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Pandemic Flu Exercise part II

by: DemFromCT

Sun Apr 06, 2008 at 15:39:42 PM EDT

There are interviews broadcast on radio as well. The idea is to raise awareness.

The original thread is here.

DemFromCT :: Pandemic Flu Exercise part II

you tube links:


other media:

Daily Kos

Redding, CT

Danbury, CT

Newtown, CT

Bethel, CT

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Nice work Greg
Everyone should view these videos.  Dem, you did very well in communicating the key messages.  Who wrote your sound bites?  They were very well crafted.  I urge everyone to write down what Greg said on camera and use them in your own interviews with the press, when speaking to legislators, and even just plan folks.  

The three S's were brilliant.  "We will be short of three things during the pandemic, space, supplies, and staff".  Wow.  that really gets to the core of the healthcare problem in just a few words.  

Well done.


credit to Eric Toner, MD
who drilled it into my head. Eric's at UPMC I heard it first from him.

[ Parent ]
A little cold water thrown on the exercise
Some critical observations from the video.  It was really crowded in those tents.  People sitting arm to arm.  Lots of activity.  These conditions are not those where good infection control can be maintained, IMO.

The participants and volunteers wore gloves and gowns but the masks were simple rectangular surgical masks, not N-95 respirator masks.  Why did you choose to use these masks that are known to be ineffective for viral protection?  Cost may have been a factor here but IMO the N-95s should still have been used if for no other reason than to teach the participants and volunteers how to use these medical devices properly.  Wearing the N-95 mask for a few hours straight is a very different experience than using a flimsy rectangular mask.  It is harder to breath, more humid, hotter and it takes careful attention to keeping the N-95 mask fitted properly.  These simply experiences and skills take time to cope with an learn to do well enough for the N-95 mask to be an effective NPI.  In fact, apparently the CDC thinks it is too hard to do well for the public in general and gave this as one of the reasons they were not recommending them for general use.

While this was just an exercise it appeared pretty chaotic just the same.  It will not be easy to prevent disease transmission in an environment like this one even if you used NPI perfectly.  Of course the one thing all exercises fail to include is the sheer panic, death, and high emotions that will characterize the real event after outbreak.  

Did you include security in your exercise and if so what were the rules of engagement given the security officers that took part?  If not why not? We know that violence is an everyday event in our ERs even without a pandemic going on.  What do you think the security situation will be at your ad hoc clinic and ERs during the pandemic?  Do you think good medical care can be provided without adequate security during the pandemic?

Dark Doctor

[ Parent ]
as to the points
all of them good, none of the answers are flippant.

  • we told everyone beforehand that in a real situation we'd be wearing N95 with just in time (JIT) fit testing, but that was a step too far this go around. We did not want to waste precious N95s from private stock on 200 staff. That was my call.
  • Crowded? Get used to it. They could handle twice the volume (and no more), but it turned out that only half the field hospital got erected because of high winds so we made do with half the space.. and succeeded.
  • we had a national guard unit for security and two uniformed officers for crowd control with prepared back up units which were not needed. There were no incidents and no 'inject' incidents because that is not what we were testing.
  • chaos? life is chaos. if you want perfect calm, watch medical shows on TV. Don't forget the first two hours are always the most chaotic.
  • part of the drill was to see how many beds we could free up on short notice. 60-150 out of hospital acute care beds was the answer. That's a big impact on a 300 bed hospital.

here's what's interesting about your comments. It';s one thing to say "we will move form "standard of care" to essential care only" and another to see it. If you're not used to it, you'd be horrified with what we don't do. But in reality on that day, you're lucky to get what you get.

[ Parent ]
Fire fighters do not train with candles.

 I understand the Doctors comments for it is what we strive for but the more real the test, the more real the results.

 One British camando team trains with real folks and live ammo. No bullet proof vests for the volunteers. Very few get hurt. They are top notch.

 Congradulations on getting the test.

 I like the quote "You do not prepare for a hurricane the day the wind starts blowing."


[ Parent ]
there is a science to drilling
and I promise you the commandos were not given armor-less volunteers the first time they were ever handed a weapon.

Firefighters do not simply start fighting fires before they are properly trained up.

No matter how reasonable and necessary it may seem to you to simply 'up' the intensity from day one, it isn't. That's true for strenuous exercise, and it's true for drills.

[ Parent ]
Not to jump in the deep end after the first lesson.

 No, I'm sure they built up to using live ammo.

 Sorry, did not mean to imply pushing teh schedual.

 I doubt teh Chinese acrobats of Tiwant, nor the flying Luwenda's (sp?) jumped from good to beyond belife in one week. It takes years to do it safely.

 I do believe people can learn to do some pretty superhuman feats. Not just breaking 15 concrete or stone briks with a bare hand. It could be saving 30 people, builing 20 working vents in an afternoon, wiring in 14Kv generator to power a hospital from just the owners manual or driving a semi because there where no truck drivers.

 Trainig is important less there will be one more victum.



[ Parent ]
safety first.

As a first drill, good. As an end point, not so great.

[ Parent ]

 Cool. I was trying to say or point out that with training people can do the seemingly impossible.

 I would not train to do 12, fourteen hour days. People normaly fall out after the second or third. After the fourth day, people are in a routine. "Welcome to the machine"

 It is interative process. Once you climb the mountian you can still see the horizon and other higher mountians. The best joy is in looking back to see you've been further than any oneles. Hopefully further than anyone else thought possible.


[ Parent ]

Just the thought of planning and implementing exercises can
be overwhelming. Today's first responders and public officials are faced with more and more demands on training time and resources. It simply is not possible to spend as much time as one might want planning, implementing, and addressing the issues uncovered by exercises. And yet this is one of the most important challenges for all of us in the emergency response and management community. Some things that often get in the way of success include:
> Overcomplicated scenarios and drills
> The wrong people or too many people at the table
> Unclear objectives
> Time constraints
> Lack of funding
> Competing interests and priorities during the exercise
> Difficulty getting buy-in and/or funding for exercises that address catastrophic issues that would have huge consequences but are of relatively low probability
> Thinking of the exercise as a demonstration that you know what you are doing and that you cannot or should not make mistakes; similarly, thinking that nothing should "go wrong" during the exercise

[ Parent ]
"If there is not enough Time to do it right, why will there be enough time to do it over" Admiral H. Rickover. Father USN Nuclear Program.

 Can you explain "Overcomplicated scenarios and drills " ?  Trying too much the first time or not enough time?

 As for the others, :o) ahh yea.....  The Joys of working with folks told to attened the turf wars. Volunteers can be easier, they are just harder to fire.

 Training is a great time to make mistakes - for they can not be made later.

"Where there is understanding, funding is not an issue"  

[ Parent ]
here's an actual example
N95s are not recommended for the public. Would it have been appropriate here? Sure. Are we okay with getting them? Sure. Do we want to teach everyone to go get an N95 mask as part of the drill? No, that's controversial and not accepted by all the partners.  Do we want to get the entire drill bogged down in that discussion, which would settle itself quickly enough in real time (if you don't have them, it's not an issue)? No. We could have spent a month on that question alone, more time than we had available.

if we added "just in time" fit testing of N95s to 230 volunteers in a 4 day train, 4 hour live drill, we would have used 2 hours of the 4 hours just to do that. If we fit tested before hand, we don't have the volunteers, who during the week would have to give up more time.

if we extended by 2 hours to make it 6 hours, plus 2 hours of 'hotwash' (i.e. what went right, what can we do better?) we lose volunteers, who are already giving a Saturday up for us without pay.

if we use N95s, who pays, who replaces, is there a shortage, can we get more? if we can get more, do we want to use up any since we should be building up stockpiles?

Decision made: perfect world: N95, purposes of drill, simple mask but everyone must wear (and they mostly did).

[ Parent ]
great learning: you do the work, we do the learning too
Not surprising we all want to see more exercises, to learn from them too.

Thing is, "someone" has to do them. O;-)

Again, Dem and all the folks involved locally (including making videos and such): THANKS!

(and ain't the internet a good thing sometimes!)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
sometimes? n/t

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Understand now.

  Understand. N-95 is not appropriate nor benifficial to discuss now.
  Also n-95 might change - doubtful
  I saw using the facemasks as "use this now, it a real emergency you will get a (___________)" as this does not waste more expensive N-95 masks. Fitting is important and will be done.

  Good example. I will use this (should a drill ever happen at my place)


[ Parent ]
"N95s are not recommended for the public"
really should be "N95s haven't formally been recommended for the public". They are not ruled in or out by the interim guidelines.


In the context of expecting official sanction, there isn't anything to say 'it must be a cardinal thing to do', therefore devote resources to the exercise to teach it.

[ Parent ]
Dr. Woodson,
I participated in the exercise and I was less concerned about what type of mask was used (for the drill) than I was that a considerable number of people who were wearing masks were wearing them improperly.  

Whether surgicals or N95's (and there was a random mixture in the crowd), way too many people working the exercise had made the decision to compromise their mask integrity.  Several were wearing their masks slung down on their neck, offering no protection to their face.  This was true even of one individual I had to interact with as a "patient" - the man had to approach my car to speak to me but he was unprotected, as was I.  

A worrisome number of people were wearing their masks improperly, with many in surgicals having pulled them down so that their noses were exposed.  If they are uncomfortable in surgicals, I don't know that they'll be less inclined to make these compromises for comfort in N95's.  

Several individuals wore surgicals that had obvious tears in them.  

It seems to me that one of the major foci of a drill such as this should be infection control itself . People need to learn to maintain the stringent infection control that is required in an influenza outbreak - it won't come naturally and the'll be human and try to compromise.  What was missing from this exercise, it seemed to me, was a person tasked with infection control who's only job it should have been to make sure those participating were cited for infection control failures of the kind I saw all around me.  I was there for most of the exercise, and did not see anyone admonished for their lax use of PPE. Training those who'll be running these clinics in the importance of this subject has got to be a priority.  

[ Parent ]
just because you didn't see them
doesn't mean they weren't there.

Several people were tasked with it, and it was an identified 'we could do better' and will be one of the things more emphasized in the JIT training. I walked around and barked at people to fix their masks (not my task), but it was better at 12 than it was at 10.

OTOH, it brings home the point that in real world situations expectations that everyone follow strict infection control protocol is not going to be met. That's especially true with laypeople.

And you're right, N95s are even more burdensome.

Information like that is invaluable and that's one of the things we learned form the drill.

[ Parent ]
They were probably there
and circulating, as you say, but then I would have conclude that the problem is even worse than I though it was.  I saw these breaches in PPE all throughout the period I was there. If I was seeing so many individuals displaying laxity, and there were people circulating to prevent this, then there's a major problem in that area.

Mostly, Dem, my concern was not about any laypeople or those playing the role of patients.  Patient volunteers seemed to do a good job and took their roles seriously, right up to the correct mainenance of PPE (including every kid I saw). They might even have been too compliant to be realistic.

What was alarming, on the other hand, was that the lapses in proper PPE protocol that I noted were made by public health officials (easily identified by their large badges and coats with labels) and by other volunteers working the site.  Way too many public health officials who should have known better were those precisely at fault, wearing their masks slung around their necks.  That's a situation that needs improvement.  I'm not sure that they understand completely the nature of what they're dealing with in terms of the infectiousness of influenza.  Maybe on paper they do, but since the last real panflu outbreak of concern was in 1968, perhaps the reality is something that just hasn't sunk in. For their own protection, and that of the public, it needs to or the treatment centers will become vectors themselves.  

[ Parent ]
Oh, btw
there was one big guy who was positioned right in the center of the patient intake activity who was wearing not just one but two N95's slung around his neck.  I came to think of him in my mind as I rotated around as "Vector Vinny."  ;-)

[ Parent ]
did you take his picture? did you take any pictures?

[ Parent ]
She tried to!

I meant to provide photos of the scenes, and thought I had taken some really interesting ones. But on arrival at home, it was discovered that there had been some problem with my sim card, so no photos. I learned something from this simulation too that I can do better next time. It never works exactly as planned for any of us.

[ Parent ]
Yeah, complete technical failure
and I had fully intended to bust "Vinney the Vector."  ;-)

[ Parent ]
PS this falls under the heading
constructive, helpful, thoughtful, and accurate criticism. Thanks, Pixie.

What people do need to understand, however, is if Pixie says 'I didn't see it" then it's gospal true. In the original post, for example, Pixie correctly identified people who were not wearing masks at all and were challenged by staff. However, they were evaluators and were not supposed to be wearing masks.

Review the videos as well. We assigned a group for our own teaching purposes that I have not received yet, and we will be reviewing those, too!

[ Parent ]
Well, I can't say
whether the individual challenged to put on a mask or, if she did not, stay out of the triage area by the National Guardsman was an evaluator or not. I did not see that particular woman's coat/badge from my car so I could not say for certain whether she was in fact an evaluator or fell into one of the other categories.  That's still an open question.  

Those I saw with large badges saying that they had been assigned very specific duties and were very specifically not evaluators most definitely should not have been exempt from PPE protocol.  Those are the ones who concerned me.  

[ Parent ]
I know the specific incident
and they were an observer.

[ Parent ]
My honest recommendation would be
that in any simulation going forward, that there be no exceptions made for anyone re. PPE in order to enforce what will be a very key element - stringent infection control by all in the area - and one that will be subject to great (and dangerous) abuse.  

Realistically, the Guardsman should not be put in a position of having to determine whether someone is "exempt" from the PPE (or other) protocol.  That's just too difficult a task, and one that opens up a can of worms.  

Whether it's the Governor, the President, or the Pope, everyone in this kind of a simulation who is on site should be required to practice the critical habit of maintaining PPE, and of expecting it to be maintained by everyone around them reciprocally.  Why?  Because, in reality, there are a lot of folks who will think they're just as important as the Governor, the President, and the Pope, and who will act like it (and who will ask for exemptions that those folks would never expect for themselves).  From public health people on "urgent business," to distraught parents, a major problematic element in the real-life scenario will be those individuals expressing their belief that the rules, for some reason which they will recite at length, just don't apply to them.

In expectation of that, it would seem more logical to train security and the Guardsmen, who'll need to enforce these standards for everyone, to expect that all participants in the drill would fall under the "nobody's exempt" category, relieving the burden on them for having to engage in and make decisions on these matters (and to better practice what they'll really have to do).  In other words, I'd rather see everybody on site - including the evaluators - in proper PPE, no exceptions.  There's really no reason for them not to be.  

[ Parent ]
recommendation rejected
observers and evaluators are invisible. You don't have to approve. Guardsmen have to be be briefed better. lessons learned, very minor point.

[ Parent ]
i wasn't there: were they visibly invisible?
i mean, red jacket or whatever, so all others are told to ignore them?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
mostly green
some blue. They had Observer stamped on the vest. But we had more observers than vests.

[ Parent ]
as I said
the multiple breaches of protocol is a 'lessons learned, need to do better' and I'm not disputing that.  

[ Parent ]
crfullmoon had an idea
for a follow up exercise, and I actually thought it could be a good one.

In a follow up drill, if staff are observed not wearing their masks or respirators correctly, they get tagged midway through and turned into patients.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
motivation! yay!

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
RE Masks-
I'm sure Greg is going to step in here, but in the meantime, DrW, I remember reading on another thread that they purposly used the masks you saw, because they did NOT want to use and waste N95's that will be more greatly needed during panflu. -k

www.EmergencyHomePreparation.org -- A 'card-catalog' style of prepping information.   -

we don't have enough
so we made that decision.

[ Parent ]
excellent drill
Even without considering what actually happened and went right and went wrong and could be done better during the actual drill, to my mind the most important part of this exercise was just in the fact that so many different organizations in the community were a part.   The newscast mentioned 40 area agencies (like Red Cross, the military, police, National Guard, health care, etc.) and I think othes involved included organizations like area high schools, Boy scouts, and so on -- I think Dem posted somewhere over 100 organizations were involved.

That's BIG. Just getting all those differnt groups to come to gether and work on something like this ha to involve a lot of collaboration and coordination.  

And those are a lot of groups who are ready, now, to have some more pandemic flu awareness, I should think.  

Not only that, but unlike other drills around the country we read about -- this one did NOT offer vaccines nor did they practice handing out Tamiflu.   This drill was to explore, what will happen, when HCW do NOT have those things to offer.

In reading about how the drill went, and people's comments, I do see some room for improvement in the GetPandemicReady.org (or other similar) handouts, with the guides for home care.   I think it would be good to have two types of guides -- one for in advance (stuff you can buy ahead of time) and one more to be handed out in the event of an actual pandemic (still having stuff you can get but with the understanding the stuff might not be available, and suggestions for how to make do.)  

The question of how people who live alone would be able to provide their own home care is a good one.   Single parents of young children will have the same issue.   Adults living with incapacitated elderly parents, same problem.   There won't be solutions for some problems.   But we can keep thinking and trying.

Even people who are all on their own might be able to help try to keep themselves better hydrated, for example, if they have some water bottles stored by their bedside. Suggestions like one Jefiner made on a different forum (using those devices joggers use to drink water -- keeping it filled by your bedside) might be a good expedient suggestion to make to people -- how to creatively
+se the stuff you might happen to have.

To my mind, though, there is no substitute for prior preparation.  This exercise focused on response, not preparation -- but I bet a LOT more people in the area have had their awareness raised, and would be ready to learn more now, about how to prepare, so as not to get infected in the first place, and to have more on hand in the event they do.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

two types of guide
or maybe even three! :-)

Here's what I mean:
- A guide for pantry preppers.  People who will stock up in advance and will have the means and will be able to use those means.
- A guide for those who didn't stock up.  People who will use whatever is available in pantryless homes and things that may (or may not) be available outside.
- A guide for those who are in a position to help communities.   This would include workshops who can make solarcookers for their communities, businesses and non-business-entities who can reconvert whatever assets they have into pandemic use, seed networks who can put their expertise to good use, etc.  This would possibly be an outgrowth of IdahoEM's "resilience" threads (can't wait to see more on that).

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
The big problem is that they think it was a success.

It wasn't. Not even close. So everyone will pat themselves on the back and do it again somewhere else.

Until they realize and accept that a severe pandemic is what they are planning for, these drills will be nothing more than a sham.

Sorry but that is how I see it.

Better to begin preparing the people for what they will really experience on a very personal and extremely painful level.

