The U.S. Centers for Disease Control and Prevention (CDC) tracks viruses that could become pandemics while the Department of Health and Human Services takes the lead on vaccines. But pandemics don’t only have the potential to make people sick. If they’re bad enough, pandemics could compromise the nation’s security, which is what the U.S. Department of Homeland Security’s (DHS) Office of Health Affairs aims to prevent.
As the former DHS chief medical officer/assistant secretary for health affairs, Alex Garza, M.D., M.P.H., led a team that monitored these emerging health threats and analyzed what a severe pandemic might mean to national security, such as preventing workers at power plants or telecommunications sites, or even police and EMS responders, from showing up to work. “We looked at where our vulnerabilities are and what measures we should take to protect the population,” Garza says, whose team also analyzed other potentially destabilizing scenarios, such as a terrorist strike involving chemical, radiological, biological or nuclear weapons.
After graduating from the University of Missouri, Kansas City, Garza worked as an EMT and later a paramedic for the Metropolitan Ambulance Services Trust in Kansas City before going to medical school at the University of Missouri, Columbia. While an emergency medicine resident in 1997, he joined the U.S. Army Reserves and served as a battalion surgeon and public health team chief. He deployed to Iraq in 2003 and was awarded the Bronze Star and a Combat Action Badge.
From 1999 through 2006, Garza was associate medical director and then medical director for EMS in Kansas City. He spent a year in New Mexico as the state director of EMS before becoming director of military programs at the ER One Institute at the Washington Hospital Center in Washington, D.C. In April 2009, President Obama appointed Garza to the assistant secretary position. During his four years in Washington, Garza was an adviser to former DHS Secretary Janet Napolitano.
Ready to return to his native St. Louis with his wife and three sons, Garza left D.C. in April to become associate dean for public health practice and an associate professor of epidemiology at the St. Louis University College of Public Health and Social Justice. He is also medical director and homeland security adviser for FirstWatch, which provides near real-time monitoring of CAD and EMS data for a range of purposes, including bio-surveillance and operational and clinical quality improvement.
Garza spoke with Best Practices about his years in the federal government and the important role that CAD and EMS data can play in monitoring threats to U.S. health and safety and improving overall patient care.
DHS has 240,000 employees and is the third largest federal department in the U.S. government. Upward of 70% of our workforce is involved in operational tasks, such as guarding the borders, patrolling the coastline and doing drug interdictions, so there are a lot of health issues involving the workforce that come up.
We also have 3,500 EMTs and paramedics who work within DHS. We don’t do transport EMS services and we’re not providing EMS to a city or a community, but we do have medics as part of a lot of our teams. Customs and Border Protection has EMTs to assist with health issues that come up when you are tracking down people crossing the border in the middle of the desert. We have specialized medics who do search and rescue missions. The Coast Guard has corpsmen. There are tactical medics who work with the Secret Service. So the internal things can be making sure we have policies and procedures in place that protect our workforce, to simple things like making sure licensing is up to date.
There’s also an external role for a chief medical officer. When it comes to protecting the health of the American public, some of that is done by Health and Human Services, specifically the assistant secretary for preparedness and response, who is in charge of the national disaster medical system, while the CDC does disease tracking. At DHS, we’re not so much focused on the delivery of healthcare; what we’re really focused on is how a health issue can affect the security of the United States. A pandemic, for instance, could have a socio-economic impact that could destabilize the government. So we look at what measures we should take to protect the population.
One of our programs is BioWatch, an environmental sensing system for biological organisms. We sample the air in multiple cities around the country, take samples back to the lab and run tests to make sure there is nothing in the environment that shouldn’t be there. A biological attack would likely be a covert attack; the only way you can figure out what happened is through environmental sensing or when people show up in the hospital sick. We think it’s better to find out before people start getting really sick.
It’s difficult to predict, as we’ve never seen a virus like that. In 1918, the so-called Spanish flu was as close as we’ve gotten. Is it possible? I don’t think it’s out of the question, but the risk of it happening is not huge because viruses usually don’t mutate to become that transmissible or lethal. But virologists will say it is possible.
