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Testimony before the House
Committee on Veteran’s Affairs November
14, 2001 Susan
Bersoff-Matcha, MD Kaiser Permanente
Good
morning. Mr. Chairman,
Members of the Subcommittee, I am grateful for the opportunity to
share my experience as an infectious disease specialist in treating
two of the patients who contracted inhalation anthrax.
My name is Dr. Susan Matcha. I am a physician with the
Mid-Atlantic Permanente Medical Group and one of more than 11,000
Permanente physicians nationwide who provide care to more than eight
million Kaiser Permanente members in eight states, including Maryland
and Virginia, plus the District of Columbia. In
my testimony today, I would like to talk about two areas: my
experience treating patients with inhalation anthrax and Kaiser
Permanente’s response to the anthrax crisis. As a
Permanente physician, I practice as part of a team of infectious
disease specialists, alongside numerous other physicians with
virtually every specialty and subspecialty represented. Our physicians
are used to working together, and we know how to mobilize ourselves as
different needs arise. The integrated care we provide to Kaiser
Permanente members provides us with broad support and resources.
In this instance, this has meant rapid consultation among
specialists, the ability to develop and disseminate practice
guidelines that effectively communicate our state of knowledge, and
coordinated collaboration with the Centers for Disease Control and
other public health authorities. Immediately
after the tragedies of September 11, the threat of bioterrorism
suddenly became real. The
seven infectious disease physicians in my department at Kaiser
Permanente began reviewing the state of our knowledge about different
biological agents. We
consulted textbooks, the medical literature, and the CDC website to
increase our understanding of anthrax as well as other potential
agents including botulism, smallpox, and tularemia. Kaiser
Permanente already had developed clinical practice guidelines for
bioterrorism as part of our emergency preparations for Y2K.
Our infection control committee, led by one of my infectious
disease colleagues, updated them soon after September 11. While
we hope our work has contributed to the public health, my principal
responsibility is caring for patients. I would like to share with you
a brief chronology of the care provided to the two patients I have
personally treated. To protect their privacy, I’ll call them Patient
#1 and Patient #2. Patient
#1 came to the Kaiser Permanente Woodbridge Medical Center on Friday,
October 19. He had been
ill for three days with fever, malaise, muscle aches, and sweats. At
that time the Brentwood postal facility was not known to be an
exposure site. But the
internist who saw the patient was concerned about the severity of the
patient’s symptoms. Since
the patient acknowledged he had never felt that sick before and that
he suspected he had been exposed to anthrax – even though a call to
the public health department again confirmed that Brentwood was not a
known site – he sent the patient to Fairfax Hospital. The
emergency room physician at Fairfax drew blood for routine tests as
well as cultures, and also ordered a chest x-ray which showed some
extra shadows in the middle of the chest.
Because of these shadows, a CAT scan of the chest was
performed. The findings
were thought to be consistent with anthrax, and the patient was
started on IV Cipro. Shortly
after midnight Saturday morning, I was called about the patient.
When I arrived at the hospital, the CDC and health department
had already been notified. Within
11 hours, the blood cultures were growing an organism consistent with
anthrax. The blood was sent to the CDC and the Virginia Department of
Health for confirmatory testing.
During this time, I was in constant contact with the CDC.
We discussed adding additional antibiotics to the Cipro, which
at the time was the only FDA-approved antibiotic for treating anthrax. The CDC made some treatment suggestions based on theoretical
evidence and what is known about the behavior of similar organisms.
Although I received input from the CDC based on laboratory research,
no one had experience treating human anthrax patients. Ultimately,
as the treating physician, I was responsible for writing the orders
and caring for the patient. I ordered rifampin because it works well
fighting many gram-positive organisms and has the ability to penetrate
white blood cells to kill organisms that have already been engulfed.
I also added clindamycin because it has been shown to interfere
with toxin production in other bacteria. With
respect to patient #2, he called our Kaiser Permanente medical advice
line on Saturday, October 20. The advice nurse was concerned about his
symptoms, headache and fever, and she referred him to a physician in
our Fall Church Medical Center urgent care department that afternoon. The
physician there was concerned that Patient #2 might have meningitis
and sent him to Fairfax Hospital for a spinal tap. The Fairfax
Hospital emergency room physician called me with the results and
mentioned in passing that the patient was a postal worker.
