March 1, 2007 - NPR Morning Edition host Steve Inskeep has recently made statements in on-air interviews with disaster health experts that assume only physicians matter, presumably because they provide all important health care. On February 22, Morning Edition ran an interview with a former U.S. Coast Guard officer who argued that the nation was not well prepared to provide health care in the event of a disaster. When this expert said that a community had to ask whether it could handle hundreds of thousands of casualties, "all requiring triage and other kinds of life and death care," Inskeep (below) asked if that meant asking whether such a place had "hundreds of vacant beds ... hundreds of idle doctors?" Today, when the "chief of medical affairs" at a New Orleans hospital noted that a lack of "health care providers" was hampering efforts to restore area hospitals to full capacity, Inskeep wondered whether even hospitals like his that had remained open "don't have enough doctors available." In both stories, the experts sooner or later worked nurses into the conversation. In fact, while physician care is of course very important, most of the critical care in such emergencies (such as skilled triage) is provided by nurses. And it is the severe shortage of nurses that would likely present the most urgent health care human resources problem during a mass casualty event.
The February 22 Morning Edition piece is headlined "Disaster Would Overwhelm Hospitals, Expert Warns." Inskeep interviews former Coast Guard commander Stephen Flynn. Flynn has reportedly warned in a recent book that the U.S. health system is "unprepared to handle a catastrophic emergency such as a flu pandemic or a major terrorist attack," at least in part because the health system has been too focused on cost-cutting. In discussing the capacity of a given area to handle a surge in patients, Flynn and Inskeep have the following exchange:
Flynn: Is this the kind of place that could handle potentially hundreds of thousands of casualties--all requiring triage and other kinds of life and death care.
Inskeep: When you say does it have that capacity, are you asking, does it have hundreds of vacant beds, does it have hundreds of idle doctors?
Flynn: Everything from, is there enough real estate to get people in, is there a place to put folks, [to] are there doctors that are available? And almost certainly the answer to all those is no, not enough.
Flynn seems to buy into Inskeep's physicians-provide-all-key-bedside-care vision here. But Flynn does at least work nurses in later, after Inskeep returns to the theme:
Inskeep: If you did a cost benefit analysis of this, you would want in any given city, any city in America that can be struck with some kind of disaster, you'd want extra hospital capacity, extra supplies, extra doctors. When you do the brutal analysis, is it going to be found to be worth it?
As part of a lengthy answer that touches on citizen emergency response training and how efficiency-focused cost-cutting hampers surge capacity, Flynn notes that one important preparedness measure would be to reach out to retired "nurses and doctors." This is at least a mild contradiction of the idea that health care consists of physicians and inanimate objects.
Today, Morning Edition ran an interview with Kevin Jordan, "chief of medical affairs" for Truro Infirmary Hospital, as part of a piece the NPR site headlines "Katrina Survivors Contemplate Care in Today's New Orleans." The theme is that care has not really improved since the hurricane struck in 2005. When Jordan notes that the city still has only about 1,500 of its prior 5,000 hospital beds available, Inskeep asks what the problem is, besides water damage. Jordan explains that people are needed to provide care, and that community infrastructure is needed to draw "health care providers" back to the area.
Inskeep: Is that affecting even Truro, which has stayed open all this time, you don't have enough doctors available?
Jordan: Well it's not a question of the doctors. It's about the nurses. The nurse's aides. It's about the lab techs. Those folks that provide the skilled technical labor. That's what we need. Is it affecting Truro? You bet. Our labor costs are up 2 1/2 times to 3 times what they were prior to the storm.
Of course, nurses are autonomous, college-educated professionals, and some might not get that from the phrase "skilled technical labor." But on the whole this is an excellent response to Inskeep's apparent assumption that only physicians matter in disaster response. It is not entirely clear if Jordan is suggesting that his hospital is short of physicians but that is not causing most of the problems, or that the hospital basically has enough physicians. If it is the latter, it might have been useful to explore why a greater proportion of physicians have returned.
In fact, because nurses provide life-saving 24/7 care, from emergency triage to skilled monitoring to a range of high-tech interventions, nurses would be central to the care of any mass casualty event patients who made it as far as a hospital. Critical patients require constant, advanced nursing care, which physicians generally have neither the skills nor the time to provide. Of course, much of the globe does not have nearly enough nurses to provide the care needed now, and one key reason is the very cost-cutting to which Flynn alludes. So in the event of a mass casualty event, the lack of skilled nurses would be a huge problem.
About a year ago, the Center analyzed an NPR story by Richard Knox about the insufficient number of ventilators that would be available in the event of a bird flu epidemic. That report gave the sense that care for affected patients revolved mainly around whether physicians granted access to vents. But nurses and respiratory technicians play far more active roles in the care of ventilated patients, and it would be their care that would mean the difference between life and death for many patients, as even last year's ABC television movie "Fatal Contact" appeared to recognize. And the time-consuming nursing care that keeps such critically ill patients alive involves much more than ventilators. The 2006 piece did not inquire where we might get the 1.5 million additional ICU nurses (in the US) that it could take to care for such ventilated patients. Sadly, it might not be a wise use of scarce ICU nurses' time to provide ventilator-related care to any flu patients, rather than life-saving care to many other patients with a better chance of survival. Of course, getting that perspective would require an understanding that health care involves more than physicians and inanimate objects--an understanding that Steve Inskeep's recent comments do not reflect.
In light of what Mr. Inskeep might call our "brutal analysis" of his comments, we urge Mr. Inskeep and the NPR editors and producers to devote a future piece to exploring how the shortage of nurses will affect the response to mass casualty events.
Please send a letter to Steve Inskeep on NPR's contact page (click on "NPR Program" and then select "Morning Edition") and send us copy at email@example.com. If you have a hard time with the contact page, let us know and we will send the letter for you. Thank you!