Serving patients and the common good
Paul A. Raslavicus, MD
As pathologists we live in two disparate worlds of medicine. In one world, we use our professional training to render one-on-one care to patients—be it in surgical pathology, cytopathology, or the more complex or unusual services within the clinical laboratory. But in our role as director of clinical laboratories, we direct the work of many people to ensure that clinical laboratory services are provided, competently and safely, whenever needed—for whatever the medical need. This professional role was foremost in the mind of our colleague, College fellow Jim Robb, MD, when the first patient with inhalation anthrax came to the attention of the laboratory he directs.
When the sentinel case was suspected, Dr. Robb’s consolidated microbiology laboratory, which serves an integrated system of 10 hospitals, proved well suited to the task of establishing the presumptive diagnosis of the etiologic agent of the disease. Diagnosis was rapid, thanks to teamwork between hospital physicians and the core laboratory.
The use of biologic or chemical agents is more than a possibility. It has happened, and it may occur again. We need not minimize the danger, but we should not participate in the panic that the news broadcasts tend to create. We need to recall that there are many more fatalities from "routine" bacterial food poisoning than there have been so far from the anthrax attacks. We need to let our patients and the public know that the medical profession, our laboratories and our hospitals, our public health laboratories, and the Centers for Disease Control and Prevention have addressed and are addressing the use of bacteria and viruses as biologic weapons. And they are doing so professionally and competently. Pathologists and others within the CDC and the U.S. Army Medical Research Institute of Infectious Diseases in Fort Detrick, Md., have studied for years the effects of biologic weapons, their modes of dissemination, and their destructiveness. With foresight, the CDC a year and a half ago published its plan for national preparedness , titled "Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response."
Although these initiatives focus on the health of the population overall, we should not forget that all health care is local. When the next person struck by biologic terrorism walks into the hospital emergency room or the physician’s office, it is the hospital pathologist who may be among the first to respond to a yet unconfirmed clinical case. Pathology, in this context, is truly the sentinel specialty. We must be aware, therefore, of the presenting clinical symptomatology of the more likely agents, biologic or chemical. We must also be prepared to advise on the appropriate care of the patient, as well as the appropriate handling of specimens from the patient. We must do this not only for quality patient care, but also for the safety and security of those who work with us.
According to Dr. Robb, the unwelcome byproduct of having a clinical anthrax case in his institution was the high level of anxiety about the patient’s ability to infect clinical caregivers and the microbiology staff. The pathologist, by understanding the nature of this disease, can do much to calm the anxieties of laboratory and clinical personnel. The pathologist’s primary responsibility is to explain the cultural characteristics of Bacillus anthracis and the nature of the anthrax disease, clarify the low level of risk to the staff, and stop rumors.
The College, for its part, is working hand in hand with our government and other professional organizations to provide the needed information to our colleagues, hospital workers, and the community.
The CAP responded in early October to the CDC’s request to contact pathologists and laboratory personnel about procedures and resources to be employed in suspected clinical cases of anthrax. College staff and members worked with the CDC to craft the language of the communication. We distributed the alert by e-mail and fax within hours of the CDC’s request so that medical laboratories would be familiar with the CDC Laboratory Response Network and have systems in place to perform the needed services, while at the same time protect personnel from potential infection.
The College continues to partner with the CDC on laboratory preparedness. We have posted on our Web site a special issue of "Statline" with links to some of the most helpful Internet sites. We cosponsored in November an important CDC Web broadcast on lab responses to bioterrorism, and in December we and other organizations held an audioconference on what labs need to know about chemical and bioterrorism. A special section on bioterrorism has been created on our Web site. We are initiating contacts on biologic warfare issues with the American Society for Microbiology and American Public Health Association so we can speak with a united voice on these health issues. Both of these organizations are working with the CDC to revise testing protocols for biologic agents that a microbiology level A lab potentially could receive. The protocols offer standardized methods to rule out or identify the critical agents or, alternatively, refer specimens for confirmation to level B and C public health labs. The College will help disseminate the revised protocols quickly once they are approved.
Of note also is the CDC’s development of a national Electronic Disease Surveillance System, which will provide real-time electronic reports from the field. The CDC now offers prepaid SNOMED RT licenses to laboratories that will use SNOMED codes to report infectious diseases electronically.
On the legislative front, the CAP Council on Government and Professional Affairs has endorsed efforts to secure funding for the Public Health and Emergencies Act, which became law in November 2000. The act would provide for laboratory training programs and would create a working group on the public health and medical consequences of bioterrorism. The council also supports the Biological and Chemical Weapons Preparedness Act of 2001, which would boost funds for hospitals, laboratories, clinics, and information networks responsible for public health services in the event of a bioterrorism attack. Bills in the House and Senate would earmark $1.65 million for such programs. A nationwide laboratory response system and education and training of health care workers, including laboratory personnel, are among the objectives.
The College has a special challenge: We must ensure that our services as an organization are never interrupted. CAP secretary-treasurer Jared N. Schwartz, MD, PhD, is chairing a new committee charged with evaluating the CAP’s preparedness for national emergencies and our ability to help our members respond. To that end we have implemented a disaster-recovery program for our information databases that would rely entirely on off-site computers. Our committees are engaged in an assortment of initiatives—exploring, for example, issues related to the irradiation of mail, new proficiency testing in chemistry and microbiology, and the creation of a how-to guide for laboratory bioterrorism response plans.
At the ASCP/CAP Annual Meeting in Philadelphia, I attended an excellent program on bioterrorism, which had been substituted for the previously scheduled Government Affairs Seminar. Judith F. English, president of the Association for Professionals in Infection Control and Epidemiology, was among the speakers. She reminded us that "the counterattack begins at home." Well said, I thought. I can assure you that the College has done its homework. It continues to support our work in our practice environments so that we can effectively discharge our mandate to serve patients and the common good.