk a little bit about some of the members of the coronavirus families.  Talk about a little bit of COVID-19.  And understand the clinical management issues that may come up, specifically for the critical care setting.  So just to give you a quick snapshot and not to recapitulate everything that Dr. Buckman talked about,  what happened with COVID-19 was in mid to late December, a cluster of pneumonia cases, unknown pneumonia cases, unexplained, was found in hospitals in Wuhan.  And most of those people had an epidemiological link to an animal market. This was 41 cases. And even if you looked at that initial data set, you knew there was something more to it  because patient one, case one, got ill on December 1st and he had no contact with the market.  So that's a big red flag, one that tells you, A, this thing had been going on for some time because you've got an incubation period, maybe six days, maybe up to 14 days.  So he got ill in November. So this was circulating in November and he wasn't at the market,  which tells you maybe this was in the community for several weeks before it was actually identified. World Health Organization was notified in late December.  So this really had a major head start even from the outset. What we saw initially was data with people dying.  And I just want to draw your attention to even now today when you see some of this data, there's something called a severity bias. They are not testing people with mild illness.  So you are seeing people who are going to hospitals and health care facilities. So that's going to skew your case fatality ratio towards the more severe  because we know that there's a spectrum of illness. Even if you look at the cases in the United States, the 15 cases, they are all very mild.  So just interpret those case fatality ratios with that in mind. We now know there's human-to-human spread. The R0 ranges from maybe two to four. We don't know what's going to shift.  This is very early days, and again, mild cases aren't really being accounted for, so we don't know what the transmission characteristics completely are.  There's actually just been three deaths outside of China. It's not something that we've seen so much outside of China,  and that's really interesting, a mystery that we need to figure out. What's going on in Hubei province? Why is the death rate so much higher there and elsewhere?  We did rapidly find out that this was a beta coronavirus, which is in the coronavirus family, and it fits sort of near SARS, and they're naming the virus SARS-CoV-2.  The disease is called COVID-19. The virus is SARS-CoV-2 because it's so genetically linked to SARS. However, it's very different than SARS, and I'll tell you,  in one particular aspect that Dr. Buckman highlighted earlier, I'm going to reiterate that. It seems to be stable in humans. It looks like it was a single introduction,  probably from bats to some animal. The speculation is now on a pangolin, but I'm not sure if that's going to actually basically stick when more scientific investigation is done.  And we're in the middle of clinical trials and vaccine development. There's dozens of clinical trials being done in China right now. Remdesivir is one that was mentioned earlier.  That's being done in a clinical trial. It was given to the first patient in Washington State here in the United States. People are trying to repurpose HIV protease inhibitors.  I'm not sure if that strategy will work. There is a drug called chloroquine, which we use for malaria, that may have antiviral therapy.  And there's also a drug that Emory is developing called EIDD-2801, which is an influenza drug, which likely has some activity against coronaviruses. So that's kind of the snapshot.  And, you know, you can keep looking at our Johns Hopkins site here, and you can get a good idea of what's going on.  But again, the theme here is most of these cases are in mainland China, almost all of the deaths are clustered in mainland China.  We have over two dozen countries with imported cases. And it's going to be very interesting to see how this case fatality ratio holds up,  because we're going to start testing for mild cases now. The CDC is going to be testing in places like New York, San Francisco, Chicago, Seattle, in their flu surveillance network.  And I think that's really important because coronaviruses have this large spectrum of illness, with mild illness being basically the norm. And even in China, 80% of cases are mild.  And then a very small proportion having severe deaths. So I think that it's really important to step back from all the headlines and scary news about coronaviruses and talk about,  what if I was giving this talk to you on coronaviruses in 2000? Probably there would be nobody in the room if I was giving you the talk in 2000.  But really it starts with the common cold. And we know that the common cold is caused by multiple different viruses.  And the ones that were initially described were flu, adenovirus, rhinovirus, paraflu, RSV.  But what was clear that there was one third of cases where they couldn't find any virus or any bacteria.  But you could take the snot from that person, literally, and give it to somebody else, give them a tissue, inoculate it into their nose, and they would get sick.  So there was some other organism there. And what ended up happening was in 1960, they did an experiment on a boy with the cold.  And he could transmit symptoms, and the secretions were able to pass through a bacterial filter. It was inactivated by ether.  They couldn't figure out what it was, and they described, they found a new viral particle growing in human embryonic tracheal organ cultures.  Coronaviruses are notoriously hard to grow. And they named it B814. So in 1965, that was when coronaviruses came to light as the first new common cold virus.  And then in 1967, it was followed by the second one, OC43. So the first one, they called it, this one actually is 229E right now in modern nomenclature. And then OC43 in 1967.  And they found these viruses everywhere. And if any of you are on farms, they have bovine coronaviruses, porcine coronaviruses. So it infects lots of different mammals,  which is really important for when we think about it as a pandemic threat, that it has many animal hosts, and they all likely are harbored in bats.  And they call it a coronavirus because it looks like it has a little crown on it. This projecting part of a classic cornice was the first use of the word corona.  I looked it up in the dictionary, but that's where the name comes from.  And there are two subfamilies. It's just important to know there's alpha, beta, and gamma coronaviruses in the coronavirinae family,  and it's the beta coronaviruses is where you see SARS or MERS. The novel coronavirus are all in there. Most of the time, they cause just mild viral URIs and some GI symptoms.  It is a single-stranded RNA viruses. In general, RNA viruses are our biggest pandemic threats, as you heard earlier. And it has the largest RNA viral genome.  So what's the epidemiology of common cold viruses that are common colds and coronaviruses causing common colds? It's worldwide.  