How many dying children were carried into this drill by distraught parents who have run out of food and any way to deal emotionally with it?

They have to get real people.

Tell the truth

Goju, I am very sorry that is how you are seeing this event.

Sham, with intent to deceive?   I don't see it that way, and I cannot understand why you do.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
Baby steps.

 Are you saying it was a light test?

 Yes, it was not a horrific one. One step at a time before jumping into the deep end. Jumping into raw sewage tainted water with burning gas on top of the water and sharks below. Pandemic will be dangerouse place to work.

BTW, I stand by the sewage water, burning gas and sharks thing as lifeboats are on back order.


[ Parent ]
No Kobie I am not saying that.
Kobie says

Are you saying it was a light test?

No Kobie I am not saying that.

What I am saying is that the focus is on the wrong thing. We are past the stage of treating an unrealistic situation. We should be doing mass communication campaigns to prepare the public.... Now.

I dont care what drills you run. When this monster hits, the hospitals will be overwhelmed in days... so why spend so much attention on it. And then say what a great drill it was?

It is useless. It will fall apart at first contact. There is no way any hospital will be able to deal with it. They barely got by in 1918 with a 2% CFR and so fewer people.

Look... the most likely candidate is H5N1. Thats what everyone is drilling for. H5N1 has a very high kill rate if not treated with Tamiflu within the first 48 hours... and tami is losing its effect. If you go on a vent, you're as good as dead.

You really think people are going to drive to the hospital or mass triage areas in small numbers? or politely? No way. If there's gas.

We'll know something is up overseas when we see tents in the hospital parking lots. With total traffic jams and panicked people attempting to get to the hospital. How long can the unit remain active? How long before they run out of PPE? And staff? Dem said they didnt use N-95 for the drill cause they didnt have enough. Will they during a severe pandemic when no supplies are coming in and they didn't stockpile tons of them to begin with?

The time for drills like this is over. The time for information like at www.GetPandemicReady.org is NOW.

People are afraid of the dark. Right now, if panflu hit, virtually everyone would be in the dark... and afraid... and panic... and everything will come crashing down around us. On the other hand, if the public was standing in the light of transparency and full information disclosure about what we are facing and what to do about it, maybe they wont be so afraid... and not panic... and things just might go on and we just might come out the other side intact.

That wont happen if all eyes are on the wrong ball.

We have discussed this forever here. Why don't you "get" what I am saying?

Tell the truth

[ Parent ]
maybe because you're just plain wrong?
maybe because no one is obligated to agree with you?

maybe because you don't know that much about drills?

maybe because you're ignoring that literally hundreds of copies (close to a thousand) of .pdfs from getpandemicready.org were given out? (Oh, yes, that was an integral part of the drill). And that the links are on the health department website via fluwiki, which is an official link? And that thousands of mailers were sent to town residents on preparation several months ago?

maybe because people are tired of being yelled at and bullied into the 'one vision' of who owns the pandemic and gets to characterize it? The pandemic isn't yours to own. the pandemic isn't yours to characterize and decide, and berate those who do not agree.

maybe all of the above?

Could be all of the above. Very easily.  

[ Parent ]
Right Dem
You are totally right Dem... very few people agree with me. And even fewer who are vocal about it.

I believe we are going to experience a very sever pandemic.
I expect it at any moment.
I know we as a planet are totally unprepared on an individual level.
I know there will be tremendous suffering as we watch our loved ones suffer then die in our arms.
I believe there will be food shortages.
i believe there will be hungry, scared and panicked people.
I believe there will be forced quarantines.
I believe many of the schools will close late
I believe it could be a civilization buster.

Dr. Webster said on ABCTV Nightline... that there is a 50% chance of it happening and if it did, 1/2 the world's population could die.

I still believe him.

TPTB seem fixated on avoiding panic.
Well, if they prepared the public, they might not get it.

The drills will help things in the early days of the pandemic... but if things go down the way I and several other high level experts believe, They wont last long. They would IF the public was better informed.

Tell the truth

[ Parent ]
I said before you have a hard head, so i don't mind smacking it now and then with a two by four to get your attention.

OTOH, yelling at some of the few people who are on tv educating the public about this and running drills to do the same is one of the most idiotic and asinine things I've ever seen.

I think you need a different approach. Think about it.

[ Parent ]
for "severe scenarios" please use this other thread/diary

There, 50/50 is considered.  50/50 means accepting CFR=50% is biologically possible, and a CAR=50% (though I doubt humankind would let CAR become that high if CFR is 50%).

May I suggest people use that diary (or others that may be set up) to deal with that?

Also, may I suggest that kind of scenario is dealt with "solutions" (and first of all, AIMS) that would be workable for as many people as possible, worldwide, together with "solutions" for each individual and family?  A tough call, I know.  But "we're only as safe as our neighbors", or something to that effect (I know I always get the quote wrong, sorry).

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
That is great stuff
Very neat planning and the CD handouts and Fluwiki link were simply brilliant.

Way to go.  This is a wonderful model for an exercise that I hope will be repeated in as many communities as possible.

It is an example of how we can get a very important message out their while working within the system.  I have learned something that obviously Greg, Lugon and Susan have known for a while.  There are still good people working within the system and they need our help. Thanks for being there guys.

The Doctor

[ Parent ]
thanks, Doc
appreciate it.

[ Parent ]
Go Goju
I do agree with your assessment old pal. It is what I think will be most likely and that the reality will quickly overwhelm plans like these but I still think the exercise does serve a useful purpose.  

I am going to go public with TEOTWAWKI scenario with my new book.  It will frighten many and that in part is my intent because I have come to the conclusion that without genuine fear the uninformed and unprepared people (U2P) will simply not get over to GPR.org and begin the process you and I and many in fluboggia began years ago.

The reason this exercise was of value Goju is not because it will work for long during the pandemic.  I agree with you it won't.  The reason it was good is because it makes a clear statement that this is an important issue people should pay attention to.  Maybe some U2P that learned about this event are visiting one of the flu sites for the first time now.  Goju I remember posting with you on the old Fluwiki forum.  I'll admit that I was pretty clueless then despite pretending to know something about the pandemic.  We have both been dealing with this issue for several years now and as we have learned more and thought about it more we have moved further down the road.  From the PR prospective, if we hit the U2P with what you and I both think will really happen, it will turn many off because they will simply think we are whacked out and just plain crazy.  Maybe I have become a little crazed, especially about this issue and just for many of the same things you expressed above.

Coming to terms with this catastrophe is a process.  It takes time to understand just how severe it will probably be and the devastating follow-on effects it will have.  This can be very depressing as it was for me over the last year.  Damn, I finished my new Dark Doctor book on July 1, 2007 and sent it to the publisher for editing.  They did there work and sent it back to me in September but I couldn't even look at it for two months.  I am not completely finished with it yet.  It is radioactive for me but still has pull.  It is like superman having a crush of Kryptonite!

Hang in there boy.  We have all come a long way together and have a ways to go still.  I really think we have to do what we can to help the U2P.  That is what I was trying to do last year with the initiative that failed and was also another reason for my becoming depressed.  But you know what?  Out of that failure the GRP.org grew and while I have not had a hand in it that excellent work it was one of the objectives we set out for the initiative and it will, IMO, save a lot of lives.  Buck up old friend.  We need to see the bigger picture here and do what we can to help those unaware of this coming catastrophe.  

The exercise Greg and his cohorts put together and participated in is one step along the path of increasing public awareness about this important issue.  Sure it is a small step and true when TSHTF might not be a very effective one if the pandemic turns out to be as bad as you and I think.  But it is just a step, not the answer.  I don't know the answer either but I am working on it as are you.

The Doctor

[ Parent ]
see my comment to goju above
since we don't know when and how bad, you could well be right and I don't condemn that approach.

But I'll have as little patience with you as I do with Goju if you insist that only your way is the right way. None of us are that wise.

[ Parent ]
explain to this hard head please
You have X number of dollars to spend
You have X number of hours to spend
You have X number of people to use

You have X time to do it all.

What do you do with the limited resources?

1 - plan for a mild pandemic - 1957
2 - plan for a mid level pandemic - 1918
3 - plan for a severe pandemic - H5N1

You need to do 3 things

1 - practice taking care of sick people
2 - teach people how to take care of themselves
3 - preposition supplies so you can care for the people and they can take care of themselves.

Theres not enough time, money or people to focus on all three.

so instead of doing 2 & 3 which will actually save lives in a severe pandemic, you do 1 and do it really good... and be happy... and plan to do another one even better.

Does that make any sense? I guess it doesnt if you are not expecting a severe pandemic.

Why are you NOT expecting a severe pandemic?

Tell the truth

[ Parent ]
"Why are you NOT expecting a severe pandemic?"
Truly?  I don't know what to expect.  One of the possibilities is a very severe one, at least in my current thinking.

That's the reason for the 4 quadrants.

Thinking about all 4 quadrants (well, we may leave out poor old "many years from now + very low CFR", so that leaves it at 3 at most) will provide insights as to what to DO, which is the only thing that really counts in my book: behaviour, action, getting things done.

Thing is, how do I put it, action preceded by some thinking may turn out to be a better (more effective, among other things) action.

Thinking takes minutes or hours or days.

Cooperative thinking may work better than thinking alone.  And "cooperative" doesn't mean "herd"; in fact, groupthink is exactly the oposite of what I'd personally like to see.  Please smash my preconceptions (if you can).  (Just use the appropriate diary so we can all go on working.)  And add your own insights and help (if you want).  Now that's cooperative thinking in my book.

And we can multitask: do some, think some.  And breathe some. :-)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
You have X number of dollars to spend

At the local level, you do and you don't.  Funding begins with Congressional appropriation containing broad, general guidance.  The federal departments take this guidance and write top-level goals and objectives to meet congressional intent, with input from the states.  Funds are fenced (tied) for the objectives.  

What we get at the local level (from DHS through the state) is a grant contract with $X for exercises, $X for equipment, $X for training and $X for Citizen Corps.  Again, these are fenced.  The Citizen Corps funding (where community outreach is funded) is the smallest of these funding streams.  All of these funding streams have to meet grant-eligibility tests.

This is not a perfect system (because we DO know what's best for us at the local level), but its what we have to work with.  And so we do.  

What do you do with the limited resources?
1 - plan for a mild pandemic - 1957
2 - plan for a mid level pandemic - 1918
3 - plan for a severe pandemic - H5N1

This seems to imply they are mutual exclusive.  Locally here, we don't separate them - they're a continuum.  We are unifying them in one planning document, with options to use based on what's presented.  Forum inputs to 'local governments and the unprepared' are an important part of this.  Public health does a similar thing, with the options available in targeted layered containment.   This reflects our perspective that we just don't know how severe it will be - much less the timing.

You need to do 3 things
1 - practice taking care of sick people
2 - teach people how to take care of themselves
3 - preposition supplies so you can care for the people and they can take care of themselves.
Theres not enough time, money or people to focus on all three.

Yes...so this jurisdiction in CT had some funds that were fenced for exercises.

What did they do?  IMO:

• an excellent job on 1 (a fundable exercise objective).
• an excellent job on #2 (not a fundable exercise objective) through media, handouts and face-to-face.

In other words, they made outstanding use of their exercise funds and multiplied their effectiveness by folding in community education.  

Great, great work!

[ Parent ]
you took the words right out of my mouth ;-)
Yes, anyone can be right.  But even the most informed can still be wrong.  

Let me give an example, since Goju said earlier that

Dr. Webster said on ABCTV Nightline... that there is a 50% chance of it happening and if it did, 1/2 the world's population could die.

I still believe him.

Yes, Webster said that, but he also said plenty of other things.  For decades he was the authority behind the idea that pigs were the mixing vessel that caused the 1957 pandemic, but recently he has changed his tune.  What was the evidence for the original hypothesis?  The following is what he told me in person, in a meeting in Washington DC.

Apparently he and Shortridge traced the index case of the 1957 pandemic to a village in China.  While there, they heard accounts of recent pig die-offs in a nearby village.  No samples were taken nor did they visit the village where the pigs were said to have died.  But after it was discovered that pigs had receptors to both avian and human viruses, the speculation-turned-hypothesis of pigs as mixing vessel was born, and for decades it became the mainstream wisdom, that pigs were supposedly the mixing vessel for reassortment that causes pandemics.  

Some 30+ years later, he was still holding onto that theory despite his inability to give direct evidence in support of it.  In this minireview published in 1992, Evolution and ecology of influenza A viruses., he could only discuss this under the heading "Is the Pig a "Reassortment Vessel?" (page 171).

However, it didn't seem to stop him from publishing the following, in another review in 2004 (Microbial adaptation and change: avian influenza.

It has been published that pigs can serve as the intermediate host or reassortment vessel (31). Both 2-3 and 2-6 terminal sialic acid linkages are present  in the cells found in pig tracheas. Having both receptor specificities could allow for human and avian viruses to replicate in the same cell, allowing reassortment to occur.  Pigs not only provide ideal conditions for reassortment, they have also been implicated in interspecies transmission events between swine, avian and human hosts (1). Quail have also been identified as intermediate hosts, since they permit the replication of all the subtypes of influenza found in wild aquatic birds and may be involved in transmitting these viruses to chickens (28).

More recently, in that same conversation in DC and in last year's Seasonal and Pandemic Flu meeting, he is now saying that "that conclusion may have been premature".  

The point is, even a great scientist like Webster can be wrong.  He was wrong for 50 years, but his erroneous and unverified supposition was taken to be mainstream wisdom by a whole generation of scientists, costing god knows how many of them to go down blind alleys.

The moral of the story, at least for me, is this: Beware of being too certain in your beliefs.  And beware of blurring the distinction between possibility and certainty, cos the latter is the sure road to premature closure, information bias, and inability to adapt to changing situations.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Absolutely agree
Of course your right Greg.

I support your approach and appreciate your tolerance of mine.

What has changed about my approach to the issue after my visit and return from the underworld has been a conscious choice for the need to be more definitive and honest about what I really think but can't know for sure.  This means moving away from the use of IF and May to one of being definitive about the issue.  Why have I changed?  I did so because I think this is the most ethical and moral way to approach the issue.  This is due to my belief that part of the reason for complacence among the U2P is because of the mixed messages they get from the so called experts, flubloggia old timers, and public officials.  

IMO, it is immoral for us, those with a better handle on this issue, to know what we know and think what we think yet hedge what we say.  In my view we have a fiduciary responsibility to the U2P to speak the best truth about this important issue rather than the safe truth.  The safe truth is what we hear from the government officials.  The best truth is what we really think even though we know that there is a lot of uncertainty around the real truth which admittedly we can't know until well after outbreak.  

Susan has spent a lot of ink getting me to see what you have said above to Goju and I think that we have worked out a good way of dealing with it.  Here is what she taught me and how I now plan to express my view of these issues.

I absolutely concede that no one can accurately predict what will happen.

I have my view, you have yours.  I don't know what yours is BTW.  Maybe I missed your post about what you "really think" or maybe you have decided to withhold your opinion based upon your role as a moderator.   What I do know about you Greg is that you are concerned and really care about us and the U2P.  So, you are, in my book a man of good will which is what is most important to me.  

My predictions for a severe pandemic are more dire, to say the least, than most others and certainly worse than the USG and other agencies like the WHO.  I am conformable with these differences and have based my projections on independent work.  I stand by my work just like they stand by theirs.  What is the value of having different projections for the severity of the pandemic?  Well, as worked out with Susan, these different projects simply represent lower and upper parameters of what might happen.  Having definite parameters helps structure the debate more clearly rather than having no parameters.  

So, the USG says we could have a 1957 pandemic or a 1918 pandemic in their US DHHS PIP.  I agree but my work indicates that the impact of these two scenarios will be significantly worse than they think.  What's more I think that with the 1918 scenario, we will experience significant non-flu consequences that will be even worse than the damage caused by the virus directly.  This is my assessment and is based on careful study of all these issues not just an opinion based upon a gut feeling.

I absolutely agree that my opinion could be wrong.  We can all hope and pray that I am way too negative and especially that I am not way too positive.  What I am simply asking for is that we as a flu board go along with the notion that Susan and I agreed to that what we are not dealing with is certainties but uncertainties that can not be accurately determined at this stage of the pandemic.  What we can agree to in general is that the discussion can be advanced by setting up some parameters to work from.  

The parameters that I propose for discussion purposes only are a CAR of 30% and CFR of 2.5% (the USG severe projection) as the low end and a CAR of 50% and a CFR of 8.5% ( my projection) as the high end.  This is just a suggestion not a demand.  I know that these estimates are faulty and the real truth is unknown but could be better or even worse than this range.  That is not the point.  The point is having something "reasonable" to work with.  By reasonable is meant some estimates that are based upon valid thinking and exploration of the current condtitions and the effects of a pandemic occurring today.  This is what the USG did and what I have done and why I recommend these parameters.  None the less, I am open to the community rejecting this idea out of hand or selecting other parameters.  Fine by me.  I have made my case here why I think we should take this approach and that is all I can do. "You can take a horse to water" sort of thing for me.  

I don't demand that these statistics be adopted.  I am sure that there are many with much better and more thorough work than mine that have developed other numbers.  That is not the point.  The point is that IMO it will advance our discussion here if we can come up with some reasonable projections regarding what we will have to deal with sooner or later.  This is preferable in my opinion than simply saying the pandemic will cause TEOTWAWKI.  This is too open ended to deal with.  

Giving us parameters, be them mine, Reveres, or Susan's or the USG is an important planning tool.  I think that this is of value because it permits people to get a better sense of the possibilities and with that they can make better plans.  Giving people these parameters allows them to plan better and better plans and preparations is the best way I can think of to help people survive the pandemic.  We need to have an upper range of severity as it is necessary to have a lower range estimate.  This is a more honest way to frame the debate than simply providing one estimate.  The risk to people is very different depending upon the estimate that a person chooses to prepare for.  This is fine with me, different strokes for different strokes.  

So, thanks for being tolerant of my views and strong opinions.  I wanted to share this with you and the community because unless you followed the recent fast and furious debate Susan and I had across several diaries then you were not aware that she has already taken me to the woodshed on this and yes, used the 2x4.  I am now fully on board with you and her and have learned an important lesion.  Thanks!

The Doctor

[ Parent ]
Multiple fronts.

 Hi. Hmmm. I totaly agree getting the message out. We should pick up that toarch and run with it through the streets.