I asked him to find out exactly where the patient worked. When
I heard Brentwood, where I knew Patient #1 worked, I remembered that
anthrax could cause meningitis and asked him if he had ordered a chest
x-ray. He had not.
I advised the emergency room physician to obtain blood
cultures, and then immediately give the patient a dose of IV Cipro.
Once this had been done, the patient was to have a chest x-ray. The
chest x-ray was difficult to interpret, so a CAT scan was done. The
results of the CAT scan were similar to the first patient’s. Both
showed enlarged lymph nodes in the chest as well as pleural effusions:
puddles of fluid in the space around the lungs. Fifteen hours later,
Patient #2’s blood cultures also returned with a gram-positive
bacteria, consistent with anthrax. At that point, I added rifampin and
clindamycin to his regimen as well. In
addition to the numerous calls I made on that weekend to the CDC and
health departments that weekend, I also called the chief of our
medical group’s infectious disease department, Dr. Miriam Cameron,
to let her know about the two patients.
Together with Dr. Adrian Long, president of the Mid-Atlantic
Permanente Medical Group, and Marilyn Kawamura, president of Kaiser
Foundation Health Plan of the Mid-Atlantic States, she helped
organized a conference call so our organization could respond
effectively to this anthrax crisis. The
elements of our response included several key steps: establishing an
emergency operations center, updating our clinical guidelines,
reaching out to our patients, expanding our capabilities, and helping
in the community. Emergency Operations Center
The
genesis of our emergency operations in this crisis was Y2K.
Kaiser Permanente developed an emergency plan in preparation
for what we thought might happen as the year 2000 began.
This plan was valuable to us when bioterrorism hit.
The manual that was created for Y2K included operating
procedures for staffing (medical and administrative), equipment
(including a generator with the capacity to run for 2 weeks),
communications (internal and external), and a hotline. Kaiser
Permanente’s response to bioterrorism was centralized in our
Emergency Operations Center (EOC), which became fully operational on
October 23. Early
activation of our EOC was vital to our successful and orderly response
to this crisis. The EOC
provided various avenues of communication: email, voice mail, and
phone conferencing that connected the entire Kaiser Permanente region. We held conference calls several times a day to discuss what
we had learned since the last call, the progress of each patient, the
volume of patient calls coming in to our advice nurses, and the volume
of appointments at our medical centers. As
the number of designated exposure sites and possible exposure sites
increased, there was great demand placed on our infectious disease
team. We set up a hotline
in our EOC for non-urgent questions, which was covered 9-5 by a nurse
who has the latest clinical practice guidelines and access to an
infectious disease physician. Emergency calls went directly to one of
us for live consultations. Clinical
Practice Guidelines Clinical
practice guidelines describe and instruct the triage and treatment of
patients by physicians and advice nurses.
The list of designated exposure sites was updated as we
received news from public health departments.
Different guidelines were detailed for stable and unstable
patients, symptomatic and asymptomatic patients. The guidelines listed
all phone numbers for public health departments.
Any and all other relevant information was included in each
update. New information was clearly identifiable.
For the benefit of all our physicians as well as the advice
nurses, we addressed what symptoms to look for and what questions to
ask the patients, such as asking where they worked. The
process we had in place for the use of clinical protocols served us
well. The information
cascaded down from infectious disease specialists to everyone on the
front lines: internists, family practitioners, advice nurses.
Our organization’s ability and dedication to update and
distribute them frequently enhanced the effectiveness of clinical
protocols. Since
Kaiser Permanente is used to communicating with multiple jurisdictions
and dealing with different sets of rules, it was natural for us to
coordinate and communicate with the CDC, the departments of public
health, and different political entities.
We shared information about our patients, and we shared our
clinical protocols. Johns
Hopkins University Hospital, Inova Fairfax Hospital, and others used
our protocols as their guide for patient diagnosis and treatment. Reaching out to patients
Kaiser
Permanente has more than 530,000
patients in Maryland, Virginia, and DC. Each of these patients has a
medical record number and an electronic medical record. Through our
multiple information management systems, we can track data to help us
respond to issues. For example, as soon as we understood that postal
workers at Brentwood could be at risk, we identified all our members
who work at the Brentwood post office by the telephone exchange they
provided to us for their work number. A
cadre of nurses volunteered to contact all 237 Brentwood employees.