Winter and spring, that's when you see coronavirus season. That's why you've started to hear people talk about maybe as weather gets warmer  in the northern hemisphere, this may die down, because we do know that that happens with our seasonal coronaviruses. And they cause about a quarter of the common cold.  So we have a lot of data on those common cold-causing coronaviruses. Reinfection is common. We know that from our own experiences,  and many people get multiple common colds even during the same season. And so antibodies are not sterilizing. Most commonly occurs in children, and about half of people become ill.  So some people can be asymptomatically infected. It's clear that they shed the virus. It's unclear how infectious they are.  That's become a major point of contention now with this novel coronavirus, asymptomatic shedding. And there are something called super spreaders,  which we really came to light with SARS. And what a super spreader is, it really reflects heterogeneity and pathogen transmission.  Somebody that spreads and infects more people than the average person. And that's why the R-naught is misleading, because some person's R-naught might be one,  and someone's R-naught might be four. And one of them might be a super spreader, one of them might not be a super spreader. And there's this thing called the 20-80% rule.  So 20% of the people are going to account for 80% of the infections. That's what we see with some of these, what we saw with SARS. And it's also seen with HIV, typhoid.  You all know the very famous super spreader, typhoid Mary, and tuberculosis. And when you look at SARS, it's R-naught fell to 2.7 when you took out the super spreader.  So this was really key to how SARS got around. And many of those super spreaders actually had a runny nose, which kind of makes sense from a symptomatic standpoint,  that that's more likely to expose you to respiratory secretions. But one of the other things about SARS, and I think we're seeing this now with the novel coronavirus,  is that the Chinese government's response to SARS made it much, much worse. This was something that was discovered, but then kind of kept quiet for a while in military hospitals  and a major head start for the virus. And these are some of the editorial cartoons from around the time of SARS. After SARS, people started thinking differently about coronaviruses.  They thought these are pandemic threats, they're not just common cold viruses. And they discovered a couple new coronaviruses after SARS.  I won't talk about that, but I just want to draw your attention to HKU1. They found this in a man in China in 2004 who had pneumonia. And then they started looking at bank samples  of people who were sick with SARS, that had a presumed sick SARS diagnosis, and they actually found HKU1 was circulating along with SARS.  They looked in the United States, they found it in the United States. They looked in Cleveland, and I'm from Pittsburgh, so nobody likes to look for anything in Cleveland there,  but in Cleveland they found it in specimens there of severely ill patients on mechanical ventilators. They found HKU1 and nobody knew anything about it,  and it was causing people to have ARDS. So I think this is really interesting because it maybe gives you an idea of what could have happened with this virus.  If you want to know in China, was this there before and just mixed in with colds and flus? And no one tests, you know, you can go to any ICU  and they're like, that guy's got a viral pneumonia, that guy's got a viral pneumonia. Nobody's ever figured out. They do the biofire test, but if it's not on that panel,  you don't know what caused it. So I just draw your attention to HKU1 because I think that's a really good parallel to think about.  We talked a little bit about the clinical features with coronaviruses. Pneumonia and more severe diseases, much more likely in the immunosuppressed, the elderly and infants.  SARS, which is the touchpoint for this novel coronavirus, 8,000 cases, 800 deaths, 25% had ARDS and the mortality was 10%. This is something that was a little bit different  than what we're seeing now. Our mortality rate numbers are on 1 to 2% with the severity bias, but look at SARS's case count, 8,000 versus about 70,000.  What SARS could not do is transmit efficiently from human to human. What SARS relied on was poor infection control. Once people understood how to treat these patients safely  and how to protect their staff, SARS disappeared. This virus is spreading more like the common cold-causing coronaviruses.  So that's why this is not something that we believe is containable. This had been going on since November, at least in China,  and you give a respiratory virus a head start like that, you cannot contain it, just like H1N1 could not be contained. So that's really important to remember as this debate shifts.  In SARS, they used a lot of different drugs, and I won't belabor them. Nothing really worked out. Some people were interested in some HIV drugs.  Some people were giving steroids, which actually probably made people worse. But the point about SARS was this happened in 2003,  and this is 17 years later, and we have no coronavirus countermeasures. This is the problem with emerging infectious disease countermeasures.  Nobody except for BARDA really actually invests in them,  and that's why we're left with nothing on the table right now. A couple of other things to talk about SARS.  Dr. Buckman talked a little bit about the link between bats to civic cats. Just remember that coronaviruses all circulate in bats, so that's where they're always going to be.  And after they actually stopped eating the civic cats and figured out how to do infection control, SARS disappeared. And since SARS disappeared, there's only been a few cases  that were really just linked to lab errors most of the time and a few little sporadic cases, but it's gone, and that's why vaccine development disappeared.  That's a picture of a raccoon dog, which is one of the other hosts that they thought about there. We did have eight cases of SARS in the United States.  Many people forgot about those eight cases. I just list them there for your benefit. You'll be able to get these probably online on the app,  but there were cases, including in my home state of Pennsylvania, many people who had traveled and got exposed. The Hotel Metropole, which is one of the major focal points  with the SARS outbreak, played a role there as well with the U.S. cases. But in the United States, we had eight SARS patients in nine hospitals with 110 healthcare workers.  Forty-five healthcare workers had exposure without any mask use and did not get infected. So I think that's really an important point to make, that we got lucky with SARS.  Touch on Middle East Respiratory Syndrome very quickly. This is the one that spreads from bats to camels to humans in the Arabian Peninsula since 2012,  and they found fatal respiratory illness in Saudi Arabia. They basically identified this in a Qatari national that was treated in the U.K. They isolated the virus,  and then they found out this was present for some time. Even in April 2012, they found it in this unexpected cluster of healthcare workers in Jordan that got sick.  