 I also agree with and support DemFromcT on two fronts.
 1) We have to drill to train folks. This is an intertive process where each layer or corse builds upon the previous.
 2) We have to know what we are working with. Today's HCW , today's health infrastructure and today's bioethics are vastly differnt. Ok, MD law is draconian but the rest of the system has evolved. By testing we can see what raw material there is to work with.
 3) Drilling also prepares the public. I do not need nor want a bunch idiots at the frong door. Even at McDonalds people have a hard time ordering breakfast or lunch. Imagin what it will be like during a pandemic.
 4) Mass hysteria cuts both ways. Seing other people prep can stimulate others. By showing DemFromCT drilling on that scale helps.

 Goju it helps both of us get the word out. We are fighting a problem the national News is not covering.

 Yes I agree the clock is ticking down. We have limited people and limited rescrouces. If we get the word out - that will be good but then what?  Phase two is treating them. Without drilling we will not be preapred.

 This paralell processing of efforts on many fronts is good. Feds doing webcasts, our spreading the word, locals training, business creating vaccines, consultants saying "your DR (disaster recovery) plans must include pandemic planning.

 Please let me know what you think.

Raise the toarch to run the marathon.  

[ Parent ]
DemFromCT -
Thanks to you, the team and Fox for broadcasting the news.

 I hope I can show my folks "See that is what the others states are doing. Why can't we do that??"

 Embarrass them, chide them, etc. untill a test is done.


Congratulations are in order
I didn't intend to criticism the success of this exercise Greg.  My intent was simply to probe some of the areas that I thought might be of use for planning future exercises.

I wish to echo ACM's comment about the secondary value of this exercise, especially the involvement of so many groups and the press reports about it.  This achievement alone, IMO, made the whole exercise a success.  

Overall this exercise was a tremendous success in my view and I hope that other communities repeat your experience and learn some of the many important lesions your community did.

The Doctor

not taken wrong
glad you brought them up.

[ Parent ]
hear! hear! ;-) n/t

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Thanks for YouTube Links n/t

Report from the Pandemic Surge Simulation - Bethel, CT, 4/5/08
Today I had the opportunity to volunteer as a "flu victim" at a pandemic flu surge simulation in Bethel, CT. A nursing home, Bethel Health Care, allowed the use of its grounds and facilities for the exercise which was developed by a consortium of public and private groups within the state. Laura Vasile, the Director of Health for Bethel, CT, lent her skills as a key organizer as Bethel played host to this event. Many thanks to the many folks at a myriad of agencies who worked together to make this happen.

What is remarkable about this exercise is, above all, that it happened. We routinely hear of vaccine distribution exercises. In fact, most public health departments around the country have run those because they've been mandated to do so by CDC, and compensated for their time and expense as well (one local public health office even ran its vax clinic on Columbus Day so everyone got time-and-a-half). Lacking a "must do" directive and its accompanying funding, along with the barrier of pandemic influenza being what most consider to be a "low probability" event, even as it is acknowledged to be a "high impact" one, we've all noticed that almost no one is practicing for the surge of patients that pandemic flu will bring. Today, that changed with the multi-agency, multi-jourisdictional, pandemic surge exercise here in CT. The organizers and participants are to be congratulated for facing such a large task head-on.

The State of CT has purchased a 100-bed mobile field hospital, and the decision has been made that, to be equitable, during a pandemic influenza the field hospital will be split up into four sections to be sent to various parts of the state. The mobile field hospital with 25 beds used in this exercise has been placed under the care of the town of Danbury and is meant to serve 43 towns in Western CT. The tent (I will call it a "tent" as that is how the public would refer to it) as set up was about as large as a catering tent for a large event. I had visions of a tent the size of half a football field but no, it was quite manageable in size. As was explained to me by public health officials who attended a tabletop the day before, the tent is not meant to be the final destination for those seeking treatment. Rather, patients will be triaged nearby, sent to the tent for further evaluation if their condition is serious enough to warrant it, and then moved on to other care facilities (empty beds in nursing homes, for example) if they are found to need hospital-level care. During today's simulation, plenty of empty beds could be found in alternate care facilites for those who needed continued care. How fast those beds will fill up and then run short in an ongoing pandemic (as patients stubbornly do not leave them as fast as new patients come in) is an open question.

I went through the simulation three times today playing the role of three different patients. I'll give a synopsis of each of those experiences, and then an overview of the exercise, incuding some of the weaknesses I noticed (remember - the point of the exercise is to expose those weaknesses, so that things might be done better when the time comes and it's not a simulation).


As a patient arriving at the flu site, I was directed by helpful and efficient traffic coordinators to join the line of cars waiting to enter a small parking garage on the Bethel Health Care site. The site itself is easily accessible. It is located midway between two exits of a major highway and is situatuated within a corporate office park. It could probably absorb considerable traffic before the traffic itself becomes a problem. At the entrance to the parking garage, I was met by a National Guardsman in a surgical mask and camouflage uniform. The sign above the garage entrance indicated in large letters that I was in the right place, and the National Guardsman confirmed this. He instructed me to wait until one of the three vehicles currently in the garage moved out, and then to drive my vehicle in, place it in park, and turn off the engine when a space opened up. I did so, and was met quickly by a team of triage nurses all wearing surgical masks and yellow disposable gowns. I was given a patient identity by these very competent nurses and the triage process began. The papers I was handed indicated that my vitals had already been taken. The nurses reviewed the data with me and asked me a few further questions. One lead nurse took charge, and was assisted by several others who I was told were student nurses. The student nurses, in fact, had a major role to play today and many of them were assisting around the site. I'll break down each of my experiences role playing a patient:

81 year old lady

I was an 81 year old lady who had pretty much everything wrong with her as far as chronic illness goes (arthritis, etc.) as one could imagine. My respiration was normal, and my blood pressure was 172/89. My temperature was 99 degrees. I (improvising my role) told the nurses I lived alone. The nurses were kind and considerate, but even though my chart showed that I wasn't in the best shape overall, I apparently did not have flu, and was one of the "worried well" that they were expecting. I was given a green tag to wear that dangled on an elastic placed around my wrist, and was told that I could go home after visiting the Patient Education area. Never leaving my car, I then drove around to the other side of the parking garage and stopped at the Patient Education table where I was given a packet of information and told I could continue on home. I had probably spent 10 minutes, altogether, from arrival to exiting the garage post-evaluation.

50 year old man with diabetes

My next role was as a 50 yo man with diabetes. bit diabetes was not the worst of my problems. I also had a fever of 102 degrees and had been vomiting and had had diahreaha for four consecutive days. I told the nurses that I really didn't feel well. They discussed my case with concern and decided that I needed to go to the field hospital tent. I was given a yellow wrist tag saying "Level 2" and told to follow the instructions of the traffic coordinators. I was directed to park in a lot near the tent, and was comforted by one traffic coordinator who was wearing a surgical mask but who reached into my car to pat me on the arm with an ungloved hand. She directed me to park, and then make my way to a small white tent some distance from the main hospital tent for intake.

I arrived at the small white tent and then spent a good five minutes just standing there, in front of the door, as officials in official vests milled about. Occasionally I said "I'm sick, I need help" but no one seemed to notice. Finally, someone did, and asked me if I was a patient. Well, yup, said I, flashing my yellow tag. (The tags were around 5" X 3" so they were a bit hard to miss, and I was clutching the required patient paperwork as well). Oh!, they said with surprise. I was not asked to enter the white tent, but was sent on to the larger beige hospital tent. I found my way (alone and unescorted, giving me the thought that providing site escorts to sick patients in a confusing new situation is maybe something that should perhaps be done) around the newly excavated area that was still a bit rough from recent rains to the main tent. I went to the middle of the oblong-shaped tent, and proceeded to wait at the door. There were no directional signs in evidence. Again, my wait was beyond 5 minutes with no one taking any notice of a patient standing helplessly although I had waved around my tag and papers and had mentioned a few times I was sick and needed help. Ironically, my own district public health person was right there next to me but she was distracted and on the phone with other business. I had time to chat with one official who, I noted, had no mask on but he said he "didn't have to wear one." Make no mistake - there were plenty of officials around and the entrance we waited at was a busy one. Finally, with the wait at this door pushing a good 10 minutes, and by then finding myself waiting along with a mom and her young son, someone took notice and told us that we were in the wrong place - the main entrance to the tent was not this busy one, but another door, further along and at the far end of the tent. Ok, so we all headed that way. The general atmosphere was one that was more "official oriented" rather than "patient oriented." That probably needs to change.

A National Guardswoman with a very serious and professional demeanor let us into the hospital tent at what we assumed was the main entrance, although there was no sign there either. Then a more typical wait ensued as other patients completed their paperwork and we waited the turn to sit and begin ours. We did have to stand as we waited, and this would have been difficult for the patient I played as, you will recall, he had a fever of 102 degrees. Providing chairs for waiting patients in the intake area would be a good idea.

Finally, 30 minutes after my arrival and initial checkin, I was ushered into the treatment area of the medical tent. However, shortly after I entered, someone sharply asked me where my mask was. I responded that no one had given me a mask. The person asking the question seemed annoyed - at me - and stated that no one was allowed in the treatment area without a mask. I stood and looked at her, since she had still not given me a solution to this dilemma. She directed me to a table back in the foyer behind me where several boxes of various things had been placed. Not faking my confusion, I still wasn't sure where those masks were. Finally, a high school volunteer looked for, and found, a mask for me. But, I had spent 30 minutes, as a highly infectious patient walking about without one.

Introduced to Dr. Ed, I was asked to take a seat at Bed 1. Dr. Ed reviewed my vitals with two student nurses. He asked me if I had taken my blood sugars that morning since I was a diabetic. I said no (improvising) because I felt too ill to bother. Dr. Ed was a little miffed at this and called me a "non-compliant" patient (he said he would not have said that aloud in my hearing if it had been a real treatment situation). He also asked if there was anyone at home to cook for me, and I shrugged and said no, I lived alone. Stymied a bit about how to handle this lack of certain knowledge about a patient or the lack of certainty that the patient would follow his recommendations, Dr. Ed pointed out to the nurses that they'd encounter any number of similar situations where there will be no existing information with a patient, and incomplete information will be all they'll have to work with.

I then improvised a bit and asked Dr. Ed if he was going to give me some Tamiflu. Dr. Ed answered that he didn't have any Tamiflu. Someone noted that they had "run out." I was a bit worried then, and asked Dr. Ed if it wasn't true that Tamiflu is the only thing that cures this flu. Dr. Ed tried to change the trajectory of the conversation and asked what medications I had been taking. My papers said aspirin, and Dr. Ed wrote me an order for some ibuprofen and some sugar-free Robitussin. "What about the Tamiflu," said I, "didn't the government buy a ton of that? Where is it?" At this point, Dr. Ed asked if I was feeling "worried" and I said heck yes, I had a fever of 102 and had been vomiting for four days, I felt terrible, and wasn't getting any better! I asked Dr. Ed if it was true what I had heard that "one out of ten people getting this thing and who had gotten sick like I had had died." Dr. Ed looked a bit taken aback, and did not really answer my question, but instead noted to the nurses that I seemed really worried and some discussion followed about whether to send me over to the psych tent.

Dr. Ed then asked if I had a personal physcian, and I said yes. He suggested that I ask my own doctor for some Tamiflu if I was that worried. I said I couldn't get a hold of him. He asked how long I had been seeing my physcian, and (improvising) I said 8 years. But I repeated that I couldn't get in contact with my doctor - that was why I was there in the tent in the first place. Dr. Ed seemed surprised I couldn't get in touch with my physcian but I told him that I had called, they said they couldn't see me for several days, and the doctor was unable to return calls because he was all tied up at the hospital. "He's not getting back to you?" Dr. Ed asked. "NO, I said, everybody's sick!! That's why I dragged myself down here!!" This seemed to make sense to Dr. Ed, and he said to the nurses that it probably reflected what could happen. (It would seem to me to be a primary cause of people making their way to the flu center when the time comes, and I nearly broke character to tell Dr. Ed I wish they had walk in clinics during regular cold and flu season, no pandemic needed, when it's nearly impossible to get in to see my childrens' pediatrician who they've seen since they were born). So Dr. Ed told me he'd write me a prescription for the Tamiflu since I couldn't get hold of my regular doctor. I had worries about whether there was still Tamiflu left in the pharmacy, but didn't voice them to Dr. Ed as I thought he had done a good job of trying to meet my needs. After instructing the nurse to give me 30 minutes of IV fluids, I was told I could proceed home.

On the way out of the hospital tent, I noticed one woman being treated on a bed was holding her small dog. (No, I didn't go there, or suggest that someone give the poor dog a mask for its own protection).

15 year old

My next role was a 15 year old asthmatic who had a fever of 101 degrees. The triage nurses asked if I was having any trouble breathing and I replied yes. They seemed a bit concerned, and there was some discussion of my case, but in the end I was told to move to the patient education area, pick up an education packet, and go home. Only a fever of 101.5 degrees qualified a patient for a trip to the hospital tent, with the asthma not affecting that determination.

Summary of patient experience

Compliments to the teams of triage nurses who did their jobs extraordinarily well. They were willing to take the time to question me, but still managed to get things done very quickly (they were being timed). I did not feel rushed at any point with them, something I think will be important for patient confidence.

All three of my patients were told to go home. I found that interesting. Two of the three patients I had role-played I had made a point of saying they lived alone. The patient education area had provided me, all three times, with a packet of informational flyers. One was a tri-fold brochure entitles "Cover your Cough." The next paper was the American Red Cross "Home Care for Pandemic Flu." It included the recipe for Electrolyte Drink as well as for a disinfectant made with bleach and water. Five pages on home treatment and first aid were included from www.getpandemicready.org , five pages on isolation and infection control, and five pages on community-based protection.

If I had really been the 81 year-old lady living alone, I'm not sure the informational papers would have been so reassuring as a follow-up. I would have liked to see someone take her name and number and promise a call-back, even if she was among the worried well. The 50 year old man who also lived alone I was particularly worried about. With a fever of 102 degrees, and having suffered vomiting and diahreaha for 4 days, the doctor had cautioned him that he might have several mere days of these symptoms due to his underlying condition. He had been rehydrated on site, but I wondered whether a person with a 102 degree fever would really read any of the educational handouts and doubted whether I would in that situation. It seemed like he was going to be pretty much on his own to tough it out. The 15 year old likely left with a worried mother. His fever was not high enough to qualify for hospital or other follow-on care, but it was high to the mom, no doubt, and she was probably not completely reassured since the education materials did not cover special conditions such as asthma.

My impression overall was that if patients such as these were going to be sent home that better communications of the guidlines for various levels of illness, for the criteria for hospitalization, could have kept some of these patients from venturing to the mobile field hospital in the first place if they had been aware of them. I would never have guessed, for example, that a fever of higher than 101.5 would mark a threshold for treatment. Making that sort of criteria very clear to the public ahead of time would prevent a good portion of those not meeting the criteria from venturing to the clinic, potentially. Not all - but some. So clearly explaining the difference between flu that needs medical treatment vs. flu that can be managed with home treatment would seem to be one major initiative that can be developed, as far as public education goes, ahead of a pandemic.

Also, it seemed that much of the educational materials on home care of patients really needs to be pre-positioned beforehand, and is the kind of thing that telephone operators trained to do the sort of triage the nurses did on site could guide patients or their caregivers to if it were available online (and perhaps printed daily in the newspaper). I won't be reading much of anything anyone hands me while I am enduring a fever of over 101 degrees, frankly. The suggestions that I go and pick up the necessary supplies listed in the materials handed out today are also a bit late in their timing. The last person you want shopping is a feverishly ill one shedding pandemic flu. (No one at the simulation told my two sick patients to please go directly home). So, thinking ahead, clearly stating any treatment criteria, and pre-positioning supplies and treatment information in the home would be a strategy that could potentially alleviate some of the crowding caused by two out of the three patients I played today who were sent home for care (and so who really didn't need to be at the field clinic). I'd also really like to see some phone follow-up for the ill who seemed particularly worried or who state they live alone. Faith based or community organizations could organize themselves to do this kind of phone check-in for any needing it.

Infection Control

Surprisingly, maintaining sustained infection control measures seemed to be a problematic issue at the site. I noticed too many public health-type staff moving about the simulation with no PPE. As I was waiting to enter the triage garage for the first time, I noticed a woman in an official jacket being stopped by the National Guardsman at the entry to the garage. He told her that she must have a mask on in order to enter the area. A conversation ensued, during which the woman kept asserting to him that she was "special" for some reason, and was exempt from that rule. The Guardsman, to his credit, insisted at least three times that she have a mask in order to enter the triage are. The woman refused, and proceeded in anyway. The Guardsman, a bit frustrated, seemed at a loss. I called him over and congratulated him for making the effort he had. Later, I spoke a couple of times to another Guardsman who seemed to be in charge of the unit working the exercise. He had already spoken to his people about this kind of an incident after our first conversation, and agreed that the pulling of rank and the claiming of privilege was very much something that his troops were going to have to deal with during a real pandemic, unfortunately.

Several times as I moved about the site I saw people wearing their masks half-on, and half-off. Most of the masks in use were surgicals, so this was not due to any real discomfort. I reminded at least three people to pull the mask up over their noses, and it was only a Guardsman who snappily did so immediately. The others looked at me strangely and grudgingly put the mask back in its proper position. Two of the people I saw in working official capacities had a 1/2" torn area right smack in the center of their surgical masks. Seeing the policeman directing traffic at the entrance to the driveway had no mask at all, I asked where it was. He opened his jacket a bit and pointed to his mask, folded neatly and firmly stuck in his shoulder harness, nowhere near his face. (I gave him a friendly tsk, tsk, and moved along). Many of the pandemic organizers and student volunteers moved about with their masks either completely missing or slung low on their necks.

The people who I never saw break proper PPE protocol were the nurses, who were always masked, gloved,and gowned. I stopped to ask the head nurse if she felt that surgicals were adequate or if she'd feel better if they were using N95's. She said, convincingly, that surgicals were all that she felt were needed to protect both herself and the patients from infecting one another in the triage situation. Some of the officials participating in the exercise wore N95's, but the allotment of who had N95's vs. surgicals seemed random. National Guardsmen wore surgicals, and wore them properly, without exception. Everyone in the hospital tent was wearing appropriate PPE (masks and gloves). They did not forget to gown and mask the journalist that was allowed in to photograph the hospital tent. The repeated failure to not give me, an ill patient, a mask to wear after I had been identified as an ill patient twice, one of those times needing further care, did seem a major oversight that shouldn't have happened.

