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Douglas P. Zipes, MD, FACC, Indiana University School of Medicine, Krannert Institute of Cardiology, 1111 W. 10th Street, Indianapolis, Indiana 46202, USA.
In the days immediately after the September 11 attacks on the U.S., we witnessed the ability of a country, its citizens, and its friends to pitch in during the most difficult of times. We all continue to be moved by acts of extraordinary heroism in New York City and Washington, D.C., and now in Afghanistan, where soldiers are risking their lives to defend our freedoms. There have been other contributions, too. Some have been celebrated, such as unprecedented cooperation among policymakers and donations of blood and funds. Others have received less attention—for example, private offerings of support and assistance, including quiet donations made by individual American College of Cardiology (ACC) members to the College for relief efforts, and physicians who consoled their frightened patients both during the attacks and later, when fears about anthrax were rampant.
On September 11, no one suspected that they would be called upon, either by duty or conscience, to help alleviate the effects of such overwhelming tragedy. Since then, many people have taken on roles and responsibilities quite different from their expectations for themselves. We all will be doing more of that in the future.
What roles should physicians play?
Consider the following:
The sun was setting on a midwestern city, and the physicians working in a large multispecialty practice had seen their last regularly scheduled patient for the week. As they prepared to close up shop, two cardiologists compared notes on the preceding days over coffee. One mentioned that he had seen two of his regular patients with an interesting, and similar, constellation of symptoms. Both patients had a history of coronary disease and had come in complaining of chest discomfort that sounded more pleuritic than anginal. They also had symptoms reminiscent of both a cold and pneumonia, which included sudden onset of fever, fatigue, a nagging headache, malaise, body aches, and sore throat. The second cardiologist noted that she had seen a similar case. As they speculated, one of their internist colleagues passed by. Overhearing their exchange, she cited two patients she had seen earlier that week who appeared to have pleuritis. The three discussed the possibility that the same infectious agent could be at the root of all the cases. One of the cardiologists suggested that they log on to the ACC Web site and, in doing so, he found the College’s biological threat clearinghouse. Concerned about bioterrorism, he hypothesized that tularemia could be the cause and contacted the public health office. The public health officials conducted an immediate investigation, confirmed the diagnosis, and traced the source to one of the community’s water reservoirs, which had been contaminated byFrancisella tularensis.
Sound crazy? Of course it does. This scenario is completely fictional.To my knowledge, no such chain of events has occurred. Rather, I offer this story to illustrate that, just as the world has changed dramatically and forever since September 11, so have our roles as physicians been unalterably affected. As case in point, I never imagined in my wildest dreams that I would write an article that included references to tularemia!
When a tragedy happens, there are certain roles we physicians expect to play. We know that we will offer up our skills and expertise as clinicians to deliver care. We will treat victims in emergency rooms, operating rooms, the ICU, and perhaps for months to come in our offices as the patients recover. Depending on our individual skill sets and specialties, some physicians might be called directly to the site, where they will triage patients and deliver on-the-spot trauma care. Others will deal with infections, burns, psychological support, and so forth. And we will all talk to the families and friends of the injured and killed, offering reassurance and condolence.
In the future, we will probably be called upon to play some new roles, or perhaps there will be new twists on roles we already know. As suggested by the hypothetical scenario above, we must cultivate a new level of awareness so that we will suspect unusual causes for the symptoms and conditions we see in our patients. In the case of tularemia, the diagnosis is often made on the basis of a cold, atypical pneumonia, pleuritis, or hilar lymphadenopathy (1). The challenge is to discard the obvious answer and consider what could be. In this case, to be effective, one needs basic familiarity with the various agents that could be used as biological weapons of terrorism. I urge you to visit http://www.acc.org, where the College has created an information clearinghouse on biological threats. The site contains links to an array of information, from general descriptions of biological agents to details about how physicians can safeguard their staff and stem the spread of a contaminant.