So this clearly, again, is another theme with coronaviruses, that even though we might discover them, it doesn't mean that they weren't there before.  And this has been in 26 countries, including the United States, and this has about a 35% case fatality rate. But again, like SARS, it does not transmit well between human to human,  which limits its spread. And people have forgotten a lot about MERS, but these are some of the cartoons that people really were worried about MERS taking off like SARS did.  But it clearly hasn't, but there are cases accruing. Even in the last week, there are new cases in Saudi Arabia of MERS,  but it just doesn't transmit efficiently from human to human. That's the issue with it. When you look, this is just where MERS fits.  It was also in the beta coronavirus family near SARS, and that's why people are very focused on this branch of the coronavirus family. Again, this is something that came from bats,  and they found antibodies in camels, and they realized that this was a camel-human interaction that was causing this virus to spread into humans. And MERS is an interesting lesson,  because they did get an imported case in South Korea that led to 186 cases and 36 deaths with massive nosocomial outbreaks.  So again, infection control is very important in ICU settings and in regular hospital settings when you're dealing with coronaviruses.  And the government of South Korea lost a lot of confidence based on how they handled that MERS case. We did have two cases in the United States.  They were both really very mild cases, and they didn't have any secondary transmission. They were handled very well. They didn't need to be hospitalized.  So we did have an experience with MERS back in 2014, which many people have forgotten about. So a couple of things I want to end on in the critical care themes,  because I have a critical care audience here. Like I said before, we have an unclear severity picture. You can see some horrible CAT scan pictures there,  but remember, these are severity bias skewed samples. You're seeing people who are presenting to hospitals. We do know that you're going to think about when you...  What I think is going to happen is we're going to get a surge of patients with this coronavirus, some of whom are going to need critical illness.  So I think it's really important that hospitals start preparing now and start thinking about this, dusting off their pandemic influenza plan,  thinking about mechanical ventilation issues, how you're going to do that if you get a run on your ventilators, especially if you're in a small hospital.  What kind of supply chain do you have? What's your ICU bed capacity? How do you deal with rescue modalities? So, for example, in China, they've used ECMO on some patients.  Do you have an ECMO program, or are you going to use ECMO if you have cases sporadically with this? Think about infection control, how many airborne isolation rooms are in your ICU.  And think about how you might trial experimental antivirals, which we did with 2009 H1N1. This should have gone down, but if you can look here,  some of these ICU patients, it's not really projecting well because the CAT scan is blocking, and the average SOFA score is 17 there, and the average SOFA score was 4,  which gives you some idea of where these patients sit. But sometimes the onset of symptoms to ICU admission is 10 days, so that's kind of interesting.  It's more of a prolonged illness. Just to remind you of 2009 H1N1, that there were 61 million cases in the United States  with 274,000 hospitalizations with about 30% admitted to an ICU, 38% developed ARDS of the patients admitted to the ICU, of the deaths, 24% died,  and patients who received treatment less than 2 days after onset, 20% less likely to develop ARDS and 22% less likely to die.  So we've been through this before, and we dealt with H1N1, and we actually used really interesting modalities, like ECMO, for example. In the Southern Hemisphere,  one-third of mechanically ventilated patients received ECMO and had a 20% mortality. And in the UK, 55% decrease in mortality just by referring someone to an ECMO center.  So that's really important that you think about what you're going to do for your severely ill patients if you don't have the resources at your hospital.  And 4% to 9% of mechanically ventilated patients required ECMO during H1N1, so we were able to handle it. And some of my colleagues at the center,  we actually tried to sell this as an approach to thinking about pandemics and using the concept of severe lung injury centers where they could do ECMO. So just a couple last slides.  What is it about coronaviruses? It's a virus. It has the ability to recombine. It has the ability to move from host to host. There's a worldwide epidemiology.  Spread through the respiratory route. Bats are a massive species that can do a lot more, can spread a lot of viruses very far. A couple of predictions.  I think this is going to become the fifth seasonal coronavirus. I don't think that this is going to be something that's containable.  I think it's going to circulate along with our other coronaviruses. And I also think, like many pandemics, that the reaction will be worse than the virus.  It's the government actions that are being taken that are not science-based, that are going to magnify the impact, the economic losses, and the societal disruption from this virus.  So thank you. Again, I hope that was useful, and it was a whirlwind tour of the coronavirus, but I think that hopefully gave you some context.  Okay. Our next speaker. Okay. Okay. Dr. He Su Young. He is a trauma surgeon, and he's going to be speaking to us about how we respond  to the things that we're seeing in society as of late. Thank you so much, Donna. Thank you, everyone, for being here today and allowing me to give this talk.  I'm sorry about the little bit of a whiplash. I guess we're taking an all-hazards approach to this talk, as well as critical care preparedness.  I don't have anything to say about COVID-19. I'm sure a lot of you are here to see. I don't have any conflicts of interest to disclose.  Financially, I am the chair of the Injury Control and Violence Prevention Committee of the Eastern Association for the Surgery of Trauma,  and my opinions and findings and conclusions don't reflect the views of my employers, affiliated institutions, or other individuals. Just as a warning, some of the images shown  during this presentation are graphic and may be disturbing to some people. My objectives are threefold. Identify violence-related injuries as a public health issue.  Describe critical care preparedness and best practices as mass casualty incidents. Explore the role of medicine and medical societies in this area.  