It would seem to be a reasonable idea to distribute surgical masks to every person presenting themselves for examination, even before entry into the triage area, as Step One, right as they sit in their vehicle awaiting initial screening. In fact, as a patient waits in their vehicle and are handed a mask, there could also be a chance for a quick explanation as to why the masks are necessary (something apparently everyone at the exercise did not understand) and a quick on-the-fly lesson on infection control. At the public education area, no effort was made to verbally educate me on any of my three separate trips around, and only written materials were provided. That, again, seems a missed opportunity particulary in explaining the importance of infection contol during a pandemic, and unfamiliar concepts such as isolation and quarantine which were never broached as subjects. Again, my impression from receiving the list of educational materials was not that I was supposed to go home and stay home, but rather to go shopping on my way home for all the things on the lists that I might not have. Not such a good idea if community spread is to be avoided.

The only de-robing area I saw was directly on the path leading out of the hospital tent, a few feet from the exit. As I exited, I had to move to the side to avoid one nurse who was there, attemting to very carefully remove her PPE and place it into an open 55 gallon-type drum. Technically, I suppose that anyone outside of the patient contact areas should not have had on any yellow PPE gowns, but they did, although I'm not sure whether they had yet to see patients or had yet to see them. Perhaps there should be some rule of thumb for this, such as no yellow gowns outside the patient contact area to make it clearer who is breaking infection control in that way.

While the ill or worried well who arrived at the site in their cars remained in their cars, thus cutting down on personal interaction and potential viral spread (a great idea), more stringent expectations really need to be voiced and enforced for those working the site itself or the place that was supposed to offer treatment and assistance could itself magnify infection.

Exercise assumptions and untested areas

This exercise was presumed to be taking place around day 11 of an emerging pandemic. The CFR is high at 7% but this did not seem to affect operations one way or another at this particular juncture. My one pointed question on this issue to the treating doctor was deflected. The level of stress to both patients and staff which would have been reflected in that kind of CFR number in a true incident I felt was lacking. There were no deaths in this exercise, and thus no stresses on mortuary services. It was also assumed that a full staff of health care workers was available. No health care workers called in sick or went home early. I am not sure what would have happened if Dr. Ed or some of the others charged with treatment had had to leave mid-exercise. One odd thing that came up in conversation is that apparently rather than increasing the authority of nurses or paramedics (as some of us have anticipated will happen), during this exercise the authority for some triage-type decisions was to be more restrictive than usual, and such decisions could be authorized only by physcians who also had training in emergency preparedness. So, rather than broadening authority of the workers they had on hand, someone had made the decision to make more narrow the parameters of operational authority - this I just don't believe will be able to be done under the stresses of a pandemic.

Supplies and aid

I've been told that the mobile hospital comes equipped with enough supplies for three or four days. Shortly after pandemic onset, they expect that the Strategic National Stockpile(SNS) will be deployed sent to Hartford. Dr. Greg Dworkin, one of the organizers of the exercise, tells me that by this point in the exercise, 50% of the SNS would have been sent to Hartford from CDC. From Hartford, it will be distributed around the state, again, apparently, as equally as possible. The logistics of how the SNS will actually get from Hartford to a place like Bethel is still being worked on. I have asked for an estimate of what quantity of PPE and basic supplies they believe is going to be sent with that initial shipment,and am awaiting that number (which I expect to get on Mon.). For this exercise, it was assumed that there were no shortages of PPE or other equipment onthis day, Day 11. During my third patient role-play at the end of the day, the nurses who were looking for a mask for me said that their supplies were nearly exhausted and they were pretty much out of the surgicals. Dr. Dworkin mentioned that he feels that they could have carried on for a few more days if supplies became tight since it was a pretty low-tech operation to begin with and that they could still continue to teach home care.

Treatment focus

I'm not a medical professional but overall, the exercise seemed geared primarily towards a few basic things: identify and send home those who do not need prolonged medical assistance, and watch for those who need hydration. People were no doubt transferred on to further medical care facilities for reasons other than hydration, but hydration, or remedying a lack thereof, seemed to be the major focus of the medical providers around me. I assume that this is because hydration is a dangerous issue with seasonal flu. For those of us who watch H5N1, however, and hear of the severe pneumonia's associated with some of our new seasonal flu strains, it's breathing problems that seem most worrisome.

For example, the simulation today seemed not quite prepared to deal with the situation faced by the latest H5N1 fatality in Indonesia, also from this morning where a 16 year old girl, recently admitted, died. The Indonesian TV station reported at 12:20 that the girl, MI, was improving. But then a short three hours later, suddenly her condition changed:

"Moments before dying, the patient had difficulty breathing," said Director RSPI Sardikin Giriputro when being contacted by the Times today. Then the doctor moved Ml to ICU space. "His condition was increasingly critical," said Tuti Hendrarmurtopo, Deputy Director Pelayanan Rspi. Around 15:40...Ml died."

I did not, of course, see every case that went through the triage or treatment areas but breathing problems, and providing oxygen and breathing assistance, just did not seem to be as much of a focus, or raise as much worry, as hydration. I worry about any panflu that's H5N1-related retaining the tendancy to cause leukocytes in patients who had seemed to be doing quite well, to descend drastically and suddenly. Homecare would be terribly complicated by any virus with the tendancy to mimic that present troubling characteristic of H5N1.

Also, of course, I worry about our attempts to treat any pandemic strain with H5N1 parentage without Tamiflu. So far, there are no reports of the patients surviving acute infections of H5N1 without Tamiflu treatment. 100% of those who have survived - and there have not been many of them - have one thing in common. They all received Tamiflu, and almost without exception they received it early on in the course of their illness (within that 24-48 window). I'd rather we be in a position of having the necessary Tamiflu on hand with which to treat our population properly before sending them home to self-care at home. Some states have stepped up and bought the recommended allocation of Tamiflu with the federal subsidies. CT has not. I feel this is a major flaw in our plan. Explaining to patients in our field hospitals that we have no Tamiflu for them, even as they hear that it is helping save lived in other states who are well supplied, may end up being a real challenge to explain to our public.

Sobering moment

Seeing the National Guard go operational in one's own neighborhood is always a jarring thing. The National Guard members working this exercise, along with the nurses previously mentioned, took their responsiblity very seriously and remained "in character" throughout. I was very impressed by that. At one small white satellite tent, I noticed a very serious young woman Guardsman in khaki's and surgical mask, standing firmly in parade rest in the middle of the entrance door. Behind her, in neat rows on chairs, were seated a group of student nurses, in their yellow disposable PPE gowns and surgial masks, watching a video shown on a screen in front of them very attentively. Something about that scene was the most poignant of the day. No mention was made, as far as I know, about the fact that these troops and these nurses are very much in the demographic that is affected by the H5N1 virus (realistically, the virus that has brought us to the point of exercising surge response and vax distribution). Something about the scene with the attentive seated nurses, and their very professional guard, made my throat catch a bit. I suppose they'll all go very courageously into this battle.

Overall impression

I'm very happy that this exercise took place. I would be much happier if it had taken place shortly after Secretary Michael Leavitt's pandemic flu summits in the early winter of 2006. Why the public health authorities did not see fit to run this kind of an exercise then will always be beyond my understanding. Now, as Dr. Dworkin always says, we at least have begun. Hopefully, the suggestion that Dr. Dworkin made that another region run a similar simulation, but do so witht the scenario moved up to week three of the pandemic, or even better in my view, to weeks four through six, is a good one. The tents are available, and this exercise has laid the groundwork for the others to improve upon. However, on tonight's TV news, the announcer mentioned that perhaps this kind of a simulation will be done again - next year. We can hope we have that long. This morning in Indonesia a cluster of 7 new suspect cases was reported in Central Java, the death of a 16 year old girl in West Java, and another 45 year old was admitted to hospital in the Indonesian city of Tangerang. Also today, a 19 year old man was reported to have died in Egyt. Thats a total of 10 new suspect cases that we know of, including two deaths, reported on the same day this pandemic flu simulation took place. I am not sure that most of those participating in the exercise are aware of the level of H5N1 activity that is going on in the background, even as they work to prepare.

Overall, my biggest criticism of the exercise (and there needs to be one for our response to become better) is that it had the look and feel to it of a more simple epidemic of seasonal flu surge, rather than one in which a true pandemic has affected everything from staffing to supplies. While officially the exercise was run with the assumption that the pandemic virus was circulating with a CFR of 7%, most of the response and tenor was geared towards what felt, at last, more like a fairly normal seasonal flu virulence. Staff seemed unworried, PPE was worn carelessly, lines were short (it took less than 10 minutes to get into the triage area), patients were highly compliant. I think that those who participated today will be much more ready for a seasonal flu surge of the kind they had in Australia this past summer. Who knows, we may yet see a seasonal flu surge of that kind here before we see a pandemic flu arrive. I realize that this exercise was just a beginning, but I'm not at all sure that the understanding of what a pandemic flu will demand, particularly one with great virulence, was what was simulated today.

The plan going forward

The greatest single flaw I saw in terms of pandemic flu planning came in the tabletop which was run prior to the simulation. Much of that meeting concerned communications and sorting out responsiblities and how those two things would flow. Almost 30 minutes of the meeting was spent clarifying the chain of command and procedures to be used when requesting help from a higher level of authority and/or the next level in the regional response chain. Clearly, everyone wanted to discuss how to request more supplies from outside the area, whether PPE, medicines, or staff. Much was said about requesting aid. Not a word was said about sharing that aid, about how one should or would or could be expected to respond when someone else made the request from your organization. Not a word. I felt that this was a glaring problem, and one that could undo the entire plan the expect to rely on to remain operational that many have in mind.

In answer to my questions about this, I was told that there are many mutual aid agreements (albeit informal ones) among our towns and regions here in CT. But given the scenario that pandemic flu has obviously arrived over the border in Westchester, NY, or on the other side of the state in New London, and we hear that they've run out of their initial materials in a week, what will our response to requests for aid truly be? If we see Westchester overrun by pandemic flu, by definition that same pandemic flu will be upon us within a week. Watching what happened in Westchester, we will be very aware that the same thing is about to happen to us. Will we send them our PPE, our medications, our nurses? Is there a mechanism to determine our commitment to that ahead of time? Do we know who will make that decision (the mayor, the health dept.) and do we know what the mechanism is for making that decision? Will there be meetings, how long will they take? What if the answer is "no, we can't share at this time"? Everyone has learned how to ask for help, but without better defining practicing the mechanisms for sharing that assistance, I think it is very likely that the monkey wrench in the plan could be this. I know they'll say that they're confident that aid will be forthcoming in answer to all these requests, but honestly, if they were that confident, they would not be hesitating to mention how it will happen, and to explore that side of the coin too, a side that was fully unexplored during that tabletop.

One small note on communications. I could not live-blog from this exercise because my blackberry service was not able to connect at that location. Since I use one of the usual major companies for my cell service, I'm sure other participants encountered the same problem. This is the kind of thing that is unforseen, but can cause major headaches if those working the site were counting on cell communication.

Also, just as the simiulation had glitches, I did too. I meant to provide photos of the scenes, and thought I had taken some really interesting ones. But on arrival at home, it was discovered that there had been some problem with my sim card, so no photos. I learned something from this simulation too that I can do better next time. It never works exactly as planned for any of us.

I am very hopefull that others will take this scenario and move it forward in time to demonstrate the response to the by-then myriad self-reinforcing complicaitons of a true pandemic. As challenging as the lessons learned to day were to encounter, those of pandemic weeks four through six will be compounded - they'll be the same ones encountered today, but having to be done backwards, and on ice skates. Best wishes to the region that takes on that simulation. All of these exercises are opportunities for learning important things - and sometimes it might just be things as simple as officials needing to learn to keep their masks on. One thing learned in one of these exercises just might save one life, you never know.

Sorry, I only had time to
link to this yesterday morning rather than posting it in full as I ran late for a trip to Boston but here it is.

In discussions on my experience, one very excellent suggestion came from quilter over at PFI who has suggested that perhaps the local pharmacies can be engaged to provide trucks full of the OTC medications that the many "worried well" or those ill who are sent home for homecare, will need.  

If those supplies are available to them right on site at the clinic those folks will not need to venture into stores in search of the supplies they might not have at home.  The patients I role-played were sent home with recommendations to take ibuprofen and Robitussin. If the facility is not going to be able to provide everyone with these kinds of basic OTC products, the on-site pharmacy trucks (which could also be set up in a drive-through manner) might be an excellent adjunct with considerable benefits for infection control and community spread.  

[ Parent ]
that's an excellent idea
and we do have a Walmart in town.

maybe i should call my friend Dr. Agwunobi?

[ Parent ]
onsite pharmacy truck sounds like a good idea n/t

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
please, do! LOL

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
thanks for posting this here, and for the
participation and critique. My response, previously posted:

Pixie, great job! That's pretty much what happened, accurately portrayed, with some additions I need to make.

Pixie recognizes that the purpose of this exercise is to find the flaws. As a drill, and as a just-in-time training exercise, it was very well done. And the cycle of plan, train, execute, evaluate, modify, NEW plan, train, execute, etc has to continue. We found a lot more things wrong than the ones you mentioned, and we can do better next time. And we found many things that were done well.

Some comments on the excellent and constructive comments:

it may be that the expense of this kind of drill (the MFH is a 1.5 million dollar piece of equipment, people's hours were tracked and even volunteers might quickly become employees in a real thing) precludes us doing it for a year here, but others can do it elsewhere sooner. Also, planning cycles take a long time if you want to maximize correcting flaws, while convincing others to do what we did. Still, a year for us can be a less than a year elsewhere.

We had a first selectman and a state representative there, and the PIO and I gave them a site tour and did an interview on WSHU public radio that should play Tuesday where we talked about the preparedness need. We need to collect media responses as well; in one sense, they're a more typical public than you are. But we also need to continue to get political support and public reassure for exercises like these. I want everyone to ask why haven't we done one?


communication: we had 10 satellite laptops from American Red Cross and an excellent redundant communication system that ranged from ham radios to paper via the many teen runners. We could communicate quite well amongst ourselves and the area hospitals and nursing homes, all of whom checked in real time.

language: the field hospital, the medical facility and the tent had to be carefully scripted. The tent was the psychosocial tent. The triage hospital (only half of which as set up because of high winds) was the MFH (mobile field hospital), and the nursing home was the medical facility. it'd be easy to confuse them so the JIT language needs better teaching and enforcement so a patient sent to the tent got to the right place. Lots of that got worked out within the first hour, so it was smoother at the end. That's normal for a drill, accident scene, etc where the first hours is chaos and thereon is controlled chaos.

volunteers/staff: we had a big number, and if it were for real, even if it were as we scripted, we'd run them in shifts to prevent exhaustion. But we had to train them, so everyone got thrown in.

patient disposition Pixie went through and played 3 patients:All three of my patients were told to go home. I found that interesting. 12 of the patients per 100 needed hospital or nursing home (23 hour) admission. We made that small to see if the triage people could find them amongst the well, the mildly ill, the somewhat ill and the worried. they found them all and got them to the right place.

Also, it seemed that much of the educational materials on home care of patients really needs to be pre-positioned beforehand, and is the kind of thing that telephone operators trained to do the sort of triage the nurses did on site could guide patients or their caregivers to if it were available online (and perhaps printed daily in the newspaper).

Absolutely! These would be newspaper supplements, phone instruction, website availability, etc. in addition to whatever we do. If people threw away the instructions, they'd be available elsewhere post-positioned, too.

infection control:As I was waiting to enter the triage garage for the first time, I noticed a woman in an official jacket being stopped by the National Guardsman at the entry to the garage. He told her that she must have a mask on in order to enter the area. A conversation ensued, during which the woman kept asserting to him that she was "special" for some reason, and was exempt from that rule. The Guardsman, to his credit, insisted at least three times that she have a mask in order to enter the triage area

The Guardsman (bless him!) was wrong. Observers are supposed to be invisible (they are the evaluators, and there were 10 of them or so) and ignored and they were not required to wear masks. Speaking of the tent., more video here:

Several times as I moved about the site I saw people wearing their masks half-on, and half-off. Most of the masks in use were surgicals, so this was not due to any real discomfort.

That's training. More of it. I did one walk around telling people to put their masks on or leave the area. Of course, patients will do what patients do.

So, rather than broadening authority of the workers they had on hand, someone had made the decision to make more narrow the parameters of operational authority - this I just don't believe will be able to be done under the stresses of a pandemic.

See one, do one, teach one. You can't possibly do this until you have run through this exercise. Now, however...

Also, Pixie noted a Sobering moment: that was a separate area for the very ill who need ventilators. Physician assistants and nurses were being just in time trained using project xtreme to run a vent. That's part of the "broadening authority" that was included in the exercise.

Re the Indo patient that Pixie mentions: here's another sobering moment: we can't save everyone. Why would you think we could? But that patient would have been identified if ill at the facility and if well, but crashed at home would have skipped the triage clinic and called an ambulance. A bed would have been found, or not, depending. A patient could have been moved from the hospital to the nursing home where there were beds (separate area, own entrance, for infection control) freeing up one in the hospital. If there's a better system, I'm all ears.

Supplies and tamiflu were assumed to be absent from the SNS. The nursing homes and hospital would have resupplied us until we ran out. At that point, perhaps a week later, it's a different plan.

More video here:

[ Parent ]
Dem, in reflecting on the exercise
there is one major flaw in the ointment that I just can't get past and that is the sheer number of people that this facility will be meant to handle during an actual pandemic flu outbreak.  Maybe you can clarify for me some of the stats on this.  Let's look at the data:

My understanding is that this facility will serve 43 CT towns, including a couple of cities.  What is the total population of the area that this facility is meant to serve?  

How many doctors and nurses are expected to be working at the facility during a full shift?  

What is the uppermost limit in terms of total number of individuals processed (a total of the well, those sent for homecare, and those triaged for further treatment) that the facility can process, say, in a 12-hour time period?  

your understanding is not my understanding
the MFH can be deployed to any of the 43 areas but it does not mean that the facility alone would serve those 43 areas.