In addition, we must be prepared to be resources for our patients. We must expect that our patients will turn to us for information and reassurance if something happens or even if there is speculation that something might happen. When the anthrax attacks occurred last fall, patients contacted their physicians for information about risk, symptoms, treatment options such as Cipro, and our opinions about what they should do to protect themselves and their families.
We might also find ourselves in situations that call for creativity and resourcefulness. As community leaders, which physicians so often are, we may need to participate in efforts to stimulate support for relief efforts. We can encourage our staff and our patients to donate blood or to contribute to charities that are coordinating such efforts. And, of course, we should model such behaviors ourselves. Likewise, many of us belong to civic organizations, and we can participate by rallying our fellow members around efforts to spread information about safety or opportunities to help.
What roles should the ACC play?
Just as individual cardiologists can make important contributions to the world’s efforts to deal with terrorist threats, so can the ACC participate. Both on September 11 and in the weeks that followed, the College was as proactive as possible. Some of our members were attending a Board Review course in Chicago on September 11. The program’s faculty and ACC staff mobilized their resources on behalf of attendees, helping them to contact family and friends, making arrangements for extending their stay in Chicago, or helping them arrange for rental cars for trips home on the roads instead of in the air. Back at Heart House, we made an effort to keep up our meeting schedule by phone instead of in person. I delivered a live ACC lecture to the Japanese College of Cardiology meeting in Hiroshima using a video link, for example.
Equally important, the College anticipated what members might need in the near future, and work began on the information clearinghouse on biological threats. This is an ongoing project, of course, and the clearinghouse will grow as more is learned about various agents. For as long as members need this resource, the ACC will maintain it. As the opening example illustrates, education is the College’s best offering in times of crisis. It has been our mission for a half-century and will continue to be our raison d’être.
Of course, the College can and will help in other ways, too. We represent an extensive network of physicians, connected symbolically by the “FACC” after our names, and literally through our chapters and our database. In the future, if needed, the College could use these resources to send you crucial information about your patients’ safety and care.
Finally, the ACC is a citizen of the world. For years, we have contributed to the efforts of the physician community and to efforts to improve quality of life. This past fall, we realized our contributions were needed more than ever. In early December, during the 34th Annual New York Cardiovascular Symposium, nearly a thousand cardiologists traveled to New York City for an educational program in a city that is working to rebuild. Our patronage alone was a contribution to that effort, but the College went further. We donated a total of $100,000 to two organizations in New York. The first $50,000 will be used to create the ACC Scholarship Fund, which will provide medical school scholarships to dependents of the victims of September 11. The second $50,000 donation was to the New York Community Trust, which will support physician education and training in bioterrorism preparedness. The College also helped to facilitate a gift of another $100,000 from our German counterparts, the German Society of Cardiology. This gift will be used to replace one of the emergency vehicles destroyed during the attacks on the World Trade Center. New York City Mayor Rudolph Giuliani was there to help receive these contributions on behalf of his city, as was Alex Loutsky, the first ambulance driver on the scene at the World Trade Center after the first plane struck.
Clearly, there is a great deal that we can do as individuals and as an organization of caring cardiovascular specialists. On a day-to-day basis, the thing to do, however, is to fulfill the requests of President Bush of the U.S. He has asked that we stay alert, being watchful and vigilant for the unusual or the suspicious. As physicians, who see and hear about our patients’ symptoms daily, we are in a unique position to do that. In addition, the President has asked us to continue going about the business of our lives. It is important that we maintain our routines and activities; if we don’t, the terrorists will have scored a kind of victory, and we cannot allow that. For the College, that means continuing to further our mission of helping you to provide optimal cardiac care and disease prevention for your patients. I can assure you that we are 100% committed to that end. A shining example of that fact is that the College’s 51st Annual Scientific Session (ACC ’02) will go on as planned in Atlanta, from March 17 to 20. We are, of course, taking precautions to provide a safe and secure environment for all attendees. Enhanced security measures will be in place throughout the meeting. I hope to see you there.
- American College of Cardiology