All right, so does this matter to me? Well, as you can see from this chart, across the world, deaths from terrorist activity is increasing. In the United States, surprisingly,  unlike most of the First World, we do have a, as you can see, it's orange, we do have a spike in deaths from terrorism. Most of that relates to events  that are probably in all of our minds and in the news all the time, probably equal time as the coronavirus. And you can see some of these pictures  from the things that we've gone through over the last decade, the mass shootings that have really pervaded our society. As you can see, mass shootings are all  throughout the country. The number of mass shooting events, as well as the number of deaths from mass shooting, are increasing through the time. And so even a surgeon like myself  from flyover country in a medium-sized city in the Midwest, we've had to deal with this as well. About a year ago, we had a workplace-related shooting event  at Paradigm in Middleton, Wisconsin.  And luckily,  our mortality was really low, but this is something that really should be on the back of everybody's minds. If not to emphasize it enough, about 15 minutes from here,  I had the opportunity to visit this when I was here two weeks ago. The Pulse nightclub, formerly, now the Pulse Memorial, where 49 innocent people  lost their lives tragically. As everyone knows, the cost of gun violence in the United States is huge, and the cost of a terrorist attack is just incredible.  So how do we prepare for this? This is a chart from the Rhode Island Incident Command Center for Rhode Island Hospital, and it's a busy chart, but this is really just to point out  there has to be communication within our health systems and interaction between the health systems. So it's really important for us as critical care leaders  and critical care providers to be at the table. The thing I want to emphasize most, though, today is not that we need to be at the table,  but also to remember our ancillary support staff that also need to be at the table. For instance, we can't deal with a mass casualty event unless there's housekeepers  that are turning over our rooms as fast as possible. If there's not food preparation for all the people who have to work double shifts and can't go home.  So as you plan with your hospital, remember all those people that work with you together in an interdisciplinary environment and make sure that they have a voice, too,  because without them, the cogs would fall off. So there are some differences in mass casualty incidents from conventional things such as traffic incidents,  which usually have low rates of emergent operative interventions, and violence-related mass casualty incidents, which have higher rates of emergent operative interventions.  But both really include unexpected surges. And so that's where this idea of triage comes from, and I'm not going to spend too much time on it  because we're running a little bit over time, but it's this idea that we have to make sure to take care of the people who have the life-threatening problems  that we could intervene with as soon as possible and provide as much care in a limited resource environment as possible.  To do this, however, we do have to over-triage pretty severely. Up to about a 50% over-triage rate is acceptable. In studies from Israel,  they noted that less than half of severely injured patients were identified by experienced trauma surgeons. So in general, we want to err on the side of caution.  About 4% of all patients who present after a bombing or mass casualty event from a blast will require ICU attention. Notes about surgical care.  Just to note, most patients won't go to the operating room right away after a mass shooting. Only the people who are immediately life-threatening will go.  And when they do go, they'll only have damage-control surgeries. And most patients will be in the ICUs or the floors or in the EDs  continuing to receive resuscitation, antibiotics, and other care as needed. So triage is an ongoing cycle. We really talk about it in the ER and in the field a lot,  but the tertiary triage is really important as well. So as ICU physicians, we need to continuously triage our patients, and that means that we really need to maximize lives saved  with the limited resources. And this can be really counter to what we do often in our ICUs. In terms of surge capacity, we really need three things, space, staff, and supplies.  For space, we really need to identify patients who can transfer out, anticipate needs for their recovery after operations, and identify areas for ICU bed expansion  and figure out how we're going to staff and supply those areas. In terms of staffing, in natural disasters,  we often lose our communication channels because something happened to them. But often in these mass casualty events in terms of violence,  our communication channels will be intentionally turned off. So it's really important to make sure that we have communication channels and then make sure that our staff  and our leadership has up-to-date contact information so everyone is reachable. We also have to figure out how to increase staffing  and use non-critical care providers to care for our patients and offer appropriate oversight. Supply-wise, we can't plan for every mass casualty event,  but we really do need to understand the current state of our inventory and as well as try to predict the most likely things that we will need  and also have a plan for rapidly increasing supplies throughout the region. Post-incident, we really must review and address all the issues that come up during these events.  And then I think a really important part that we miss, we talk a lot about taking care of our patients outside of the ICU,  but we also have to figure out what are we going to do with our providers, our staff, our patients and families who come through,  and the post-traumatic stress that they go through after events like this. So what else can I or we as a society or a medical profession can do?  SECM, a plug for us, is that we have courses and books available for disaster management and disaster response planning.  The American College of Surgeons puts on the advanced trauma life support course, and it's really important to try to raise the amount of knowledge in terms of trauma care  because hemorrhage resuscitation and trauma support is slightly different than other things that we might be doing in the ICU.  So after the Sandy Hook event or the Sandy Hook tragedy, we quickly recognized that we can't get to people quick enough to save them  if they have life-threatening bleeding in an event like that. And so what we identified is that we need to teach the people who are there,  the bystanders, how to stop life-threatening bleeding. This is an initiative that was put together by a group of national stakeholders.  Today and throughout Critical Care Week, we'll be having Stop the Bleed courses here at SECM, so please stop by.  But it's really teaching people who are going to be there, so that's your relatives, your mother, your wife, your children, how to put on a tourniquet,  how to apply direct pressure, simple things that they can do to temporize bleeding to stop. Let me shift a little bit to advocacy. So I know we talked a little bit about this.  