It's meant to serve primarily the Housatonic Valley Council of Elected Officials area, which is 10 towns including Danbury Hospital and New Milford Hospital (~360 beds). Once the concept is there, it doesn't have to be the only facility doing this, either.

As I have repeatedly emphasized, this is meant to make a dent, not be the total solution. If you run the numbers, you are still left with home care.

DEMHS region 5 is 43 towns, but this facility can't service them all. Norwalk and Sharon were there as observers, but they'll have to figure out something similar closer to home. So will all the towns outside of HVCEO.

If the field hospital were employed in Sharon,. e.g., we'd use the garage triage and use the nursing home as the medical facility rather than the field hospital, or do something similar closer to Danbury Hospital (but not at the hospital) and use the nursing homes to dischange and move less ill patients there.

We will cooperate with all area hospitals (especially the immediate region) and figure out how best to share resources. But this doesn't mean we can handle whatever comes.

[ Parent ]
and, if there are numbers to that, then
What would be a way to decrease population density?

Maybe use "covers" that play the role of tents but are much cheaper?  I tend to think of http://www.hexayurt.com but there must be other options suited to the task, depending on weather etc.  I'm sure there can be some ingenuity directed at this specific challenge item.

And, of course, the bigger question: what's the purpose of using a tent in the first place?  Is it because there are cars around and tents are an add-on to cars which are there "by design"?

If the tents are a way to provide things beyond cover, then we could "challenge" (in the soft meaning of "challenge": "accept it as an option and at the same time accept there may be other options (all of that before assessing each option)") ceiling, walls, and maybe other elements.

I think if we understand the rationale behind using tents we'll be able to come up with alternatives.


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
cheaper and of course larger - less people per square foot :-)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
portable, rugged and
self contained with cots and other items that would not be replenishing.

If the concept worked, and this is not a stand alone MFH concept, it could be packed, practiced and applied elsewhere.

Then, if the MFH were elsewhere, the concept could perhaps be adapted without the MFH.

[ Parent ]
and by the way
theres are exaclty the questions we hoped the drill would raise... so that all the area and out of area health directors would be asking the same questions!

If they do, a benefit of the drill.

[ Parent ]
Ok, so can you toss me some of those numbers
I agree with this:
If you run the numbers, you are still left with home care.

I think that's maybe our most potent tool, frankly, in motivating movement in that direction.  

So help me out - toss me some numbers.  I can help move part of the peanut ahead as well, and that's why I'm asking for the numbers.  You, and the health directors, need other facets of the public engaged to get this done.  The solution is not necessarily evident without incorporating those numbers so they're going to be necessary for any of us who wish to move from point A to point B.  The health directors may ask that question, but I'm asking it now.  Parallel paths are a good thing.  

[ Parent ]
pick your town
make your assumptions and run flu suge and flu aid. I can't do it for you right now, but there's multiple estimates on line.

Talk to your local PH so you are using similar numbers. if you don't your numbers will be dismissed (been there, done that).

Figure out how many excess patients per week or per day for 6 weeks. estimates vary on how many need hospitalization.

But that is an excellent thing to do (part of the greater plan). So we did this, and we run the numbers, and... what next?

[ Parent ]
Stats per town are not useful
here in determining the load on this particular MFH facility which will draw patients from multiple towns (10? 43?) if it is erected.  It's the fact that this is a facility drawing from (and meant to draw from) multiple towns that gives it a factor separate from efforts which would be town-specific. If there was going to be a facility like this MFH set up in each town, sure, the individual town stats would be more relevant, but we're not expecting delivery of a MFH tent here anytime soon.

I'm just looking for the data, the stats, that were assumed for this particular regional MFH and which were used during the exercise, it's planning, and which will be used for any follow-up.  They should be on paper somewhere.  Flu-surge and flu-aid are great, but this exercise did better and no doubt produced some very specific numbers/projections.  Why fudge them and do it all again if it's already been done and calculated?  

[ Parent ]
no, it's backwards
the numbers exist for each of the cities and towns (I don't have access to them, I'm not public health). So take the ten towns and add their population together. The census numbers are on the web. But that's not how the exercise was constructed.

For this exercise, we needed to know more basic things: could we stand it up? how many support beds were we dealing with? what could the MFH handle given the site (and as you saw, with only half erected due to weather)? would the drive by triage idea work at all? would community groups and private-public entities cooperate?

next task is to work the numbers and see what kind of area/regional impact it had based on various numbers and assumptions. That has not been done yet, and that's a good thing because no assumptions have been made.

I'm not on that committee.

[ Parent ]
Pixi - incorporated towns census info

  Cencus tracks are used to get info and protect privacy.

 This lists all places that are incorporated.


 Main site : http://www.census.gov/popest/c... and then select which one you want.
 You can also break it down by age and gender - but not for cities.
 You may have to write your congressmen or pay to have it broken down by age, city over 1,000 folks, gender, handicap.

 I say gender for males tend to rush out into the fray so I am guessing there will be more male deaths. I am not trying to be biased.


[ Parent ]
This is why we need pandemic parameters, IMHO

[ Parent ]
Public health directors
have and use parameters, but they keep them too close to the vest.  

The general feeling is that they are proprietary numbers, not for public consumption.  

Unfortunately, that leads us right back into lack of public awareness, lack of public engagement, not enough public pressure on public officials, so not enough funding, so public health can't do what is needed; they they get defensive (and hold those numbers closer), and we end up in a big circular dance.  

Pandemic parameters (all kinds of expectaional statistics, really) are used by public officials and they are available through FOI, but generally, FOI requests are required to obtain them as one has to basically tear them out of their cold, dead, hands otherwise.  

[ Parent ]
we need to sort of ignore officials on this one ;-)
I mean: wish them good luck (we're all in this together, after all, so no need to get adversarial at all), and also go ahead and explore the whole set of parameters, starting at the corner of our liking (=emotional preference, based on n=1 judgement).

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
I bet if you filed a FOI Act request for these numbers
it would be denied by the US DHS who would also instruct the US DHHS to deny the request.  While I have not tried to obtain this information making this statement wholly speculative, it is my opinion that the reason they would give for not honoring the request would be the new Orwellian catch all "National Security".

Dark Doctor (he's back)

If we have an legal eagles here with us maybe they should file a FIOA request for this information and see what happens?  

[ Parent ]
I've been through FOI training as a public official myself.  I've already run the subject of requests for information re. pandemic planning in my state past the guy who runs the state FOI office.  

The only things that should be redacted from information requested are the specifics about where SNP stockpiles are kept (which is fine by me).  

All other planning rubrics for a pandemic I have been assured do not fall under FOI exempted parameters, the criteria for which are really quite specific. They can try it, but I've already been told it won't fly.

Also, for example, just on the face of it, if a member of the public (say, DemFromCT) is invited to a meeting, all materials utilized at that meeting or provided to that individual are also available to other members of the public, ipso facto, should they request them.  

FOI laws were enacted because officials like to keep information to themselves, but that's not appropriate because, really, what they are supposed to be doing is the public's business.  It's a rare public official who truly appreciates that what FOI is for is to ensure that members of the public who are also interested in how the people's business is trasacted have the ability (and the right) to do so.  From journalists to private individuals, FOI is intended to honor our peculiar form of participatory government, in spirit and in fact.  

[ Parent ]
it's a great thing
and may I add that in New England we take our civic duty rather seriously. Grimly, even.

[ Parent ]
clarification re the numbers
the MFH is for the region 5 as a whole, but the triage centers would be stood up (as a concept) wherever they'd be needed.

There may be one physical Ottilie W Lundgren 25 bed component MFH, but whether what we did serves all (doubtful) or just the immediate region is not at all certain (other triage clinics would have to be stood up depending on what else was going on).

[ Parent ]
Is the MFH the right choice for the pandemic?
IMO, No.

Why, well what is the purpose?  The MFH is costly because it is designed to serve a whole range of disasters not specifically an influenza pandemic.  This is what the DHS's FEMA is telling local governments they need to do.  They are using the pandemic concerns to get their real agenda, better overall preparedness, in place. This is a good goal but it is not one that will be very effective for coping with the pandemic.  

Take the MFH for instance.  It is a very expensive triage tent.  If the purpose of the triage exercise was to sit between the home and hospital to determine where the ill needed to be treated then this could be accomplished in a much less expensive and as Lugon points out more commodious facility.  The type of structure I intend to deploy is 24" x 40" double walled hanger-type structure that costs only about $15,000 and can be erected in a couple of days with a small crew.  It can be subdivided easily into different areas for different purposes.  Using an influenza pandemic specific approach will cost a whole lot less.  I think you could have one of these simply triage centers errected and setup in all 42 towns in your district for what that single MFH costs.  The problem is that the grant from FEMA was for the MFH or nothing.  So they took the MFH.  Fine, an MFH has its uses but those uses other than for serving as an influenza triage station are surplus to the requirements and the reason for the high cost of this.  Thinking out of the box about this is what we need to do.  FEMA thinks in the box and they are trying to come up with one answer to all disasters and unfortunately that will not work.

A triage facility needs cots, blankets and some medical supplies such as NG tubes or IF to administer fluids to dehydrated patients that can be sent home or for urgent use for those being sent to the hospital.  It needs a hospice for those too ill to benefit from hospitalization who can't be sent home to die there and sadly it needs a mortuary where the deceased can be held until removal for burial.

There will need to be bereavement counsellors on site.   Home caregiver instructors will be needed to teach them the basics of good home care and to give these caregivers a contact point if new problems develop.  Obviously having lots of ready printed handouts in paper form will be important since we might not be able to depend on the Grid or our computers and many may not even have or know how to use a computer.  For now, the CD is great but come pandemic having home care instructions as paper booklets is more reliable and will be a better bedside tool as well.  The idea having a large stockpile of inexpensive generic OTC meds available to dispense in adequate quantities to treat those patients not too ill to return home for care is an excellent idea and one that the local governments or non-profits in the are should consider funding.  


there isn't right or wrong
you have to get out of that mode of thinking... there's good, and there's better. For example:

advantages of a MFH: in theory, it can handle comorbidities better. it is prtable it is rugged it is flexible. if it is all-hazards, and people drill on it, they are comfortable and know its limitations and strengths, it comes with some equipment like cots and toilets, it can be assembled in 1-4 unit size

disadvantages: it is expensive, it is limited in size, there are 4 for the state only, it is weather dependent (high winds are bad on stand-up day)).

Can other structures serve the same purpose? The garage drive-by can be done many places. The hydration station could as well. Vents for the critical patients? not so well.

all good points to be sorted through.  

[ Parent ]
idea generation and idea assessment are two different things

and trying things out gives information that's difficult to get in any other way

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
those ideas,
including the lighter building, would really go into the design of Low-cost community care (aka "austere" care).

The exercise reported in this diary has its own value.  I suggest let's think about a different design in a different place.  We've used enough room here as it is! LOL

And the important point about the alternate design is that it would need NO funding at all.  After all, we're kind of planning for "soon and worse", no?  (Some of us are looking into that seriously, as a design area that deserves some extra energy.)  A tough challenge, but that's where some useful ideas come from, at least according to this inventor.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Mass email
Here is a copy of an email for others to use


Gist: Case one of Bird Flu (H5N1)  was infected by birds while cases 2, 3 and 4 where apparent H2H infections. Two of the four did not make it.


Date: October/November 2007, confirmed and reported April 3rd, 2008

WHO details: http://www.who.int/csr/don/200...

Official Text: These laboratory test results support the epidemiological findings from the outbreak investigation in December 2007, and the final risk assessment that suggested limited human to human transmission likely occurred among some of the family members which is consistent with some human-to-human transmission events reported previously. This outbreak did not extend into the community, and appropriate steps were taken to reduce future risks of human infections.

Note: Two folks who had contact with case one, but no bird contact, died. 50% CFR which is less than the 67% world wide.

April 30, 2008: final webcast on the State planning and assessment process. The Department of Education will be featured and will address issues relating to the dismal of students during a pandemic. You can send in your questions before and during the webcast.
Source: http://www.pandemicflu.gov/new...

 April 5th, drill with over 100 folks.


Reference:  http://www.newfluwiki2.com/fro...

Please pass this along to those who could use it.  

another story on the drill...
BETHEL, CT (2008-04-07) If a pandemic flu ever hits Connecticut, local hospitals will quickly be over-run with very sick people. Over the weekend, hundreds of volunteers joined health officials for a simulation, to test the state's readiness for a major flu outbreak. WSHU's Craig LeMoult played one of the sick patients.


i apologize ahead of time...
I have been away for most of the day. The conversations we had yesterday have been swimming around in my "hard head".

It seems I stand alone. and alone I will stand.

Come Pandemic time, all of the training and drills will meet the monster and will be trampled to the ground. It is impossible to treat the symptoms. better to do preventive. Its always the case...

Time for a story.

I began studying karate at the young age of 18 from a very well bred Japanese high level teacher, some say from a Samurai family, here in NYC. I spent 10 years studying with him and acheived a 2nd degree black belt in empty hands and 1st degree in weaponry.

I had style, grace and looked damn good doing my forms and in the 2 man drills we practiced.

One day my teacher announced he was leaving the states for Italy.

I began teaching in Queens NY. I amassed about 150 students  ages 7-80.

One day one of my students told me he had taken a dance class in the city and after his class there was a karate class. The class was the exact style we were doing... which was rare in NY. he told me the teacher had actually opened the school i had originally attended but had a falling out with the Japanese teacher the master from Japan had sent over. Seems he disagreed on the way the Japanese teacher was teaching.

So out of curiosity and a desire to seek a teacher who knew more than I, I went to see him.

He was a short, stocky Chinese man who was quite jovial and loose in his teaching style. No uniforms, No belts, No major formality... just hard training.

He asked me to show him my forms which I did.. to the best of my ability.

he then said "punch me in the chest as hard as you can"... hesitantly... but eager to show my stuff, I settled into the most powerful stance I had and blasted at him. Much to my surprise, I literally bounced off. he didn't move.

Then he gave me 2 telephone books and told me to hold them to my chest which i did. The man just stood straight up... no special stance, put his fist on the telephone books and wham... I was thrown back 10 feet, landing on my butt.

He then said...  "you look like a nice silver gun, well made and impressive.... The only problem is that you have no bullets."

Meaning if i hit someone with my impressive, flashy and graceful technique that I would just bounce off doing no harm which is exactly what happened.

It's not the idea behind the martial arts. You need that bullet and it better be hollow point.

I had to change my entire way of doing it from the ground up since my concept was wrong. seems my original teacher didn't "have it right" but looked really good.

It's the same with all these pandemic vax and surge drills. They are like the nice shiny gun. Sure its good to practice dealing with the initial pandemic period of about a week or so under controlled conditions... but in the first real contact people trained this way will quickly fall apart.

I believe its better to prepare the people for whats coming. Thats the magic hollow point bullet... not polishing the shiny gun.

I know I'm gonna get blasted... but what i see when the Pandemic begins, is block after block of cars trying to get to these triage areas. Parents leaving their cars in frustration and carrying their dying children to the area screaming for help... for vaccine they were promised would be there... for the Tamiflu they were promised to be there... for the doctors and nurses they saw on TV at the drills who probably will not be there. It will be a nightmare scenario.

If there's one sure way to create panic its to believe that the concept of these drills is sound and keep doing them till you think you are ready.

We will never be ready for a severe pandemic if all we do is spend the cash on these drills.

So you might say... "you are right Goju, but we need to do both"... well I only see the nice shiney gun being drawn over and over and everyone saying "wow, nice draw... nice gun... maybe we can pull it out a little faster and aim a little better next time.

Well folks... I've looked in your gun's chamber and there ain't no bullets in it.

Tell the truth

you seem intent on sabotaging
other people's efforts.

Why is that?

[ Parent ]
I see a great wrong
Because Dem, I see a great wrong being done.

I embraced early the concept that no one could survive a severe pandemic alone... that we are only as prepared as our neighbor is.

I see a great swell of support behind this surge capacity drill and deep down in my soul I believe it to be a flawed direction to pour so much time attention and money into.

I have stood in a parking lot in the dark in New Canaan arguing with my PH officer about the need to prepare our neighbors. I still can see the contempt he had for me as I honestly begged him to do something to save the lives of the people of our town. To date nothing has been done that will actually save anyone and it sickens me to my stomach.

I repeat... this drill is a sham designed to divert our attention from the one true way to save our people... preparation on a personal and massive scale.

This drill gives a false hope that someone else will be there to save us when in truth, these oasis's of hope are mere shadows of salvation.

I strive to sabotage no one nor anything Dem, and to accuse me of it is shameful and objectionable.

I await a meaningful message to prepare our homes. i wait for honesty about why these exercises are being done. I wait for the truth to be told to the American people that H5N1 is the most likely candidate for the next pandemic and its kill rate is virtually 100% without the administration of Tamiflu within the first 48 hours. I wait for honesty.

No one wants to hear about the horrors that await us.... so we practice drawing our shiny gun... over and over... at an enemy so vicious it laughs in our faces... one death at a time, in far off lands.

Perhaps I react so strongly because I see the lemmings following the leader to the slaughter. I thought higher of my fellow Flublogians than to be enticed by the grandeur of the shining gun rather than the power of the hollow point bullet.

Maybe I stand alone in my thinking. Maybe others agree with me silently, afraid to speak against the rising tide of support for these misguided attempts at avoiding panic by the appearance that we are doing something.

Are we so easily swayed from our course by the glitter of gold when all people will want is a loaf of bread on their table?

Tell the truth

[ Parent ]
I think both things are needed. People in the medical profession will try to do the best they can. Practice is needed. Maybe a lot of lives will be saved at least in the beginning.

You are right though in that people need to be informed so they can prepare. There is room for both directions and both are needed.

My husband plans to see patients in the event of a pandemic. There are no drills being done here nor any info on how to best manage a solo family practice in the event of a pandemic.

Since he plans to work, I would dearly love for there to be some kind of infrastructure no matter how tenuous that he could be a part of. Some drills so he could network with other healthcare workers and support groups and practice working as a team. Better to do it now than be thrown cold into it in the middle of a crisis.

I am looking at my little piece of the picture as well as the big picture. I hope I am making some sense. I am half asleep.

Life is not so short but that there is always time enough for courtesy. Ralph Waldo Emerson

[ Parent ]
lets train our troops going into battle in Iraq with broomsticks.

maybe i wouldnt be so upset if i saw ANYTHING that approaches public education.