But even a less lethal virus could have a significant impact. Influenza circulates around the world and is constantly changing. It can spread rapidly and become a pandemic if you get the right genetic re-assortment. The two big ones we’re keeping an eye on now are the Middle East Respiratory Syndrome (MERS) coronavirus and the avian influenzas coming out of southeast Asia. The most recent one is H7N9, an avian influenza with a high mortality rate that was circulating around China earlier this year. They culled their dog and wild bird population to cut off the chain of transmission. Some of the preventive measures we take is making sure nobody is importing birds from southeast Asia. There’s a smuggling operation that Customs and Border Protection tries to stop.
Has there ever been a pandemic that has risen to the level of threatening security?
The short answer is no. A lot of what we worked on at DHS are what if? scenarios. We think about what would occur if a terrorist organization had the capability of developing various conventional, chemical, biological or radiological weapons. Then we develop a risk profile for the United States, and we develop plans and policies to protect the American people and mitigate the risk.
The closest we’ve come is the 1918 pandemic, which started in Kansas, spread rapidly and was very lethal. We certainly have better medical care now, so how that would correlate to what would happen today isn’t certain. But certainly it would have an effect on society.
You would see a lot of the same things we saw with H1N1 but to another degree. There were some folks advocating closing schools, canceling public events, quarantining folks who were exposed, limiting travel to unexposed areas, all things that happened in 1918.
It’s concerning. At least from what we understand, MERS has a substantial mortality rate. All of those things put together make it something you should have on your radar screen.
While there are case reports of it transmitting from person to person, on the plus side, it seems like you have to have significant exposure to catch it. There hasn’t yet been sustained person to person transmission. But viruses are notorious for genetic rearrangement, so we have to keep an eye on it. For EMS and 911 centers, what that translates to is making sure we are keeping good track of our data and being aware if you see an uptick in respiratory illnesses or an illness that is not easily explained. EMS providers also need to be aware of what is going on globally. We live in a global culture; if your patient has a respiratory illness and has been to the Hajj in Mecca, you might want to put a mask on.
A virus that has high transmissibility and high lethality can destabilize the security of the country, which is why the Department of Defense has their own vaccine stockpile so they don’t have to compete with everybody else for a vaccine.
Other than being aware of global health issues, what can an EMS agency do to be prepared?
By using FirstWatch to monitor CAD data, you can look for complaints in the community and compare them against a historical average. It’s similar to what traditional epidemiologists do when they look for flu-like illness in emergency departments and clinics. But when the CDC puts out its data, it’s usually lab confirmed and it’s two weeks later.
With CAD data, you can look for people who call 911 with respiratory complaints analogous to the flu and plot that against historical data. It could serve as an early marker of flu in the community.
You’re an advocate for the importance of data collection in EMS, particularly transforming data into actionable information. Why is this particularly important now?
It’s important for a few reasons. The Affordable Care Act is changing the landscape of healthcare, including expecting providers to show they are improving quality and spending less. The only way you can demonstrate quality is through data. In the analysis of data, there’s a saying: Garbage in, garbage out. If you give me bad data, you’ll get bad analysis and it will lead to bad decisions. So it all leads back to the quality of data. If you can capture quality data in a timely manner and analyze it to see where your challenges are or to show people you are doing a good job, you can either fix your issues or show why you should be paid more.
EMS is at a point where it can decide if it wants to be a grownup or stay a teenager. When I was a medic, EMS was, Hey, we like running lights and sirens. Doing exciting things, taking care of critical patients—that’s great. We still need that. But in order for EMS to really move into this new healthcare paradigm, you have to do more than that. You have to provide quality of care, show the medical community you are serious when you talk about taking care of patients, and show you can do a good job. EMS as a profession really needs to embrace the idea of being able to document that it can provide quality care.
Why is it so challenging for agencies to make meaning of their data?