This was mentioned at the plenary. This is a tweet that went out in 2018, about a year ago, by the NRA, and they said,  Someone should tell self-important anti-gun doctors to stay in their lane. And obviously, appropriately so, the medical community was outraged by this  because of what we've been seeing and what we've been experiencing and really the lack of concern for a clear public health issue.  So my point here is that it's really our responsibility to our patients to go beyond the ICU and to note that policies that are developed at Washington and our state legislatures  or even locally in our cities and towns, all these policies affect our patients and their health. There are limits to organizations in terms of nonprofit status  and things like that in terms of advocacy. But there are things that we can do. I think the East is a great example of what we can do,  and the American College of Surgeons has done a wonderful job of coordinating some of this.  But really, we really need to look at firearm injury and firearm violence in terms of a research perspective. And at the end of the week on Wednesday during Critical Care Week,  one of our leaders in this field, Dr. Marie Crandall, will be giving a little bit of talk  describing the different evidence-based practice management guidelines that we've been putting out as well as consensus statements.  So it's really important to go back to the data and think about it as much as possible in terms of addressing this issue, this public health issue.  So just to conclude, preparedness for violence-related mass casualty incidents must be thought of in terms of a critical care coordination model.  And it's really important for you, as critical care physicians, to become involved within your own community. Thank you. Okay. I'm going to finish on a slightly different topic.  And I am going to speak about climate change and how it is affecting our public health. Okay.  I work in an organization in South Florida, and I have no disclosures other than we have lots of pineapples and pine trees, palm trees, pine trees up north. Okay.  Our area is very densely populated, and we exist in an area known as Hurricane Alley. This is a slide of all the known Category 5 Atlantic hurricanes over this period of time.  And it is an area of the world that is at the most high risk for dealing with hurricanes. All right.  This is a particular slide that is demonstrating what is actually happening in our global climate presently. We do have warming. We have increased thunderstorms.  Our wind is actually changing into a vertical shear, and the speed and the height of the wind is increasing.  The other graph is demonstrating this is a five-year running mean of Atlantic hurricane with related indices from 1800 some odd to 2016.  And if you look at the last decade or so, there is absolutely an increase in Atlantic hurricane activity.  These are coming from our government, the National Oceanic and Atmospheric of our particular government.  So I don't know how we can, some folks can try to refute that this isn't happening. Okay. Surges, hurricane surges, water.  There's a tremendous amount of evidence that the water has already risen. We're not waiting for it.  It has already risen, and the projections are quite significant in a fairly short period of time. And this is the extent of the science regarding sea level rise. Okay.  How I developed this Florida perspective. I came from Boston, and I moved to Florida, and the worst thing I had ever experienced was the blizzard of 78. Any New Englanders here?  Yeah, back there. Yeah, yeah, yeah, yep. You remember the blizzard of 78? Okay.  And New Englanders are fairly hardy individuals, and, you know, it didn't seem to affect our psyche, you know, too much.  When I moved to Florida, some phenomenon was taking place where people who lived there had, like, PTSD over Hurricane Andrew, and it affected their lives so significantly.  I was like, is this, like, people just, like, exaggerating their experiences, or, you know, is there something, you know, really remarkable that took place?  So they called it the night of terror. Our world had never experienced 165 mile-an-hour winds before.  There were immediate storm-related deaths, but the medical examiner, for months, continued to have more and more dead people arrive because after everything cleared,  they were able to locate patients that were previously, you know, you couldn't access them because of the debris and everything in the roads.  And there were an awful lot of deaths from stress. Elderly folks kind of tipped over, and it was a very significant amount of deaths.  All the literature gives varying quantities of death. They don't really know because after this hurricane, 30% of South Florida population left and never came back. Okay.  Okay, so in the aftermath, five days, no food, no water, nobody had employment to go to. There were tent cities, field rationings, shootings, people brought out their guns.  It was like third world country of, I had never heard of this living in Boston.  It happened in 1992, around 91. I mean, I had young babies at the time. But I didn't know the devastation that occurred in Florida.  I guess we didn't have that mass media like we do, you know, as of late. So it was quite significant, and it was the most, it was the worst storm that had been seen in modern times,  but now it's been surpassed by Katrina and Sandy. Okay, this particular gentleman here, this is Dr. Alexander Leaf.  He's a scientist of all varieties of scientists, and he wrote an article in New England Journal 30 years ago, which they recently brought back.  He was a physician that was an advocate for de-escalation of nuclear war.  He developed many worldwide physician societies to be advocates, you know, to de-escalate world nuclear wars. He won a Nobel Peace Prize.  But one of the interesting things that he did say 30 years ago was that human effects of global climatic and environmental changes,  effects on minds, bodies, and ecosystems will be analogous to those of nuclear war, including global starvation.  And five days of that did occur in South Florida before Army and Marines came along.  This is a recent physician paper that came from the Angels of Internal Medicine, and it's a call.  It's a call for the medical community at large to start becoming more engaged in these issues that are going to affect our society,  that we have more respiratory and heat-related illnesses. The prevalence of vector-borne and water-borne diseases are increasing.  We have food and water insecurity, and on the best of days, we still have malnutrition and starvation.  And in the world that we live in nowadays, it's kind of sad that we have to say that.  There has been great increase in global health security from an interconnected world perspective.  The WHO and USA got together in 2005 to try and build capacity to detect and assess these things. But they weren't really getting much progress until Ebola started showing.  And in 2014, they accelerated things, and they've gotten much better. However, this Global Health Security Alliance primarily focuses on the weakest of countries.  