If you're going to do a drill to test your surge capacity then TEST your SURGE capacity with thousands of panicked people, lack of staff and supplies.

Throw a nightmare at your group and see how they respond.

This is like practicing for a fight by pretending to fight. we are beyond that now.

Are there any shrinks out there that can tell me why i am so upset by all this?

Please someone help poor Goju become sane again.

Tell the truth

[ Parent ]
response to this thread
I've seen old photos of people practicing swimming by lying on a sort of stool, practicing moving their arms and legs as though swimming in water.  Probably didn't help much or at all once they were in the water.

Bad analogy.

Imagine the people in the small town in CT, getting sick with severe flu, or seeing their families, neighbords, acquaintances, teachers, students, etc getting sick and some dying.  Imagine them reading about deaths and illness and social breakdown on the news or seeing it on TV, or around them.  Imagine many with lacks of foodstuff, maybe clean water, maybe sporadic infrastructure disruptions, maybe communications interruptions.  Imagine criminals taking advantage of this, and maybe borderline people acting desperate.  Imagine mentally ill people losing control.  Imagine garbage pickup interruptions, and maybe sewage treatment not being up to par.

Imagine this happening all over the place.  Imagine no vaccine, little to no antivirals, or a flu that is resistant.  Imagine a CFR of 10% or above.  Imagine this in the dead of winter, during a blizzard or icestorm, with electricity, natural gas, gasoline and heating oil supplies diminished, interrupted, or unavailable in some areas.  Imagine some or many stores closed due to lack of workers, aforementioned problems with energy and/or communications, or supplies.  

How will the exercise will have helped in such a situation?

The only way it looked to this tiny observer to have helped would be if a goodly percentage of the people involved decided to look deeper into the pandemic potential, went to the links and more links, read up, and decided to personally prepare for a pandemic, and do what they can do to influence or help others - whether relatives, neigbors, fellow workers, employees, or people in organizations they may be connected with.

It would be interesting to do a follow-up with every person involved and find out:

1. If they had done any preparations for pandemic before the exercise or thought there would even be a need to.

2.  If, after participating in the exercise, have they made a decision to take it more seriously and prepare; or not.

3.  If yes to number 2, have they indeed actually started to prepare.

If the majority of participants didn't think after the exercise that pandemic is a likely possibility and they should do something to personally prepare, then I don't see how it will have materially saved anyone's life or protected anyone's health in the event of pandemic.

I realize that people may say "Well, Rome wasn't built in a day, this is a good start, incremental change is all you can expect, there's not enough funding/volunteers etc to do more, if you can't do anything then don't criticize people who are at least trying" etc.

This is my answer:

No matter what kind of practices, drills, exercise, plans, outlines of plans, etc made - if they do not include or are not founded upon a mass education of the general public that pandemic may be hitting the world at any time from tomorrow on, and that each individual and household needs to personally prepare for this - such drills, exercise and plans will do little to nothing to help the public.

[ Parent ]
can mass education be "tried"?
At first sight, it looks like it is either done or not done.  (This deserves a whole diary.)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
I understand where you're coming from, I think. But a few points:

- It is possible that the next pandemic will be 1968-style, or between that and 1918. (Maybe next year H3N2 will do another change, and that will be the result.) That's not just "like a really bad pandemic, but less so". A different kind of preparation is needed - the kind Dem has been doing, for example. For example, in a really bad pandemic, it might be acceptable and right to say "if you're infected, stay where you are. The hospitals are not functioning. There's nothing we can do for you. Just don't infect anyone else." Bad news for the individual, but maybe right overall. In a pandemic that was only a bit worse than an ordinary flu season, saying that would be unpardonable. We need to have ways to expand capacity a bit, to cope with a moderate surge. Even if you think what's being done would be totally useless in a really bad pandemic (and I don't), it's still worth doing.

- For a really bad pandemic, two things are needed: understanding that preparation is needed; and preparation. I think that in urging strong challenges be used, you're aiming at the first: you're assuming that if people were strongly challenged, shocked, they would understand that they needed to prepare, and then go on to do it. But the shock is no use unless it actually does lead on to preparation, and I think you are wrong in assuming that that would be automatic. In knocking you off your feet, your martial arts instructor was doing nothing towards helping you to be a better fighter; he was just demonstrating that you weren't, right then. Most people, having that done to them, would give up the martial art. They'd be wiser, perhaps, as a result - or perhaps they'd rationalise it out, e.g. by saying this one guy was uniquely strong -  but they wouldn't become better fighters.

[ Parent ]
In knocking you off your feet, your martial arts instructor was doing nothing towards helping you to be a better fighter; he was just demonstrating that you weren't, right then.

In knocking me off my feet he showed me that all of the drills I had practiced over and over for years had been done wrong. Period.

Congratulations for wasting years of valuable time chasing my tail.

Tell the truth

[ Parent ]
Misdirected anger
Goju, you are simply flooded with anger right now. I'm not saying that your anger is wrong (there is ample reason for frustration), but it is misdirected, and it has gotten the better of you just for the moment.

When we are flooded, our anger targets anyone who can be targeted whether or not that anyone is the cause. We can yell at the people who are on our side, and that's what you are doing. Dem, the Bethel exercise, and the people who participated, are not the rightful target of your frustration.  Instead, those who muffle the preparedness warning at the highest levels are.

You need to take a break, think, and calm down. We've all been there, so we get it.  When I'm there, sometimes I need help to see that.

I would say this to everyone.  No one's interests are served when we fight over whose pandemic it's going to be or which One Way is best. Instead, damage is done, and energy and time that could have been spent constructively building upon the work is wasted.  People get wounded, and we discourage them altogther or for the span of time required for healing. I truly believe we'll get farther faster if we piece together multiple approaches and recognize how various contributions can complement each other and even how we'd be in trouble without the part each plays.

There is a spectrum of possibilities with regard to the next pandemic, and we've got to work along its span.  Lugon's thread "Timing and Impact: a Framework for Strategic Thinking" is a great place to pursue that work.


[ Parent ]
I couldn't agree more
thank you.

[ Parent ]
Mojo, I plan to hand out the Good Home Treatment of Influenza
booklet to my patients and urge them to buy all the items in the kit to care for all their family members because I know that they are going to have to treat them a home for the most part.  You can download this from Fluwiki or from BirdFluManual.com.  

For those that have the Bird Flu Manual, I will write them Rx for the drugs needed to treat flu in addition to the OTC drugs.  If your husband really thinks that the pandemic is real and serious, maybe he would join me in this effort.

If he wants to talk to me about this, he can email me at gwoodson@mindspring.com

The Doctor

[ Parent ]
This is a very good thing!
Doctor, I am so glad to see that you intend to provide your patients with the prescriptions for medicines they might need.
Best case scenario - those meds sit on a shelf until hell freezes over, never being needed.  But next best scenario is that people will have access to meds when they need them.  Few and far between are physicians willing to do what you say you will do.

I'm among the fortunate few, one who took Dr. Osterholm's Foreign Affairs article to my family physician, who took the time to read it, and who then reached for his prescription pad and began to write antivirals and antibiotics for my family.  That was in the fall of 2005.  He has since come to the conclusion that I'm obsessive/compulsive about the whole issue, but at least he didn't conclude that until long after I'd filled every script that he wrote.

I've always wondered if someone or some organization had a word with him about not prescribing meds for the situation I presented to him, his about-face was so abrupt.

But - regardless, kudos to you for being willing to put your money where your mouth is, so to speak.  I was able to obtain scripts for all the meds on your list and then some,
and I've been remiss in failing to thank you for those guidelines which are, in fact, very much appreciated.

[ Parent ]
Thanks Doc
I'll give the manual to him to read. Appreciate it.

Life is not so short but that there is always time enough for courtesy. Ralph Waldo Emerson

[ Parent ]
ah, let's get to the heart of Teh Stoopid

this drill is a sham designed to divert our attention from the one true way to save our people... preparation on a personal and massive scale.

And who would be the designers of the 'sham' and the 'diversion'? Who would be behind this nefarious scheme to kill your children because of a hidden agenda? The local community groups? What's the hidden agenda? There's no pandemic tomorrow. This group took nearly a year to organize and a month to plan. If it took twice of each, it'd still be done and worth the time. Personal prep on a massive scale? Please outline those efforts and tell me how this is a diversion from them. How do you divert from something that is not happening? Stoopid isn't the word for this.

Since you are making this up out of whole cloth (you have no data, of course, because none exists), let's spell out your entire conspiracy theory and see it if meets the smell test.

the one true way

More Stoopid. There is no "one true way". What makes sense to me doesn't make sense to you.

You know what I'm seeing? I'm seeing months and months of you being immersed in a fantasy culture that accepts and encourages conspiracy theories and magical thinking, and now your world view is being dashed on the rocks of reality.

I'm seeing outrage because someone is daring to tell you you're full of it. And doing something rather successful (not complete, mind you, merely successful), thereby proving some of your sillier theories (non-cooperation with  local tptb) utterly wrong. If they are cooperative with other people and not cooperative with you, maybe part of it is you and your approach.

Deal with it, but don't belittle the hundreds and hundreds of community volunteers who came together to do this because they disagree with you and recognize its importance as a good, solid first step.

  • They'll come together to do other things.
  • education was an integral part of this (it interferes with your outrage, so you ignore that like you ignore other facts like the local media coverage bringing up the topic)
  • this is small town New England - neighbors and friends are talking about the pandemic, at least in passing, at the bus stop,/li>
  • the 40 community groups/organizations/health care entites now have internal dialogue on the topic, and other invitations to educate will spring from this... they already have
  • the state now has to analyze the exercise, putting it back on the stove (doesn't matter which burner

In other words, reality in on our side.

[ Parent ]
Bravo! Well said!
And who would be the designers of the 'sham' and the 'diversion'? Who would be behind this nefarious scheme to kill your children because of a hidden agenda? The local community groups? What's the hidden agenda? There's no pandemic tomorrow. This group took nearly a year to organize and a month to plan. If it took twice of each, it'd still be done and worth the time. Personal prep on a massive scale? Please outline those efforts and tell me how this is a diversion from them. How do you divert from something that is not happening? Stoopid isn't the word for this.

The only problem is I suspect as always your questions are not going to be answered, but sidestepped.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
trying to understand people's objections
Goju, I am reading through what you have to say against this drill, and of course what you and others have to say here on this forum:


Setting aside for the moment your quote of people in flublogia being like "lemmings following the leader to the slaughter"...

Am I correct that it appears to boil down to these two objections?   Is there a third?

Objection #1)

In this drill, the health care system did not demonstrably collapse.  

Therefore you are afraid that all those involved (including HCW, planners, and the people who volunteered their time as victims) as well as the general public reading about it in the news, are being left with false reassurances.  

They are being left to believe that "They/We did a drill for pandemic flu, everything is fine, we don't have to worry about it anymore."

QUESTIONS regarding objection #1:

Dem?  Do you get the sense that the planners/HCW/student nurses who worked on this drill were left with a sense that everything is now under control, no more drills or planning need to happen?

Pixie?   Did you say some of your homeschool listserv friends participated?   If so, any reaction from them?   Did they leave with a sense of reassurance that the area had pandemic flu under control?

Does anyone else who participated or who lives in the area have a sense of how this is being received by either participants or the general public?  Is the general public now reassured that they do not have to worry about pandemic flu?   Or have they been more unsettled about it -- this is serious, there won't be a vaccine, might not be medication?

Objection #2)

Money was spent on this drill, that should better have been spent on a massive, state- (or area-) wide pandemic flu awareness and preparedness campaign, telling all members of the public that pandemic flu could start at any time and could be massively fatal, and that therefore people should prepare in the following (very serious) ways.

QUESTIONS regarding Objection #2:

Would it have even been technically (legally) possible to take the money that was spent on this drill (for hospital/health care preparedness) and instead spend it on a Public Education campaign?  

And if it had been legally possible to spend the funds that way, who would have had the final authority as to the message of the campaign?

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
answers as I understand them
and bless you for asking.

QUESTIONS regarding objection #1
Dem?  Do you get the sense that the planners/HCW/student nurses who worked on this drill were left with a sense that everything is now under control, no more drills or planning need to happen?
Absolutely not. There's always "look at the cool equipment" people, (cowboys, we call them) but the vast majority found it both fulfilling and sobering and we are talking hundreds of people. Fulfilling, because whenever you're a part of something, you take a piece of it away with you. But sobering because the overwhelming nature of a pandemic sinks in when you have to try and manage something and realize you can't. The entire drill cycle is based on plan, train, do, revise, re-plan, re-train and re-do. All volunteers heard this mantra over and over for four days.

We still have to run the numbers and check and see under various scenarios, and defining the region we cover (some debate about that), what we could do and for how long. We know it's not forever. We may not run at all by week 4 or 5, but if we can get 3 solid weeks in, or even 2, we can maybe help.

QUESTIONS regarding Objection #2:

Would it have even been technically (legally) possible to take the money that was spent on this drill (for hospital/health care preparedness) and instead spend it on a Public Education campaign?  

And if it had been legally possible to spend the funds that way, who would have had the final authority as to the message of the campaign?

This was a group of public-private organizations. I have no information about they funded it. The interest was there for this. I doubt that was something that could have been simply switched.

I am also unaware of anything that was not done or canceled because this was done.

[ Parent ]
ACM, thanks (i'm learning)
and yes, we have to see if Goju or others agree that those are the concerns.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
objection #3
I think I have identified a third objection to this drill:

Objection #3)

No one exhibited fear.  Although a 7% CFR was supposedly used as a planning parameter, (which should be high enough to scare anyone) HCW did not always wear their respirators and masks, and people playing patients did not seem to be scared.  

When Pixie (pretending to be a flu patient) expressed concern that there was no Tamiflu for her condition, and that she was worried because she might die (7% of victims with her condition would, in the next few days, so it was a reasonable fear) the doc treating her seemed to think she had a psychological problem.

When people came or brought their children and learned there was no medication left to treat them, or learned that they were not sick enough to get treatment, they didn't protest. They didn't scream or yell or fight, they just passively left.

People fear that this was unrealistic, and might have left participants with the idea that this was also how people would act, in a true pandemic.  

They also are concerned that the planners and HCW involved in this drill (and certainly the volunteer patients) have no understanding of how fearful people will (legitimately) be of a 7% CFR pandemic (or of course greater).

Questions to Objection #3

Was a major part of this drill intended to get participants to feel and react as they would in a real pandemic?   To help them anticipate and deal with legitimate emotions of fear and anger that people will face?

Were the people playing the patients briefed that the disease they might have could be fatal in 7 out of every 100 people?

In the materials given out to HCW working the drill, was it stressed to them that the fatality rate of this illness so far was essentially, as high as SARS had been, and that therefore the people coming in to see them would be legitimately afraid of dying?

Were they given suggested responses to questions patients or families might have?   I can imagine true life questions might include:  "Am I going to die?" or "How fatal is this?  Is my child going to die?  Can you save him?"  and that the response should not be 'You seem worried -- go to the psychological tent."  

I don't know what the right answer is.   I do think that esp. for doctors or nurses who do not routinely work with the severely ill, are very uncomfortable telling people that they have a fatal illness.   But maybe something like, "This is a very serious illness, and it is understandable that you are worried.  We'll do everything we can to help you." would be a good response to practice.  And so maybe it would help if more patients in the drills asked this question.

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
excellent points
Questions to Objection #3

Was a major part of this drill intended to get participants to feel and react as they would in a real pandemic?   To help them anticipate and deal with legitimate emotions of fear and anger that people will face?

No. It was a logistics drill to see if we could set things up, use the facility, use the beds, communicate and also to see if we could track beds, use the drive-by concept, triage large numbers of patients, and teach them something in the process.

Were the people playing the patients briefed that the disease they might have could be fatal in 7 out of every 100 people?

No. That was not an intent of this particular drill. Someone may have wanted it to be, but it wasn't.

In the materials given out to HCW working the drill, was it stressed to them that the fatality rate of this illness so far was essentially, as high as SARS had been, and that therefore the people coming in to see them would be legitimately afraid of dying?
No it was not. It was stressed that there would be stress, just as there is in any trauma or mass casualty situation, and that there'd be psychosocial issues crop up, but it was not a part of the drill because the patients were not being trained to play that role. It's a good idea at a second drill, but it's a different drill. You can't do everything at once, especially a first time drill.

Were they given suggested responses to questions patients or families might have?   I can imagine true life questions might include:  "Am I going to die?" or "How fatal is this?  Is my child going to die?  Can you save him?"  and that the response should not be 'You seem worried -- go to the psychological tent."

No. That is within the scope of their profession and an every day thing for them, at least for those within the tent who are not students. For the students, that's a tough one. But for the doc that examines the kid and sees no life threatening issues because the scenario didn't have that assigned to that patient, the doc;'s going to think you're worried well and treat you as such, and within the context, that is highly appropriate behavior. If you try to play the role of a worried parent on your own to test the system, but the patient was "fine", you'll be sent to the psychosocial tent.

I don't know what the right answer is.  I do think that esp. for doctors or nurses who do not routinely work with the severely ill, are very uncomfortable telling people that they have a fatal illness.   But maybe something like, "This is a very serious illness, and it is understandable that you are worried.  We'll do everything we can to help you." would be a good response to practice.  And so maybe it would help if more patients in the drills asked this question.
That would be a different drill, and that is an important drill concept. You lay out specific objectives and drill to it, and stick to it.

It's a foundation concept. Drill the logistics, drill the location, drill infection control, drill communication. Drill signage. There's an infinite amount of things (some very important such as mass casualty and psychological response of staff, less staff, no supplies) that could be added but not all at once and not as a first drill. Those were not objectives, those were not taught, those were not stressed. IOW, those were not tested yet. That's why you go back and reevealuate and redo.  

[ Parent ]
thanks! n/t

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
Thanks AMC
You pretty much addressed my objections without creating the perception of a shrill yell.

The answers are very clear.

Tell the truth

[ Parent ]
and there's nothing wrong with the answers.

[ Parent ]
What good would fear do?

 Yes, in one Mass casualy test we where "victums" left behind in a burning buss after the bomb went off.
 We yelled and screamed. It was more for the firemen and paramedics then us.
 One of us had a second device. Once they found that they had to back up even though she crawled out and we pleaded for our lives for them not to abandon us.
 It was all good fun for some pizza and mulage (sp?) or fake scars.

