Question

In what ways were the challenges applicable to the SARS event similar to and/or different from those created in the aftermath of Hurricane Katrina?

Answer 1

SARS (severe acute respiratory syndrome) exploded on the face of the global village and on health care like a dormant volcano erupting in the dead of night. Members of the health care system and the public were caught off guard. Patients, doctors and nurses in hospital intensive care units (ICUs) arguably bore the brunt of the SARS epidemic more acutely and painfully than most other groups, especially in geographic hotspots' such as Toronto.

There are many ethical issues raised by the SARS epidemic, including global cooperation and information sharing, isolation of patients and their families, quarantining of patients and health care workers, lack of patient access to medical care, loss of privacy, stigmatization of individuals or populations, and appropriate priority setting and use of limited resources.

Much has already been published describing the epidemiology of the illness, its clinical symptoms and its treatment. There has also been some discussion of the nonmedical effects of SARS and potentially future similar outbreaks on the relationships between health care providers and patients and families, their notions of professional integrity, and issues of resource allocation. Such ethical and psychologic issues – the collateral damage' of the outbreak – cannot be ignored because they challenge some deeply held convictions and ethical conceptions in ways that they have never been questioned previously and, as a result, may be altered for ever.

Trust, truth-telling and relationships with colleagues

During the SARS outbreak, frontline health care providers found themselves in the midst of conflicting and confusing reports of the nature, seriousness, infectiousness and precautions needed. Although droplet transmission was repeatedly said to be the main mode of transmission, providers were ordered to take not only droplet but also fomite and airborne precautions as well, all the while being told that this was not an airborne virus. On the one hand, measures to increase personal safety were welcomed; on the other, the reassurances that did not always match infection control directives raised concerns about whose information, among infection control and public health colleagues, was most reliable. Health care workers suffered from lack of accurate information because the nuances of this strange new epidemic were not fully understood. Media reports further contributed to confusion and lack of trust by sensationalizing world events, with daily headlines reporting the number of suspected and probable cases, the number of dead and the number of health care providers succumbing to the illness.

Another challenge to our previously unconditional trust of our colleagues occurred when staff members found themselves watching others to ensure that infection control measures were strictly adhered to and confronting them when they were not. Although such vigilance is crucial to the success of infection control protocols, it engenders a lack of trust and challenges multidisciplinary professional relationships in an unprecedented manner.

Public health and infection control in the intensive care unit

Although infection control measures were welcomed and understood, they severely compromised quality of life and heightened the degree of complexity of work tasks that were previously fairly straightforward. The physical discomfort associated with containment precautions, such as wearing tight-fitting masks all day, two sets of gowns, goggles, double gloving and washing hands repeatedly in alcohol-based cleaners, tested workers' endurance and patience. At the beginning of each shift, they had to stand in lines outside the only open hospital door, filling out forms, having their temperature taken and washing their hands before onlooking volunteers or redeployed workers. Such restrictions and monitoring were unprecedented. On the positive side, new close relationships were forged between infection control and ICU teams, and it was a unique opportunity for us to work together, learn from each other and gain a deep respect for each other's knowledge and expertise.

Professional integrity and relationships with patients and families

SARS has forced us to confront our notions of professional integrity. Patients with SARS were cared for in negative pressure isolation rooms and staff were told to minimize entry as much as possible. In many units video cameras were used to monitor patients. In recent years ICU teams have focused on bringing the humanity back into our highly technological environment, and so having to decrease human contact and deploy more technology struck many of us as sadly ironic. Furthermore, the ICU team, trained to rush in to save someone's life and to respond quickly to any deterioration, found themselves being asked to put aside this ingrained sense of professional responsibility and to ensure that they took infection control precautions and were properly attired before rushing in. The resulting delays when every minute counts led many to question their professional integrity – how do you balance your own safety and your patient's needs?

Imagine the devastating psychological distress when you must deny patients access to the hospital for relatively urgent tests and/or treatments and deny families access to hospitalized patients; in other words, imagine the distress of health care workers who are functionally paralyzed from doing their job for patients. For professionals who pride themselves on caring, to deny access and to fail to be able to support patients and families during this time was devastating psychologically. It quickly became apparent that many patients who would have to be denied access might well die or be irreversibly compromised by delays in their care. Receiving referral calls about patients who required your centre's particular expertise, and either being unable to accept them because of a lack of beds or knowing the delay in transfer and/or treatment required to observe the necessary infection controls might result in worse outcomes was demoralizing.

Conclusion

The psychological distress to both consumers and deliverers of health care that result from a tragic outbreak such as SARS cannot be underestimated. Public health officials, hospital administrations and governments must do everything in their power to ameliorate the suffering of patients and health care workers. Perhaps the best defence for such a disaster is to have a contingency plan in place, to have well conceived and developed plans well known in advance and rehearsed, in order to limit the damage a natural disaster like SARS can unleash.

In order to protect patients, families, doctors, nurses and other health care professionals, public health systems and their component hospitals must have access to up-to-date scientific information, as well as conceptual, ethical and practical frameworks in place to minimize the damage and support all parties when an unforeseen and unexpected enemy such as SARS arises. These modern day plagues are unlikely to go away, and in fact SARS perhaps was a light dress rehearsal for the next anticipated massive outbreak of influenza, for which there is ongoing planning and intense surveillance.