Of course, they need it, but in the United States, in our wonderful, you know, first world country,  within 48 hours of a mass, or not a mass, but a natural disaster, most folks aren't going to know where to go or what to do.  So we've learned, fortunately, we've learned from modern disasters and wars that we must prepare, think laterally,  think about the secondary implications of these events, logistics before, during, and after, and evacuation plans.  Because we are learning from past events, however, we have to consider what occurs after the event. These are our traditional natural disasters.  People, when they're preparing for natural disasters, need to do a hazards risk analysis of their particular location,  because your location is most important when you're preparing for these things. South Florida, we're not going to prepare for like the fires in California or Australia.  We're preparing for hurricanes, storm surges, and the like. I know people experience, they prepare for tornadoes. You know, it's most significant to your particular environment.  Critical care is quite important in this venue, because critical care is going to be involved in assessing strengths and weaknesses  and making decisions for triaging for life-saving health care.  Okay, this particular slide is telling us that within like 24 hours, we have to change from standard of care to sufficiency of care.  And our degradation of care is something that we need to prepare for in our own particular organizations.  We have to build triage protocols, evacuation plans, and make partnerships with alternative hospitals.  And everyone knows nowadays that we have disaster preparedness responsibilities. However, we don't do it in a very high fidelity way or frequently enough.  The tabletop exercises really aren't sufficient.  After somebody has experienced one of these events, you see that the experience really prepares you and teaches you for subsequent events.  It's critical that we are familiar with the different types of disasters and action plans in our environment.  There are many resources and tools that are available to help you kind of design your own plan and your own organization, how to triage and build up capacity.  And because we're going to be in the situation that we're going to have to decide who is going to be receiving life-saving therapy and who is not.  So I'm going to bring this question to the audience.  If we had a 40-year-old female asthmatic with respiratory failure, a 52-year-old man with COPD and a new pneumonia with respiratory failure,  an 18-year-old boy in septic shock, respiratory failure, and anuria, and you could only offer one person life-saving therapy, who would you select?  We'll come back to it, you know, if you want to ponder this for a little bit. Okay.  In our organization, my organization, we have extremely structured plans and we have drills four times a year. We plan for four hurricanes a year.  Putting together your team, those are the individuals on the team that is ethical and pastoral in addition to, you know, executives and clinical providers.  Ideally, the people that are making the decisions are not involved in the clinical care of the patient. And we use quantifiable criteria.  There's more exclusion criteria than there are inclusion criteria.  We base it on, you know, SOFA, and the highest SOFA scores are the people that are least likely to receive life-saving care because they're on the spectrum that are least likely to survive.  So, we have tools, and as I said, it's people with a single organ or a moderate severity of illness that will be first selected for life-saving care.  It will be reassessed in 48 hours, and if the people that were receiving the life-saving care are not improving, they will be withdrawn upon and other patients that have a greater probability of surviving will receive those services.  Now, this is ethically traumatic for people. So, when we go back to this, which one would you think would receive the life-saving care?  Female. Okay, well, believe it or not, it's the 48-year-old female, yes, it is, because that person has a single organ, respiratory failure, likely to live.  The other folk, the other gentleman that has the COPD, a new pneumonia with respiratory failure, because he has chronic comorbidities, he's less likely to live, and the boy is the  least likely to live because he has multiple organ dysfunction. So it's a very horrible thing to have to contend with, but it's  real. And the other thing that's to be, must pay attention to is that our duty is to your plan. We move from autonomy to distributive justice, and interesting quote here, as long  as the reason of man continues fallible and he is at liberty, different opinions will be formed. We all agree collectively, but none of us agree individually, if those were your  family members. But what I learned, the key is, all of these plans are made in solidarity with your community, your local, other hospitals, and it's communicated readily to  the public and to the society, and with other institutions, and everyone is in solidarity, because as you can imagine, this is a very difficult thing to contend with.  All right, quickly I'm going to just show you a great example of how South Florida did this. Irma, a couple years ago, there were no hurricane related deaths. Baptist Health has a  policy that they believe their responsibility is to the community to maintain public health and safety. And this has implications for how the organization operates. Okay, we  go into, you know, operation command, and we activate our teams. We, an entire organization of 25,000 employees, we have an A team and a B team that are re-randomized for those  four hurricanes per year, and when it becomes more of a warning, as opposed to a watch, the teams get activated. So, A team comes, and they're before the threat is imminent, they're  one, team A is in all the facilities. We evacuate days before an event, and emergency operation incident command is a very effective group, and after the all clear is made, which  may be three days, four days, when emergency vehicles can start getting around again, that's when A leaves and B comes in. Telehealth played a significant role in augmenting  critical care capacity. Our emergency departments, and someone was saying about the degree of overcapacity for a facility, they were 100% overcapacity. All ICUs were  full. Teleintensivists became the triage folks of the organization. And other things, I think was mentioned earlier before, that embracing civilian caregivers becomes essential.  