 However for regular folks why?

 There is so much about the basics yet to be covered and worked out.

 Every first aide and rescue course says "Never look at the victum and go "ohh gross!, Hey Bob come over here - you gotta see this one. Ever see anything like that before??"

 Always be calm, professional, honest (no false hope or promises) and positive.


[ Parent ]
Fear can be one of the greatest of motivators n/t

[ Parent ]
yes and no
Some are motivated, some are paralyzed and/or go into denial.  Different people react differently, so methinks it's still best to use a large number of different motivators, to cover different types of people.

And, different people are motivated by fear of different things.  Many in this day and age fear ridicule more than losing their lives, oddly enough.  It is partly related to the culture of (and social pressures for) 'positive thinking', such that being worried is seen by many as weakness and a character flaw.  Such traits are particularly unacceptable in front of work colleagues, and I suspect more prevalent in males than females.

It's a problem that cannot be ignored, but may be best handled by circumventing than confronting it head-on.  IMHO.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
I think this has been the greatest hurdle to pandemic awareness all along.
TPTB are more worried about over hyping the risks of a pandemic than they are about the consequences of an actual outbreak.

That said, I'm continually amazed and pleased that our governments are doing anything towards preparation. It could be a lot worse.

[ Parent ]
yes it could be a lot worse
OTOH, we start from a very low base already, in the UK.

I'm looking forward to what Bruce Mann might have to say in next month's meeting.  After publishing the National Security Strategy, we'll have to see whether the political will exists to make things happen.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
I wonder?
Since there is great risk here, why aren't the governments doing more?  We have been told why the WHO has abandoned the field.  As I understand it they think that there is really no way to help the developing and third world, their area of UN responsibility, survive the pandemic so why scare them with the truth.  Remember they are still at Phase III and holding despite the large number of small H2H clusters that clearly indicate H5N1 has moved to Phase 4.  (I think the reason may be political.  China does not want the WHO to declare Phase 4 until after the summer Olympic games). They know what the advanced nations know and have told them that the governments of the advanced nations are on their own as far as pandemic planning and prep is concerned.

OK, so why have the advanced nations done so little?  Sure they have a little Tamiflu and bought some rather questionably effective vaccine based on early strains of H5N1 from Vietnam and Indonesia, but really nothing else at least nothing of substance IMO.

Why haven't the governments done more?  Are we all simply wrong about the pandemic?  Are we just paranoid fools?  

Dark Doctor

[ Parent ]
Why have the advanced nations done so little ?
Ask yourself, are your politicians (on both sides of the arena) more worried about getting elected or solving your country's problems? Do they strike you as deeply intelligent and concerned for the welfare of the people?

We elect our premiers for their nice teeth and sincere expression, not their track record for wisdom and determination to get things done.

There is a conspiracy, it's a conspiracy of shallow values.

[ Parent ]
Fear - no.

 I agree that fear is a great motivator. It gets people moving without much thought or planning.  Using fear IMHO is no different than a drug dealer pushing cocaine or crack.

 Fear can burn a person out and is at best short lived.

 Goal or visions are better. Visions can out live the people who create them and can not be killed.

 Set people free. UK-Bird has asked why developed nations have done better. Is is because people have better access to information? IMHO - no.

  I believe the people, the citizens, feel they are in charge, can do something and fear TPTB will not do it for them.

  Yes this is fear at work, but only to boost or guide hope.

  Clawdia I agree fear is great stimulant. It can also paralize a person.

 Hope is a great stimulant and does not paralyze.

"avoide the paralysis of analysis"  

[ Parent ]
To take your anaolgy further
Instead of a self confident, trained young man, you had been a vulnerable woman, eager to learn a bit of self defence?

How would you have reacted to being 'thrown back 10 feet, landing on my butt'?

How about a cocky young teenager who doesn't have the drive or inclination to acquire the right skills without encouragement and cajoling?

How about a gang of men who have something to 'prove'.

Or just an innocent bystander who came in to tell you, you'd left the lights on?

You have to suit your training to the people you have to work with. Terrifying, subduing, annoying and just plain attacking those who come to you, doesn't advance your cause one iota, in fact it will most probably get you into trouble.

[ Parent ]
I was NOT. I was a trained and "thought" skilled fighter.

My previous years of training "read drilling" was a sham.

The pandemic will be like his fist... only without the telephone books to soften the blow... In our art, we have "the one punch kill".

A severe pandemic will be like a one punch kill.

Why is no one really addressing my issue?

This was a well planned drill, scaled to fit. That is not usefull in my book.

We always train to fight someone better than us. This drill did not do that.

It was White belt training when we should be having senior Black Belt classes.

Why is everyone so damn happy about it?????????

Tell the truth

[ Parent ]
start a new diary, please?
Why is no one really addressing my issue?

I suggest you start a new diary.

It starts off with a question: how do we design and implement a better drill?

You select the starting parameters: CFR, disruption, whatever.  You set the stage.  It's not much use arguing "who's pandemic is it anyway?" because we can all have our own pandemic [for the time being ;-)].

I suggest you design the drill on paper/screen first, then move things forward in real life.  It may be difficult, but it may be possible.

With input from as many here as will feel invited and will have time and energy to help.

Please do.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Goju, remember when you were 18?
When you first started training for martial arts?

Or, better, remember before that, when you were 8 years old?  

Suppose you were 8, and suppose you have never been beaten up nor suffered any other physical pain or public humiliation, and the very first time you got enthusiastic enough to try out a martial arts class, the teacher throws you 10 feet.  What would you have concluded as an inexperienced, frightened and humiliated 8 year old?

You have a lot of courage and grit; I admire you for that.  Perhaps even as an 8-year old you would have decided right there and then to go and learn everything and train to be the best fighter on earth.

But most people (ask everyone here) are likely to come to a different conclusion.  Most 8-year olds would have decided NEVER EVER to try martial arts again.  Yes, you learned some positive and empowering lessons from that experience, but keep in mind that lessons depend on context, and people differ.  In the case of an inexperienced 8-year old with little maturity to go beyond the surface, many would have been put off for a very long time.

I thank you for telling your story.  Let me tell one here.  My youngest daughter has never been well endowed in the motor skills or coordination department.  I took all my children to swimming classes at the age of 2.  Whereas the older 2 took to it like ducks in water (literally! lol) my youngest one, unfortunately, had a very bad experience on top of her normal timidity.

The first swimming lesson we went to, one of the first things mothers were asked to do, was to hold the baby in the posture that a swimmer would take, ie on their bellies with their heads above water, and encourage the kid to swim towards the coach standing maybe 3 strokes away.  Well, in this instance, the coach was a big Western man with dark skin and a very hairy chest.  He was standing in waist deep water.  

My little girl had up to that point NEVER seen anything like that before.  Imagine, viewed (from eye level) from the eyes of a 2-year old, the guy's glistening mass of dark hair on a hulk of a body was the most terrifying thing she had ever seen.  I'll tell you that she screamed and kicked and whatever we did, there was no way she was going to go near that person!

After that, it took us something like 4 or 5 years to get her to even GO to a swimming class again.  It was only when we threatened that if she didn't learn to swim we would not take her on vacation that she finally learned to swim, since I had no intention of always keeping an eye on her if she didn't know how to swim a short distance to save herself!!

Goju, people have different life experiences.  We all become who we are partly influenced by them.  The same experience will also cause different people to come to different conclusions.  The important thing here, at least for me, is to acknowledge that none of us has the corner to 'truth', and none of us know the BEST way to deal with this monster, and to believe that we can all do different things in different ways, some of which will succeed more than others, and that over time the sum total of all efforts will have positive effects.  

I know you'll say "but we have no time".  Even if I were to subscribe to your certainty (which I don't), I still think the formula for success in any venture has to include taking into account people's differences in temperament and readiness.  Not everyone is ready or capable of plunging their minds into worst case scenarios like yours, and to do that and INSIST that everyone has to do it your way, is the same thing as if I had FORCED my 2 year old to go to that swimming class week after week after week.  What kind of a child do you think I would have ended bringing up?

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Thank you Susan
For your soothing words.

Going back a year or two, Sec Leavitt said quite clearly "we are on our own"... no one is coming to the rescue.

How can you reconcile that statement with this exercise?

I want to say right here and now I admire the efforts everyone involved in the drill put into it. The coordination of so many orgs and people was impressive.

The drill as it was intended was a wild success and all involved should be congratulated.....

It's just that it didn't test anything in any kind of real life scenario. Are we drilling and preparing for a 1957 style mild pandemic? or are we preparing for H5N1?

I say start over and put our energies into a more productive path... one that may save the lives of my and your children.

Tell the truth

[ Parent ]
I say tone down the rhetotric
and stop calling hard working committed people "soothers" and hard-fought projects "sham" and "distraction" if you want to be taken seriously.

Right now you sound like a little kid stamping their foot for attention.

[ Parent ]
yes, that too ;-) n/t

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
I can reconcile it
How can you reconcile that statement with this exercise?

because I know that most if not everyone who took part in that exercise took away some valuable lessons that will come in handy in a pandemic.

I can reconcile it because I know that agencies have budgets and logistical limitations, such that this is as big and complex as it can reasonably get for a first drill, and still be able to get out of the committee room into the streets to become an actual drill.  

I can reconcile it by believing in the ingenuity of human beings.  We are distinguishable from other species in our tremendous ability to THINK.  For the many who before that drill might have had more simplistic views of pandemics, I'm sure many would have seen the flaws (which btw was one major goal of such drills) and realized how unprepared we are.  I believe they will go home more inclined to think about this more carefully and to seek more information, not just professionally but for themselves.

I can reconcile it because it bought significant press coverage at a time when interest in pandemics is low to nil.

I can reconcile it because there is a limit to our own physical endurance, as individuals.  Dem and all the people who put this together no doubt put all they could put into it, and as always it falls short of everyone's expectations.  BUT to the extent that now instead of say 100 people (these are hypothetical numbers) being keenly involved in planning it, we have maybe 500 who are now brought to a higher level of awareness and involvement, such that the NEXT TIME, there will be far more hands on board, to plan the next exercise.

I can reconcile it because I know that plenty of other people are doing plenty of other things to get the world prepared, that we are not dependent on any single exercise or effort to turn the tide, but the sum total of all efforts will eventually reach a tipping point.  In fact, due to the unique diversity that is inherent in human nature, the more we approach this problem from many different angles and assumptions, the more likely we will 'convert' enough people to cause a tipping point to happen sooner rather than later.

Just a few thoughts... ;-)

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
and for those who don't know
"soother" is code word for an official spokesperson who uses logic and clear language to damp down righteous outrage.

There's a group of people on line who have pushed this harmful and hurtful idea (alas, without challenge) and now it comes home to roost. That makes us part of the official conspiracy, hence Goju's use of 'sham' and 'diversion'.

To Goju "soother" is the most despicable insult imaginable. To the rest of us, more of Teh Stoopid that prevents anything from getting done.

Have the courage to say it directly, Goju.

The drill as it was intended was a wild success and all involved should be congratulated.....

That's what bothers you about all of this. You're the quarterback who likes to throw long on every play and you're mad at the coach and the running backs because they keep grinding out first downs. The rest of the team values your arm, but is scratching their head.

[ Parent ]
"put our energies into a more productive path"
I would say "Ya gotta start somewhere". As this FIRST drill was a success, and it is dissected by the contributors, problems and faults will be found and hopefully remedied.

What "more productive path" would you have in mind?

[ Parent ]
btw do you acknowledge
that you do not have a corner on 'the truth'?

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
I hold no monopoly on the truth
I believe we are playing in the wrong stadium.

i meant what i said to Susan so please dont twist my meanings. She has indeed struck a chord in my soul and did "sooth" me Dem.

500 people?

How much money and time was spent on this drill?

i was part of GetPandemicReady.org. small contribution but still a part of it.

That is a noble project. That is the right message. That is the right game to play as we move down the field.

I do not need to call attention to myself Dem. I dont care for the spotlight. I care for the light in my children's eyes and do not want to see that light extinguished. That is my goal. It has been since day One when i read about the birds dying at Qinghai.

Tell the truth

[ Parent ]
notice the word 'believe'
I believe we are playing in the wrong stadium.

The dictionary says the word 'believe' means "accept something as true; feel sure of the truth of".  Which means that it is subjective, based on conviction and faith and not necessarily evidence.

i meant what i said to Susan so please dont twist my meanings. She has indeed struck a chord in my soul and did "sooth" me Dem.

I'm glad it struck a chord.  Pray tell?  I'm just trying to find some clarity on what you are saying, thanks!

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
we want the QB on the team
stop yelling at the linemen and running backs.

[ Parent ]
Do you interpret my pleas as yelling?

I am sensing a certain hostility Dem... undeserved and out of character.

I am merely saying I think all the energy would be better spent elsewhere as we have been discussing for years now.

and yes Susan this is wholly my own subjective belief.

Tell the truth

[ Parent ]
well it's all subjective
and yes Susan this is wholly my own subjective belief.

including whether someone is pleading or yelling.  Or whether some comments are constructive criticism as opposed to resentment or hostility.  And whether the comments are justified based either on evidence and/or on the overall merit of the project.

Each to our own.  I always believe in agreeing to disagree, but I do not believe it is useful to use one's personal opinions as basis to build conspiracy theories, which are THEN used as justification to challenge the motivations of others.

Presuppositions built on personal bias magnified by insinuations and unfounded suspicions of malign motivations - that is the LAST thing we need on flublogia.

KISS - keep it simple, stupid, is IMHO a good motto.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
let's see
a "certain hostility", eh? Have I misinterpreted 'sham' and 'diversion'?

this drill is a sham designed to divert our attention from the one true way to save our people... preparation on a personal and massive scale.

I don't think so. You've accused me of being associated with something deliberately designed to kill people rather than save lives (which is what it is, was and will be).

Take responsibility for what you are saying, boyo.  

[ Parent ]
To take your anaolgy further
A martial arts teacher would not do this to a newbie student. Been there as a student and a teacher.

when training and teaching you do it to save lives. Start with the basics and teach the student to live to fight another day-stocking up, learning what to do in case the power goes, the stores are out of food, medicine on hand at home.....

If the drill brought more awareness and people start prepping then awesome otherwise your still teaching the people to depend on tptb/others and not taking personal responsibility. Why bother to become self reliant whenothers will be there to save the day.

[ Parent ]
thank you!!! everyone who participated
as a volunteer was taking personal responsibility by showing up. They didn't have to.

This is a group we can now work with.

You can't 'make' people do what you want, but you can provide the tools.

The links (flu wiki) and teaching sheets (on home preparedness) provided from getpandemicready.org are a start.

Tonight is a medical town meeting I'm presenting at (public invited - they are the audience) to put the drill in context.

All town resident received a preparedness packet about stocking up at home.

Area officials will be briefed on this as well in various and sundry venues.

Any other ideas are most welcome. Tell us what you've tried and what works.

[ Parent ]
yeah that's for sure!
You can't 'make' people do what you want

I couldn't make my baby go swimming until she was ready!  ;-)

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Goju - Temporary fix at best?

 Hi. Do I read your post correctly in saying "Hospitals will be over run so why think they will help. Train people to survive an near TEOTWAKI event with limited to no outside medical care" ??  


[ Parent ]
but of course that's true
just not instantly, everywhere and forever.

At no time was there ever a suggestion that preparing the medical side was a substitute or to be done instead of what folks need to do at home for themselves.

All the exercises including CDC, HHS and this one, all point to the importance and primacy of home care. That does not mean avoiding responsibility to wring out of the system what one can.

[ Parent ]
DemFromCt - Trying to understand Goju's reaction.

 I'm trying to figure Goju's reaction.

 Hospitals, as far as we know, will be overrun becase there is very little surge capacity and the specilized equipment, vents, as well as general equipment like beds are in short supply.

 Goju seems to say that any HCW drill is pointless. I do not agree. Hospitals will be there and should be improved to give the best they can.

 To train as if they where not their means the hospitals will not be improved.

 It cuts me deeper than that. "Rigid flexability" it is called.

 A spegttie strand breaks.
 Cook it and it flops like a wet noodle.
 Gather up a handfull and they lay in you hand like a dead squid. They lay every wich way but up.
 Weave them and you get a flexible rope that can stand on its own yet bend.
 With out watering the rope lasts only for a while and then reverts back to a rigid stick.

 Here multiple strands are better seasoned than as raw recruits. Working together they form a flexible rope instead of so many wimp noodles going in every direction but up.

 Water it with habbit.
The key to cross-agency information sharing: habit

 The tao of pan-effort ?


[ Parent ]
Goju seems to say that any HCW drill is pointless.

No Kobie - just make it "real"
I think that we will most definitely need these kinds of care facilities and operations especially in a severe pandemic. I want to see them pushed to the breaking point.

i think everyone came away from the drill feeling it was a really good start... Perhaps that is what got me going. It would have been fine a couple of years ago... we are way too close to Panflu breakout now... you saw that TPTB are acknowledging there have been many limited H2H clusters in several countries now. That is new. Phase 4 anyone?

I also think the lack of public education funding was missing from the swirl of euphoria following the drill.

You all know me. You know what I believe is going to happen. You all know I am in this to save my kids - very selfish.. but you also know that I KNOW that if my neighbors fall, I will most likely fall too.

I am not involved in Government operations. Not privy to the inner workings of these drills and it is so easy for me to be critical after so many have done so much.

I do applaud any efforts toward saving lives but don't accept that this was a smashing success for that sends a signal that we are not on our own. Hence "why do I need to prepare?"

Tell the truth

[ Parent ]
what euphoria?
Goju, this is really bothering me.  All this talk about people congratulating themselves, and being self-satisified.

Where did you get that idea?

This WAS a good drill.  Compare it to all the others we read about.

1) They drill to see how fast you can vaccinate people.  And we say "With what vaccine?"

2) They drill to ssee how fast they can distribute Tamiflu from the SNS, and we say "What Tamiflu"?

So a drill without those two things, is a really big paradigm shift for local authorities.

It's OK to say, "Good job" on a drill, without having it mean, "You are all done, the problem is fixed".

It's just -- it was a big effort, and worth congratulations.      For the whole group that did this drill, and is STILL doing the follow up report.   THAT's where people discuss what the problems were and what more they need to drill the next time (and what additional components they need to test).  They haven't even GOTTEN to the afterreport yet.  