Nurses asked our members if they had gone to DC General for
testing, if they had received their medicine, were they taking it, and
how did they feel. People
who were not taking the medication, for a variety of reasons including
suspected pregnancy, were encouraged to take it medication as
appropriate or to come in and see a doctor. Some people were directed
to an emergency room. Appointments
were offered to anyone with any symptoms. We
can use this system to communicate with all our members or a subset of
them. For example, we
could call all our members to remind them about flu vaccines – which
is something we are currently doing, or for mass immunizations. We
were able to instantly create a special category in the medical record
for this current bioterrorism crisis to identify, collect, and sort
anthrax-related information. And we were able to generate hospital
admissions and emergency room visit reports that were valuable to us
and to the DC Department of Health staff, who said it was the best
information they received from any of the area health care providers. The
importance of physicians using the electronic medical record system
was reinforced. Most infectious disease physicians were spending time in the
hospitals. To make it
easier for us, we could dictate our notes and have them entered into
the electronic medical records to keep them up to date. Expanding
our capabilities
Because
the anthrax crisis was so fluid, with different parts of the
Washington area being affected at different times, we had to be fluid
in our staffing at our medical centers and urgent care centers, as
well as in area hospitals. Because
of the integrated nature of our organization, we were flexible enough
to shift people quickly throughout our region and other parts of
Kaiser Permanente. Because
we are part of the larger Kaiser Permanente organization, we were able
to draw on other resources. Physicians
from other regions came to our assistance. We had infectious disease
physicians and primary care physicians providing us support in a
variety of ways. Some of
them saw our HIV patients, others took routine office appointments,
supported our advice nurses, and helped in the EOC. The
out-of-state doctors had to be licensed and credentialed very quickly
to work with patients. The
State of Maryland was extremely cooperative.
Our credentialing department processed the paperwork swiftly
after the State approved the physicians. In
part because of our resources as a large organization, we were able to
obtain large quantities of medication and vaccines.
On Friday, October 26, a decision was made to get enough doses
of Cipro in case we had to treat all our patients who are postal
employees and their families. We needed 10,000 doses, and we had them by Monday, October
29. We also obtained
100,000 doses of flu vaccine. And
we already have a plan in place to distribute medication to a large
population and will be testing it with the flu vaccine this year. As
the anxiety increased in the general population, our medical centers
organized and announced group appointments.
These were helpful to our members with justifiable concerns
about anthrax exposure, as well as those who were concerned but had no
significant risk factors. Patients from the group meetings who wanted
to be seen individually were seen individually. Pitney
Bowes management called us for help in the early stages of this
crisis. They have many employees who are contracted to the postal
service, and some work in the Brentwood facility.
These individuals had concerns about anthrax exposure, but
could not be seen at DC General because they were not postal
employees. We agreed to
test 300 workers, some of whom are members of Kaiser Permanente, some
who are not. While we
were doing blood testing and x-rays, we found a lung mass in one
person, hypertension in another, and other conditions of concern
unrelated to anthrax. All
of these patients were referred to their physicians for follow-up. To
help deal with the emotional trauma our patients were experiencing, we
arranged for our mental health providers to be available at all our
urgent care centers. In
fact, we have had group meetings available almost every evening since
the events of September 11. Helping
in the community Kaiser
Permanente has a long history of community service. It is an integral
part of our mission. Prompted
by an offer made by one of our leaders, 13 of our Mid-Atlantic
Permanente Medical Group physicians volunteered to help the DC
Department of Health by providing weekend treatment, evaluation, and
counseling at DC General, giving DC health department physicians a
needed break. Conclusion The
events of weekend of October 20th were stressful and
humbling. My infectious
disease colleagues and I were confronted with a disease that few other
clinicians in the world had seen.
We felt a responsibility not only to our patients, but also to
the broader medical community. As
a result, we have taken numerous steps to share our clinical
experience. We have posted our guidelines on the Kaiser Permanente
website where it is available to physicians across the nation and the
general public. We have responded to numerous inquiries from clinicians
across the country. Finally,
we have written an article for the Journal of the American Medical
Association on what we learned about diagnosing anthrax, and we are
currently working on another article to discuss what we learned about
the course of hospital treatment. When and if other physicians are
faced with anthrax, they will know what we did and what we learned. Again, thank you for inviting me to speak to the Subcommittee. I would be pleased to respond to any questions you might have. Back to Witness List |