Pre-emergency planning is a requirement for every organization. The Occupational Safety and Health Administration (OSHA) and the U.S Environmental Protection Agency (EPA) have several regulations that require the development of plans to address foreseeable emergencies in their workplaces, such as chemical releases, fires, weather-related emergencies and workplace violence. Health and safety professionals are often tasked with completing these requirements; however, few pre-plans include information on managing the “worried well.”
Worried well is defined as “people who do not need medical treatment, but who visit the doctor to be reassured.” (Worried Well, 2016.) Similar to the general industry, hospitals also conduct pre-emergency planning to reduce the potential for injury and illness to emergency room staff and patients that might be exposed to a contaminated victim.
Managing Potential Chemical Exposures in a Hospital Environment
The premier event that highlighted the need for better protocols to manage potential chemical exposures in hospitals occurred on Feb. 19, 1994. During this event, a woman was transported to the ER at Riverside General Hospital in California. Upon evaluation of the patient, several of the staff noted a fruity, garlic-like odor coming from the patient’s mouth and an oily sheen covering the patients’ body. ER staff who had close contact with her quickly began to experience symptoms of nausea or fainted. Due to the rapid onset of symptoms and concern about a potential toxic exposure from the patient, an evacuation of the ER was ordered. In total, 23 people were affected and five ER staff were hospitalized. (Stone, 1995.)
Following this event, hospitals across the country developed standard operating procedures to include protocols for managing patients with a claim or concern of exposure to a chemical or biological agent or radiation. The procedures require staff to immediately isolate the patient and store their clothing and personal belongings in a hazardous materials bag. The patient then undergoes a full decontamination by trained health care workers dressed in chemical protective clothing before they are allowed to enter the ER for medical evaluation.
The Effects of Psychological Stress on Worried Well Patients
When humans experience psychological stress, such as anxiety, the human body releases adrenaline, cortisol and norepinephrine stress hormones into the bloodstream. (Kline, 2013.) This is often referred to as the “flight-or-fight response” and it is characterized by rapid heart-rate, increased energy, and increase oxygenation and blood flow away from the body’score.
This natural response is beneficial when we are faced with a life threatening situation; however, it has a negative effect on our mental and physical state when no danger exists. Subsequently, we experience symptoms such as dizziness, dry mouth, feeling faint, abdominal pain, headache, nausea, shortness of breath, tremors, and finally weakness/fatigue. (Kline, 2013.) The physiological effects of fear and mental stress on a person who has no actual potential exposure to any chemical can mimic the general symptoms of an actual exposure.
The Importance of Real-Time Communication with Health Care Providers
In some cases, the worried well may overwhelm response efforts. Several years ago, a transportation accident involved a chemical release and subsequent fire near a community. Based on the recommendations found in the Department of Transportation Emergency Response Guide, the on-scene incident commander called for the evacuation of a two-mile radius, displacing about 2,000 residents. Over the next several days, more than 100 people from the local community went to the ER complaining of various symptoms, including headache, eye/nose/throat irritation, difficulty breathing, and nausea.
The local hospital had a well-established emergency plan that included procedures for managing mass casualties from chemical exposures. Following the notification of the transportation incident, the hospital promptly activated their emergency operations center. Staff set-up their decontamination unit and were ready to receive patients. Of the more than 100 people who went through the process, only four were held for observation at the hospital overnight; the remainder were released within a few hours.
During this incident, the transportation company provided members of the local emergency management agency and on-scene incident command with continuous updates on the results of real-time air-sampling conducted within the spill area, and throughout the evacuation zone. Additionally, the local emergency management agency conducted daily press briefings and utilized the city and county websites and social media accounts to provide status updates for community members. Throughout the incident, local weather conditions were stable and visual observations of the smoke plume from the fire showed no ground level down-wind impact for more than a mile. Also, sample results demonstrated that there were no detectable levels of the compounds of interest within the community.
While this information was readily available to the local emergency management agency, it was not received at the hospital in a timely way. During an “after-action critique” with the hospital, it was determined that the best way to get information to the correct hospital staff was to contact the house supervisor or the hospital incident commander directly. When a hospital implements its emergency action plan, the hospital incident commander becomes the best point of contact for the company officials or local emergency management agency. Due to the high volume of calls coming into the hospital, it was requested that instead of a call from the company official with information on the incident, a face-to-face visit to brief the house supervisor and/or hospital incident commander would be more effective.
A follow-up review of the worried well patients that reported to the ER was performed to determine their geographical proximity to the incident. Based on the patients’ physical location to the incident, it was determined that most of them had no potential for exposure. These patients were experiencing anxiety symptoms based on the information broadcasted by local TV and radio stations, as well as social media channels. Their anxiety was likely compounded by the decontamination process at the ER, which was implemented without any consideration for actual potential exposure. If the ER staff had had real-time information about the chemical, plume direction, and airborne concentration levels, they would have been able to provide more appropriate supportive care for the patients’ anxiety.
In conclusion, health and safety professionals conducting pre-emergency planning should include criteria for communicating with health care providers to manage the worried well. Local citizens will become anxious about what they are hearing from TV, radio and social media. The worried well should be accounted for during emergency planning and response activities as they may create a burden on the ER resources.
Health and safety professionals should consider adding the following as part of their emergency plans:
- Include clear lines of communication between the local emergency management agency and all other responsible parties involved in the incident.
o Include hospital representation in the unified command.
o Establish lines of communication between the unified command and hospital incident command.
- Company officials and their consulting subject-matter experts should reach out to the hospital incident command early in an incident and provide critical information regarding the chemical released, weather information and air-monitoring data.
- The hospital should geographically triage patients to determine if they had the potential for an actual exposure to the chemical, biological or radiological agent involved in the incident.
- The hospital should amend requirements for decontamination of patients based on the actual potential exposure risk (e.g., temporal relationship between the patient and the incident site).
- The hospital should include provisions to move patients exhibiting symptoms of anxiety with no potential exposure, away from the decontaminated and treatment corridors. These patients still require medical evaluation and possibly treatment, but they might be triaged to a lower category to avoid affecting the immediate medical response.
Bullock, W.H., Smith R.E., and Heligman, C. (2018) Managing the “Worried Well” during a large-scale incident. Journal of Emergency Management, Vol. 16, No. 1.
Kline, S. (2013). Adrenaline, Cortisol, Norepinephrine: The Three Major Stress Hormones, Explained. The Huffington Post. Retrieved August 20, 2016 from http://www.huffingtonpost.com/2013/04/19/adrenaline-cortisol-stress-hormones_n_3112800.html
Stone, R., (1995, April). Analysis of a Toxic Death. Discover Magazine. Retrieved August 20, 2016 from http://discovermagazine.com/1995/apr/analysisofatoxic493
Worried well. (n.d.). Collins English Dictionary - Complete & Unabridged 10th Edition. Retrieved August 20, 2016 from Dictionary.com website http://www.dictionary.com/browse/worried-well