If a Pandemic Strikes: Is Radiology Prepared?
Two years after the SARS virus first made news in Asia, health officials are again raising concerns that the United States remains perilously vulnerable to a pandemic, prompting fresh doubts about the radiologic community’s readiness to meet the challenge. A swift, coordinated response is key, they say, as it could mean the difference between a manageable problem and a grave national crisis.
In the June 2007 issue of Radiology, Indiana University radiologist Richard Gunderman, M.D., Ph.D., MPH, and fourth-year medical student Brandon Brown, BA, conclude that as the threat of pandemic grows, the radiology profession’s ability to effectively respond may slip further behind. The implications should concern the entire imaging community, they say, and serve as a wake-up call to mobilize now.
As their jumping-off point, Gunderman and Brown note that the U.S. may have managed to dodge SARS and the avian flu, but full-blown pandemics materialize from seemingly nowhere, reach an unpredictable flashpoint, and spread like wildfire. Historically, they strike about two or three times a century. Most victims are “old and debilitated,” but the 1918 pandemic claimed fully one-half of its estimated 20 to 50 million influenza victims as “young adults in the prime of life.” The death toll was double that of all the combatants killed in World War I.
Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, estimates that a similar pandemic today might kill upward of 1 million Americans. In December 2003, researchers for the Centers for Disease Control and Prevention came up with another projection, noting, “In the United States alone, the next pandemic could cause an estimated 89,000–207,000 deaths, 314,000–734,000 hospitalizations, 18–42 million outpatient visits, and 20–47 million additional illnesses.” These projections “equal or surpass many published casualty estimates for a bioterrorism event.”
While medical science during the past 89 years has advanced by leaps and bounds, today’s international jet travel and haphazard screening offset much of that gain by speeding a disease’s stealthy spread. “In case of a major pandemic,” Gunderman says, “we would probably not be equipped to handle it very well simply because we don't have the needed personnel, facilities, or equipment.” Issues of which radiologists need to be mindful include the following:
Radiology Emerges as a Critical Resource. In the event of a pandemic due to a respiratory virus — the most likely threat, officials believe — Gunderman and Brown see radiologists having “crucial roles to play in the diagnosis of disease, gauging disease extent and severity, monitoring response to treatment, and assessing for treatment complications.” Chest radiography and CT would likely top the list of diagnostic tools.
Demand Overwhelms Supply. In the wake of SARS and the avian flu, one would expect U.S. public health officials today to be ramping up the nation’s preparedness, but Gunderman sees the opposite. “We’ve been closing hospitals and reducing hospital beds and ICU beds … that might be required to support patients through the most serious phase of illness,” he says.
The likely consequence is that, during a pandemic, huge demand, driven by worst-case-scenario news reporting, would likely overwhelm hospitals, creating radiologic bottlenecks. “The fact that [a pandemic] is primarily a respiratory disease,” Gunderman says, “indicates a great need for many more images in a very short amount of time than we’re used to performing.” In a “dire circumstance,” a pulmonologist, cardiothoracic surgeon, or emergency room physician “might be able to interpret chest radiographs” but would be unable to create those images, notes Gunderman.
This leads to another bottleneck: the current shortage of radiologists and allied health care workers, Brown says. “Even if you are able to open a previously closed hospital or convert warehouses or other buildings into hospitals, this effort would require not only physicians, but all health care workers to provide care for the additional patients.”
Contamination of Personnel and Equipment. A revolving door of potentially infected patients could turn radiologic equipment (and staff) into pandemic breeding grounds. When personnel in the radiology department themselves become patients — or when they avoid work out of concern about becoming infected — an already strained radiology department could reach a breaking point, Gunderman and Brown say.
A proactive approach might entail restricting access or even quarantining the department. “At the very least,” Gunderman says, “you probably need a way to sequester patients with suspected pandemic influenza from other patients who are down in the radiology department for other reasons, such as being treated for cancer. Certain hospitals might be designated specifically as pandemic centers, and all other patients would need to get away from that setting to prevent transmission.”
Teleradiology might seem an attractive option for certain physicians, Gunderman notes, but left unresolved is the fate of other radiologic personnel, hospital physicians, and lab workers who don't have that option. Maintaining proper hygiene — proper hand washing and use of gloves and masks — would go far in keeping a lid on transmission, they also note.
Triage. When demand outstrips supply, questions arise as to who gets treatment, who goes without treatment, and who makes these difficult decisions.
Will the decision to withhold or withdraw life-sustaining treatment or support go to public health policymakers, hospital administrators, department medical staff, or perhaps politicians? Will the decision be based on medical condition, prognosis, chronological age, pre-existing condition, insurance, or something else? Would allocation limits survive an expected flurry of legal challenges? Among the other thorny questions Gunderman and Brown ask: Should potentially life-saving care be withheld from pandemic patients because they are disabled or have a serious primary disease such as cancer?
These issues, they say, must be resolved in advance of a crisis. Reflecting on his medical school’s recent training in mass triage, Brown says the important message they learned is that “it is much more effective to make the difficult decisions beforehand and then, during a pandemic, focus on implementing them.”
Ethics and Professional Duty. The medical response to pandemics raises key issues of professional duty. The researchers note that dozens of health care workers became infected during the outbreak of SARS in 2004. In Toronto, Gunderman notes, health care workers were working in full isolation suits, such was the concern within the medical community. Exposing oneself (and by extension, exposing one’s colleagues and loved ones) to a virulent disease would give anyone pause. Nevertheless, radiologists and other health care workers have a duty — indeed, a social contract — to provide care and to serve the sick. “To fail to answer [the] call would be an abrogation of professional responsibility,” Gunderman and Brown say.
Looking to the future, Gunderman offers a parting thought. “Sometimes adversity brings out the best in us. We discover new capacities and commitments we didn't know were so deep, so that we end up being better physicians for it. It’s a hopeful vision, but it’s not an unreasonable possibility.”
FURTHER READING:
1. Gunderman RB, Brown BP. Pandemic Influenza. Radiology. 2007;243:629-632
2. Gensheimer KF, Meltzer MI, Postema AS, Strikas RA. Influenza pandemic preparedness. Emerg Infect Dis. 2003 Dec; 9(12):1645-1648. Available from: http://www.cdc.gov/ncidod/EID/vol9no12/03-0289.htm
3. More information available at: www.cdc.gov/DiseasesConditions/