They can really do quite a bit. We as clinical people are leery of lay people getting involved, but they absolutely help make  that sufficiency of care. The community that we serve, the circumstances of one of these events, the post event utilizes  more disaster resources than the primary event. We're dealing with non-hospitalized individuals with critical illness that either deteriorate outside or inside our organization. We  have families of those hospitalized and non-hospitalized patients. In our particular organization, the doors are not closed to anyone. Anyone who shows up at the doors is allowed  in. All these hospitals are hurricane impact resistant. Anyone who is due to have a baby in less than a month are actually called to come in. And all family members and staff  family members are also allowed in the organization. You get very creative. A couple of things pre-event. Everyone's trying to get their shutters up. There's a lot of traumatic  issues that come about when people are trying to prepare their house. Also, carbon monoxide poisoning occurs from everyone having generators. And our hyperbaric chambers were  knocked out. You have to know where your other areas in the state are that you can utilize. You have to make friends with all of your resources around. And we had a nursing home  crisis. Nursing home patients, a lot of them just died because they didn't have sustainable resources and they were not able  to evacuate and they were not able to transition to other facilities. We have a transfer center also that transported patients all around. And we made a plan for the folks that are  electrically dependent. You can't send patients home or family members home to no electricity. So, we created a we used one of our auditoriums that was open for discharged  patients. And we also have one of our local universities. And both of these areas have access to telehealth. Debriefing wise, as you know, you lose communication, which was  mentioned before. Walkie-talkies was generally the method. And we realized we have to have many, many, many more of those walkie-talkies. Debrief shower signs. Garbage fills up very  rapidly. And bathroom capacity is also very challenging. And based on the last hurricane, we decided to develop a Team C.  Food is gone very quickly. You got to plan for food. And why were there no hurricane-related deaths for Irma? It was because  of the experience. The emergency operation command, everything was pre-planned. And everyone agrees, nobody, you can't think outside the box during these events. Your duty is to the  plan. And, you know, field hospitals were ultimately set up. So when I think about blizzard versus hurricane, I've come to appreciate that hurricanes are a long-range event  that has long-standing implications for the health of your entire community. And critical care's role is so significant in deciding who gets life-saving resources and who  doesn't. And preparing for that and educating for that are very important. Thank you. So we decided that we would be kind of just available if  anyone has questions for our entire panel regarding any of  these subjects. Okay. Thank you very much. Oh, yes, we do. Can you go to the mic? Hi. I have a question. How do you create urgency for a  non-imminent event, preparation for a not-imminent event at your local institution? That's an excellent question. Dr. Heast, who probably would  be able to answer that best. I am used to dealing with more of these pre-planned events. So I know our emergency medicine colleagues have, like,  incident command and a lot of preparation from the hospital side. But I have had trouble getting mobilization from an in-hospital admitted decanting standpoint, if that makes sense.  I'm sorry. I couldn't hear what you said. I meant more from the, not from the triage coming in ED standpoint, but as hospital staff, ICUs, and within the  hospital, our role is to decant. But getting people to do drills and prepare for that hasn't been as readily received as much as the imminent bed management, like, the  tabletops for the coming event. I think you bring up a great point. It's really easy to get the ER sort of involved and EMS involved. But downstream  health care workers, it's a little harder. There definitely are financial pressures in terms of disaster planning and  preparedness. It really starts with leadership, though. So I think it's really important for us to engage our hospital leadership and our regional leadership in trying to figure  this out and trying to develop allies within our health care system to do that. Sadly, these events happen all the time. So one thing that I  have found in our institution is when these things start popping up in media, it's a really good time to stop by your leader's office, your hospital leadership's office,  just to say, hey, listen, this can happen at any place at any time. We really need to prepare for this. And a lot of the stuff that's revolved around disaster preparedness at UW,  for instance, has happened around some of those things being in media. So again, it's sort of a sad tragedy of how we live today.  Thank you. Has anyone here had to deal with any of these types of events in your organization? What kind of event did you deal with?  So I'm actually from Puerto Rico. And I was in Puerto Rico when Maria came to the island. I was just recently graduated from my residency. And I was actually working in an ED and  an ICU back home, a pediatric ICU back home. And as you probably all know, there was a big disaster. In general, we weren't prepared for it. And it's very interesting because  you talked about zero direct related hurricane or event related deaths after Irma in Florida, whereas whether you believed the 4,600 or not number from the recent study.  I work with a nonprofit back home, and we established an urgency clinic in one of the municipalities that had a huge flood and had to evacuate like 6,000 people  at 2 a.m. We ended up running the clinic for about 10 months and we saw like 14,000 patients. And it worked more as an  urgency clinic. And what we actually saw was that the hospitals were getting all the brunt, the bigger hospitals were getting all the brunt, but mainly for non-critical illnesses.  There weren't that many traumas, actually. It was more that we lost most of the primary care because a lot of the primary care physicians left the island or lost their offices.  So we ended up dealing with more preventive medicine and the things that you usually see after a disaster, the infectious  stuff, you know, bouts of conjunctivitis and skin infections.  But I was wondering because, you know, you were, and sorry, I was a little bit late, so you might have mentioned this, but in terms of ICU and what the role of the ICU physicians  at that point, I feel that education for the general physicians that are actually dealing with these patients is very, very critical because most of the ICU patients and most of the  ED visits that we saw were basically hypertensive crises, diabetes, uncontrolled, you know, stuff that's usually dealt with in the primary care standpoint and ended up becoming  a critical illness because there weren't, you know, there weren't the resources. So other than just establishing, you know,  urgency centers, I feel, and it's more of a comment that a lot of the involvement has to do with education and, you know, creating networks with your local physicians to deal  with these things before it actually happens. Certainly. I think identifying a location for a lot of, you are correct, a lot of people with chronic or maintained  illnesses, they tipped over into, you know, great deterioration. But having a location, having a location and a plan. Okay. All right. Thank you all.