You know, when Leavitt said "You will be on your own" he wasn't actually saying every FAMILY would be on its own -- but that communities would be on their own with no aid from the feds.   THAT's WHAT this community decided to come together to work on.  It is a START Goju.   They got a lot of community groups and organizations together and got them to start THINKING about the problem.

If I lived in the area, I'd be working like crazy as a community organizer to capitalize on this excellent effort.  And, I'd KEEP saying "Excellent start!  This was a great job!  Yay, you... now let's do even more.  How can I help?"

GetPandemicReady.org - non commerical website with practical ways for families to prepare.

[ Parent ]
ACM said:
If I lived in the area, I'd be working like crazy as a community organizer to capitalize on this excellent effort.  And, I'd KEEP saying "Excellent start!  This was a great job!  Yay, you... now let's do even more.  How can I help?"

You bet!If I lived up there, I'd be notifying as many as I could offering to get the RMA display to as many places as I could. This drill was a great stepping stone for those in that area to begin their own public awareness campaigns (ESPECIALLY if they feel -- as most of us do -- that their local governments are not doing that job adequately). Now is the time to jump on this, while it's still fresh. -k

www.EmergencyHomePreparation.org -- A 'card-catalog' style of prepping information.   -

[ Parent ]
Goju - make it real - in steps

 Hi. Make it real in steps?

 I totaly agree more information needs to get out.

 I thinkg TPTB should hear how ignorant and closed most people are to the H5N1 message. Look at how long it took global warming to get moving? Do we have that sort of time to do much, so much more?

 I hope "the swirl of euphoria" will lift people to do more without thinking they have done more than the first of many thousands of steps.

 Look at the Tiwanese Acrobats or Kung Fu masters who can do "in human" things because of training.

 Now, the deeper question of "are we studying under the right teacher or going down the wrong road" is another matter beyond me.

 The floor is open.


[ Parent ]
Yes Kobie
Now, the deeper question of "are we studying under the right teacher or going down the wrong road" is another matter beyond me.

Kobie - only time will tell.

Tell the truth

[ Parent ]
Time Will tell,

 So true. I hope thre is a whole lot of looking and listening going on.

 I fear plans made are thought complete and good even though they have not been tested.

 I fear TPTB do not hear the simple questions of look at the ripple effect of prduent changes. A simple 2 hour rolling black out could affect some for five or six hours while not affecting others at all. (diary http://www.newfluwiki2.com/sho... )

 Even if our plans are not right, testing shows the plans actualy work the way we think they do and increases the skills of the layman for this and other disasters.

 Goju when you say "There is no way for your life.  You yourself are the way. " I find that scary yet empowering. It is comferting to think that problems and obsticals are "out there" not "inside."  That is not the truth, is it? Problems are inside. Solutions are inside.

 This is why the chain is self healing. Unlike a pice of metal that can not change once it starts to give, we can change.

 The bigger goal of the Wiki and others is to pass this along to any who participate. Any who want to live through the pandemic, not die. Any who want to help instead of suffer.

 If folks can not look within, then please follow the good actions of others. We are relying more on change than chance. Seeking some work and muscle not for people to work miricles (note: miracles fully accepted though not tax deductible contributions)

 Goju you are right - do. Dreams, ideas and good intentions are warm and exciting like a summer afternoon. They will disapear just a quickly without taking action on them.

 It is weird how and when things work. Telling someone about the pandemic brought grief. Leving stuff out for others to read brought some results.  Using company email brought warnings, passing around a Gartner pandemic presentation the company paid for brought "let me hold on to this, I'm re-reading it and need to make a copy."

 Multiple things must be tried to find out what to do.  :o)


[ Parent ]
From Old Buddhist Sayings
There is no gate on the way of life that refuses entrance to those who want to pass through.  If, you want to go somewhere, take any way, there are thousands and all are equal.  If, luckily, you succeed in your goal, the way will disappear and you will become the way.

There is no way for your life.  You yourself are the way.

Tell the truth

[ Parent ]
that is so true
What I often see is people being hesitant or unwilling to start on their way, fearing they might be making a mistake, or thinking they don't have enough information.  (Sound familiar?  Not enough data!)

But what they don't realize is great leaders make decisions based on inadequate information all the time.  They make educated guesses, and as they get on their way, they continue to collect information and adjust their path accordingly.

But here's the key, for Kobie.

You won't have that information unless you get started.  People (like officials or scientists) often spend their time looking for answers.  That is necessary, but only up to a point.  After that, it is your ACTIONS that trigger the rest of the feedback or answers that would not have been available ever, if you didn't get started.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]

take a pencil and drop it on the floor.

Try to pick it up.......

If you actually picked it up, you didn't try... you "did" it.

There is a great difference between "trying" to do something and actually "doing" it.

I think many people "try and never do".

Trying is a great excuse for not doing.

Tell the truth

[ Parent ]
yes, some do that
some are even worse.  They don't even try.  ;-(

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
btw, don' t know if you misunderstood
I didn't say 'try'.  At all.  Cos I'm well aware of this issue, constantly.  LOL

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Kobie, I don't believe
I thinkg TPTB should hear how ignorant and closed most people are to the H5N1 message.

it is a case of ignorance, on tptb's part.  At least not the leaders at the national level, who ultimately are calling the shots.  I don't think they are THAT clueless; I think they are perfectly aware of how unaware the public is.  

Again, I posted this question http://www.newfluwiki2.com/sho... 6 weeks ago now.  I don't believe I will ever get a response.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Why keep us ignorant?

 TPTB, actually their predicessors, did not always have teh answers nor a complete plan, yet they engaged and informed the people.

 Are they so scared they do not know how to take care of themsevels, and hence can not take care of us?  No, because we are alredy working on the problem and most solutions come from people working on the problem not administrators or managers.

 Do they not care about us? Well as horrible plagues in the past have shown - the people left will be too busy working for themselves to take care of TPTB.

 Are they afraid of "egg on the face" for being wrong - agian? No. The could always say "we do not have any proof it will be that bad, but if you the unwashed masses wish to prepare like that please do. You will be more prepared. BTW, we will do some stockpilling ourselves. After all, your ability to take care of yourself will take a strain off us and municiple services." This allows them to support preparation efforts without taking the fall.

 I just do not understand SusanC. So many options - so little action.


[ Parent ]
you just do not understand ;-)
The key lies in the fact that even though we here live the pandemics issue day and night, the rest of the world don't.  Rightly or wrongly, governments have to worry about a whole lot of things, including the recent and ongoing turmoil in the global financial markets.  To them, these issues are more immediate and therefore always have precedence.

Add to that the fact that especially in DC but also in capitals round the world, it is the rich who can hire lobbyists to have THEIR agenda take precedence in the minds ot tptb.  They can make or break the careers of politicians by their wealth and influence.

I'm not saying these are right.  I'm just stating my observations.  I view this as the biggest challenge we have to overcome.  We cannot overcome it directly, they are many orders of magnitude more powerful than us, if it ever comes to a head-to-head.  

I believe in people power, used strategically, wisely, and with our eyes wide open.  We have to stop believing in our own rhetoric too much, and take a strategic and pragmatic approach to this problem.  It cannot be solved by us repeating ourselves like a broken record.  We have to learn to speak their language and somehow play their game.  It doesn't mean losing our focus, but the exact opposite.  We have to use our focus to generate the kind of willpower and stamina needed to sustain actions that will overcome such resistance.  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
"What we have here; is a failure to communicate" ;-)

 Sigh, then I agree with you. Sometimes it takes more than just a good idea or cause.

 The DC beltway bandits and lobby folks - I understand.

 The outcry of the people should also be heard. From airline delays, to passport delays, to global warming all got the US government moving.

 Actually they are moving, but way too slowly - in my opinion.

 I agree there are lots of pressing issues. The U.S. Homeland security, HHS, CDC and other departments are making progress.

 Thanks for listening.

[ Parent ]
Great start Dem!
I hope the ball keeps rolling :-D

Pixie's eye view was very useful too. I know that during a simulation I was involved with (not pandemics) I learnt more as a victim than I would have as a part of the observer or action teams.

Crfullmoon's idea (passed on by Average Concerned Mom) about 'staff are observed not wearing their masks or respirators correctly, they get tagged midway through and turned into patients' is a great one.

yeah, i liked that one a great deal! n/t

[ Parent ]
and, as I've said elsewhere
Pixie's observations were excellent and her conclusions were helpful constructive criticism.

[ Parent ]
Thought I'd weigh in.......................
Most all drills or exercises have preset goals and objectives.  Dem's Drill was based on state/local outcomes and funding. It was not his own money to spend the way he wanted to.
Dem's Drill seemed to encompass many different areas.  I really liked the handouts that were used to help educate people. The media involvement added an element we have all been hoping for and made this event priceless.

I have one small suggestion.  I noticed that people entering the triage area were given paperwork and a pen. Pen covers should be included in tent preps. A small item but it could be important.

Dem deserves kudos for his part in this drill and for all the effort he put into it. Congratulations, Dem.

Goju, I don't think anyone here will disagree with you on the importance of getting individuals prepped and prepared, especially for home care. We will need it when the tents fail. An important determiner of how you are heard is found in how you present your material.  Please lose some of the static.


good point
Pen covers should be included in tent preps. A small item but it could be important.

or disposable golf pencils, or wipes. I will pass that along

[ Parent ]
Goju wrote earlier that if he had been there as a patient,
he would have acted really sick.  I wonder if there was discussion of how the facility would deal with many fluid-emitting patients, and feverish patients shivering or sweating, and how the staff can clean up after them, or if the visibly sick can be whisked off somewhere without first doing paperwork.

Supplies such as blankets, mops and buckets, wastebaskets and trashcans, changes of gowns for staff, maybe table-protectors like those at salad bars to keep them clean and dry (yucky image, but stuff happens).  Even close-by portapotties for emergency dashes.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]
good thoughts
When everyone has flu, the concept is different than when everyone doesn't. Nonetheless, we had portapotties (2) and we had disposable gowns for fluid splashes. We didn't bother but the field hospital comes with showers and toilets.

Supplies such as blankets, mops and buckets, wastebaskets and trashcans were readily available.

The paperwork can be streamlined... and will be. We can do better. We used something called 'smart tags' on patients. A bracelet that can be flagged green, yellow or red, and that had space for vital signs and pertinent positive findings. However, we had one registrar. two would be needed, as long as that registrar did not have to play traffic cop as well (only one family member with the patient, the others to the psychosocial tent set up for that purpose, wear your mask).

[ Parent ]
Ps if you act sick in a drill or real life
and your vital signs say you are not sick, you get shipped to the psych tent (or hospital holding tank), with very large escort (size and number) if needed, or escorted off the grounds. You don't get to screw around to 'prove' anything to anyone. It's a safety issue for everyone else. Those issues can be built into a drill, and better to do so.

We didn't need it, but the drill had ample security, from national guard to uniformed officers.  

[ Parent ]
But still
when my diabetic "patient" who had a fever of 102 degrees and who had been vomiting and suffering from diarrhea for four days told the doctor that he'd heard that 1 out of 10 people who were "sick like him" were dying (he was not corrected by the doctor and given the information that the number was really 7 of 10) and discussion ensued with the nurses about whether or not to send him over to the psych tent.  

I let my "patient" be mollified by the doctor writing a prescription for Tamiflu to be picked up on the way home.  But the patient might have known that Tamiflu was ineffective at day 4, and who knows what he might have heard about the pharmacies being out of stock. The Tami prescription might not have really mollified him.  

This patient was sent home, in spite of his fairly poor condition.  A real patient in that situation, who would be very much aware that this flu (for people who really did have it as he did) could be fatal, could reasonably be expected to worry.  

My concern is:  how are we going to handle that very reasonable worry?  Not the worries of the "worried well," but the "worried (and maybe for very good reasons) sick"?  

[ Parent ]
Sorry - lost my zeroes there
The CFR question should have been 10 out of 100, and 7 out of 100.  

I've been spending too much time over in Indonesia..yikes.

[ Parent ]
your hypthetical doctor would handle a hyopthetical
problem in a hypothetical pandemic in a different hypothetical way. Different circumstances require different responses. This is getting lost in the trees and not seeing the forest.

he was not corrected by the doctor and given the information that the number was really 7 of 10

You mean 7 out of 100.  He was not corrected because there was no need to correct him (1 out of 10 is 10% cfr, and close enough to 7% to pass).

But there is a need to correct you.

CFR in population p  =  (# dying from disease Y in population p) divided by (# with disease Y in population p)

7% is 7/100
70% is 7/10

As far as that patient being sent home, that's debatable, and as previosuly discussed, and I haven't examined the records. Did you get an IV? If the resp. status was stable, hydration and home might be appropriate in those limited circumstances and be considered 'essential care', not 'standard of care', with f/u from the primary care doc, and it might not be. Depends what the doc thought.

[ Parent ]
MFH - offical, comferting and proven
Military Field hospital tents.

 I'm not sure they are the best for a pandemic. They need heat in the winter, cooling in the summer.

 However they are "official looking" which can be comferting. This is big bad more than industrial, it is military grade stuff designed to take a licking and keep on ticking.

 They are also standard and proven technology. Ok, there are a variety of designs from 1950's forward.

 I still go with using a school, mall and sports complex/stadium. This is not a "suprise" event

 Here is why:
 1) It could be the dead of winter or dog days of summer when it hits.
 2) Parking - need lots of parking for family, staff, vendors, clergy, HCW, etc.
 3) Sewage - got to have a large connection there for all the liquid and semi solid stuff from Cafateria, labs, and 100% post patient by product.
 4) Water and power hookups.
 5) Bathrooms. Multiple bathrooms. Even some showers.
 6) Pedestrian traffic routs. Setting up a MFH requires you look at traffic flow and security. Can someone pick up a child and walk out. Are there blind alleys where a woman can be acousted or worse.
 7) How do you move food/supplies in and take trash out with out their lines crossing.
 8) Sinage. Schools have signs and a numbering system.
 9) Intercoms and communication in place.

 Let me know what you think.


MFH- Male, female, pediatric, child and family
  Umm, most hospitals are broken into male and female secions and then subdivided again by age.

  Since this could affect a whole family, you might have a whole family staying.

  Has this been explored?


these days, families stay together, and it's room by room, not ward by ward. because peds patients are not admitted frequently, it's not unusual to have a womens and childrens floor with male borders in some of the rooms.

IOW, not the issue it used to be.

[ Parent ]
Not segregated around here . . .
I spent way too much time in hospitals a few years ago when both my parents were terminally ill.  In no case were they segregated into female only or male only areas.  They were placed on appropriate care floors; i.e., the surgical wing, where everyone regardless of gender was a surgical patient.

The only separation I saw of patients other than by need for level of care (ICU, for example) was that young patients were placed on the pediatric floor or wing.

I've never had any experience with hospital care being separated out according to gender as you describe, or by age other than pediatric and geriatric care needs.

[ Parent ]
Don't forget compassion
I think the drill is excellent and I hope it will never be needed, but it is comforting to know that some are preparing to help as many people as possible.

On a side note, in a real mass emergency, you'll be dealing with a lot of freightened children, parents, and people in general. It sounded like you had a psych area set up. When my baby was critically ill, the comfort provided by the pediatric ICU doctors, nurses, and counselors was sooo important. When your baby is possibly dying and you're helpless to do anything and everything seems to be moving too fast and spinning out of control, knowing others really do care not only about your child but about you as frantic parents helps tremendously. I'll never forget the compassionate doctors and staff (as well as the unknown blood donor) who saved my daughter's life.

Dem, thank you from the bottom of my heart for trying to make a difference.

thank you
how can you read your post and not try even harder? ;-)

[ Parent ]
Dem, you must be happy because of the sheer number of comments
We've run in many different directions: happy and unhappy and suggesting.  You folks created quite a stir.

146 comments plus those of the first thread.  And those written on other forums.  And some people reading without writing.

All starting with one sooo simple tiny drill exercise! ;-)

So much learning ... when's the next one, then?


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

I am fielding some NZ inquiries
as we speak...  ;-0

the drill heard 'round the world...

[ Parent ]
The Drill Heard Round The World

Yours truly,


Tell the truth

[ Parent ]
hey, Kobie! BSA Troop 137 participated in the Pandemic Preparation Drill in Bethel
The boys enjoyed an opportunity to earn a requirement for Emergency Preparedness Merit Badge while helping local emergency and health care workers in a practice response to a massive pandemic flu outbreak. The scouts were assigned various symptoms and were directed to either return home with instructions to treat their illness or were asked to report to the emergency tent for further evaluation. Nurses, Student Nurses, Physician Assistants and Doctors checked the serious cases and either "treated" them in the emergency tent or "sent" them off to the hospital. The drill was an excellent learning excercise and gave the scouts insights into the complexities of managing a large pandemic flu outbreak. The emergency and health care workers were very appreciative of the boys taking the time on a Saturday to assist in this important excercise.

DemFromCT - Saw this, thought you told me. Passed it along to my local council and a few troops.

  I even left a message on their webpage saying "they where lucky to get involved"

  While scouts are not free labor, the chance to help and learn is often used. It is good to see partical part of prepping.

  I also hope events like this mean there will be more trained folks to call on. Kids listen to kids. So getting them educated helps.


[ Parent ]
DemFromCT - numbers and newspaper article.

 Found this in the newspaper
"Dr. Gregory Dworkin, Danbury Hospital's chief of pediatric pulmonology, spoke about the history of major pandemics including the type H1N1 Spanish Flu of 1918. Pandemics are categorized by levels one through five increasing in severity. " Source: http://www.acorn-online.com/ne...

  Also: how much room did the MFH take and how many folks can you fit in one? I'm looking for a number like 24 - 30 square feet per patient for sizing estimates. I'm starting to think our high school is not large enough for CFR 2% or higher - not that we have the staff.

 Thanks in Advance,

From the article . . .
Dem - I saw this phrase, which begs the question of its accuracy . . .

"Dr. Dworkin believes a present day level five pandemic would occur with very little warning and possess the ability to travel overseas within months."

Do you really believe it would take months for the virus to travel overseas?

Also interesting that we almost always think of the virus erupting "there" and then traveling "here"; however, although seemingly unlikely, I think it's a possibility and I'm surprised that it's only rarely mentioned.  

[ Parent ]

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