Part of it is the immaturity of the industry. For a long time, EMS was not held to the same standard as the rest of the medical community for the amount and quality of data they were expected to collect. But if EMS personnel want to be respected by the medical community, part of that is showing value. The other side of that is we don’t really want to fill out these ambulance care forms or be held to collecting reliable data. You can’t have it both ways. If you want to be respected, you have to show you’re doing a good job.
EMS agencies are starting to realize this and are taking data collection more seriously. EMS has been somewhat forward-thinking in this with the development of NEMSIS.
Another factor is the rest of the medical community hasn’t told EMS what it thinks is important. In certain parts of the medical world, you have measurable metrics. For hospitals to get reimbursed by Medicare for STEMI patients, they need to show that patients who come to the ER get aspirin and ECGs, and door to balloon time is measured. EMS can also give aspirin and do ECGs, but they’re not being measured. We measure door to balloon time, but the time we should be concerned about is the time from injury to the time the artery gets opened. EMS plays a part in that.
FirstPass is a new offering from FirstWatch that’s getting buzz from the EMS medical director community. Why is that?
What FirstPass offers is the ability to review clinical work done by EMS providers in a timely and efficient manner. When I was a medical director, we did most things by hand. The quality improvement manager’s job was to pull reports for whatever the medical director wanted to look at and present it. But those statistics were usually at least a month old.
The benefits of FirstPass are that it pulls the data electronically, soon after it’s been submitted, and puts it through an algorithm to see that the proper steps were taken. What was a very time-consuming and cumbersome process is streamlined and done almost automatically. A medical director can see what’s going on in near real-time and make adjustments as needed and present that information to supervisors and providers while it’s fresh in their minds. For example, with a STEMI patient, you might look to see if the patient got an ECG and how quickly, or aspirin, or how long it took on scene and to transport to the hospital.
What are the challenges in monitoring every call?
The challenges are that there are nuances in every call. For example, with the STEMI patient, if somebody didn’t give aspirin because the patient had already taken aspirin, then it gets kicked out that the responders didn’t fulfill that requirement even though there’s a good reason for it.
Other clinical conditions don’t easily fit into an algorithm, such as cardiac arrest. In the midst of resuscitation of a cardiac arrest, there are so many different things going on that make it tough to interrogate the record to any degree of specificity. Cardiac arrest will always take a person to look through that record, which is important to do because it’s a high consequence call.
For low acuity calls, there isn’t as much impact and not as much payoff in monitoring it. If somebody calls 911 for a sprained ankle, other than an analysis of pain reduction and vital signs, there isn’t a whole lot else there. You want to choose interventions to monitor that have impact, and you want your quality improvement folks to focus on those things. Those things include cardiac arrest, STEMI, stroke, trauma, pain reduction, diabetes/hypoglycemia, seizures, narcotic overdose, and you could argue for respiratory issues, such as asthma or COPD. For asthma or COPD, you could measure peak expiratory flow rate and show that the patient had improved by the time they got to the ED. For these types of calls, you want to focus on gathering good data and documenting that you had an improvement in patient condition, or at least that you met the standard of care.
What surprised you about your experience in Washington?
One was the amount of information you need to consume daily in order to be effective. When you’re a clinician, you take care of patients and dabble in some administrative stuff. But in a political appointee position, you have to be invested in a lot of procedural things in the government, such as the budget process.
You also have to think about how you message what you’re doing in your office to multiple audiences—to the DHS (your boss), the White House, the congressional staff, the Office of Management and Budget. Each is a different customer, and with the OMB in particular you have to make sure you can explain why your office is a good investment.
Any President Obama stories to relate?
I’ve only met with the president a couple of times. There is a notion that if you’re appointed by him you go golfing with him, but that doesn’t happen.
The only story that jumps out in my mind is when I was in my office two months, I was summoned by the DHS chief of staff to go to the White House to be there with Secretary Napolitano to brief the president in the situation room on how H1N1 preparations were going. I was waiting to go in, and out of the corner of my eye I saw this tall figure walk down the hall. It was so uneventful I didn’t realize it was the president. I shouldn’t have been shocked—it was his house. The president is just like you see him in interviews: very calm, cool, collected. He asked pointed questions, very deliberatively.