Video Summary

The video provides an overview of the history and context of coronaviruses, highlighting the emergence of SARS and MERS as turning points in understanding the potential severity and global transmission of these viruses. The current COVID-19 outbreak is discussed, including its origins in Wuhan, China and its rapid spread worldwide. The importance of understanding clinical management, testing for mild cases, and considering potential treatments and ongoing clinical trials is emphasized. <br /><br />The panel discussion focuses on disaster preparedness and response, emphasizing the need for communication, coordination, and collaboration among healthcare providers and stakeholders. The role of critical care in triage and decision-making during mass casualty incidents is discussed, as well as the importance of educating and training healthcare workers for effective emergency response. Ongoing planning, drills, and debriefings are highlighted as means to improve preparedness and response efforts. The ethical considerations involved in allocating limited resources during disasters are also mentioned.<br /><br />Overall, the video highlights the significance of being prepared for different types of disasters, such as pandemics and climate change events, and stresses the importance of taking action to protect public health and save lives in emergency situations.

Asset Subtitle

Infection, Worldwide Data, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Explore the art of war battle strategies for the next influenza mutant enemy
Analyze antiinfective infantry artillery power to combat pandemic pathogens
Discuss worldwide critical care preparedness to address a catastrophic contagion
Evaluate the role of medical societies in worldwide tragedies that are knock-knock-knocking on the ICU's door
Assess potential societal threats during pandemics

Twenty-First-Century Viruses

Timothy G. Buchman

Antiinfective Artillery: Are We Winning the Battle but Losing the War?

Anand Kumar

Biological Threats, Pandemic Preparedness, and Containing Contagions: How Prepared Are We?

Amesh Adalja

Tragedies Depleting Critical Care Capacity

Hee Soo Jung

Critical Care A La Mode During Natural Cataclysms

Donna L. Armaignac

Meta Tag

Content Type Presentation

Knowledge Area Infection

Knowledge Area Worldwide Data

Knowledge Level Intermediate

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Crisis Management

Tag COVID-19

Tag Resource Allocation

Year 2020

Keywords

coronaviruses

SARS

MERS

COVID-19

outbreak

Wuhan

clinical management

testing

disaster preparedness

response

critical care

triage

emergency response

public health

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