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Leadership Outlook

After the Disaster — Denial, Cognitive Dissonance, and Preparing for Next Time

Davidson, Steven J. MD, MBA

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doi: 10.1097/01.EEM.0000292625.29053.bc

    I had planned to write about the experience of going live with our electronic medical record system. We switched it on at 7 a.m. Eastern time Sept. 11, and switched it off shortly after 10 a.m. and reverted to paper. Our small loss of time pales into insignificance next to the human tragedy and now wartime circumstances we find ourselves experiencing.

    How well did we do at Maimonides, 7.5 ground miles and a 12-minute drive from what we now call Ground Zero? Given the small number of injured, mostly rescuers, for whom we cared, it would have been difficult to have performed poorly. Yet, as I write this piece, newspapers and airwaves are full of alerts about anthrax and the count of those exposed to or sickened by the disease, which, while still in single digits, has grown daily. So too has the stress upon our ED staff. Two nights ago, I was paged at 3:45 a.m. to advise me that the ED had been contaminated.

    Perhaps the most important lesson I can offer from our experience of Sept. 11 is that activating the disaster plan doesn't truly activate your plan. Rather, the experience of caring for your first patient is the true activator. “Cognitive dissonance” is the term used by psychologists for describing the confusion and denial we experience when abruptly wrenched from business as usual to attack and disaster management. Having experienced cognitive dissonance on Sept. 11 and subsequently reflecting on that experience has caused me some personal discomfort as well as appreciation for our team.

    It took me 60 to 90 minutes to recognize that the disaster meant shutting down the electronic medical record system. Fortunately, it didn't take others as long. This wasn't merely because of my psychic investment in the project but more a delay in recognizing how much circumstances had changed. Because the attack occurred during prime work hours, our vice chairman and medical director, Dan Murphy, MD, who also chairs the disaster committee and was the lead author of our hospital disaster plan, was on-site and led our efforts. He knew that all non-essential activities — the very definition of a “go-live” — must stop. His experience at running drills and critiquing them gave him the assurance for necessary action. Practice made it easier — though still not easy — to change gears and move to disaster mode.

    Common Frame of Reference

    Our staff was and still is fearful, although less so as we train with personal protective equipment and review plans for responding to chemical, biological, and radiological events. Sharing copies of faxes received from the New York City Department of Health containing authoritative recommendations for surveillance, patient evaluation, and treatment may be helpful for some.

    Confidential conversations among staff members are reassuring for others. Strong support from senior management through regularly scheduled town hall-type meetings and visits to patient units, including the ED, also help. The passage of time also helps, but I'm convinced that establishing a common frame of reference through focused training supported by authoritative sources gives a better result both for the individual and the organization than simply allowing people time to heal.

    In the aftermath of the collapse of the World Trade Center towers, many individuals spoke about their desire to help — to do something. Capitalizing on this impulse by improving preparedness gives proof to the staff of their value to the organization as individuals and caregivers while simultaneously reassuring them about their personal safety and their capabilities as responders.

    Routine Disrupted

    I also learned patience on September 11. In the early hours, even when I was ready for action, delayed though that may have been, not everyone around me was as prepared. Other parts of the hospital were less willing to respond at first, many comparing the events of the day to the experience of responding to the 1993 World Trade Center bombing where very few patients arrived yet all routine was disrupted.

    Our chief operating officer asked me to join the senior management meeting she convened (our CEO was on vacation in Europe), and I spoke directly to the needs of the hospital's disaster plan. Initial reticence to changing gears was overcome through discussion as all came to a group realization of the extraordinary, human tragedy unfolding. To their credit, administrators listened, changed their minds, and acted appropriately and necessarily on behalf of the hospital and the community, doing so not precipitously, yet still in a timely way. My leaders and colleagues did the right thing.

    All of us now have been bloodied, our brains will shift gears more quickly the next time, and denial and cognitive dissonance will be less likely. A delay in incorporating the consequences of terrorism won't be a feature of a response this week. As the days pass, however, it is likely that the alertness we have developed since Sept. 11 will diminish. Next time we may not have the luxury of more than an hour before the first patient arrives yet activating our disaster plan must help us activate our brain and behavior more rapidly than occurred on Sept. 11.

    I think that what helped the staff in the ED gain the proper mindset was seeing Dan Murphy standing at the corner of the nurses' station with a sight line into the ambulance overhang and triage station with only the red binder — our disaster plan — open in front of him on the counter. All came to him; he did not roam.

    Locking down the ED also sent a message. We transferred ambulance patients onto our stretchers in the ambulance bay and did not permit EMS providers into the ED. Only our staff and police officers with badge and weapon were permitted into the ED. Hospital staff that did not have an ID badge coded for ED disaster status (a red border around their picture) were stopped by hospital security and turned away.

    Responding to disasters is what we do in emergency medicine. One patient or many, it's the career we've chosen, yet most of us are not trained for the battlefield itself. Acting effectively when cognitive dissonance and fear for our loved ones and for ourselves slows our response and requires new and additional preparation we are just undertaking, but undertake it we must.

    © 2001 Lippincott Williams & Wilkins, Inc.