1. Pandemic flu: the final frontier Dr Ratna Makker Consultant Anaesthetist and Clinical Tutor_ Hemel Hempstead General Hospital 10 th May 2007 St Albans Sports Club GP Connect meeting

2. First Anaesthetist : sometimes first and last stop! " And the Lord God caused a deep sleep to fall upon Adam, and he slept" Genesis 2.21

3. Ghoul

5. UK Influenza contingency Plan Menon et al (2005) Flusurge. 8 week epidemic and 25% attack rate. Impact of neuraminidase inhibitors. Upgraded all level 2 beds to level 3

6. Findings >35000 weekly admissions to hosp >5000 daily admissions Total mortality >36000 >200% critical care bed capacity Despite antiviral therapy and bed upgrades impact would result in unsustainable occupancy/ resources overwhelmed.

7. History of flu Hippocrates: 412 BC At Perinthus (North Greece) Italian for influence Also called grippe

8. Copenhagen 1952 Polio epidemic Copenhagen: left many patients paralyzed and medical students were allocated to ventilate these patients continuously by hand (due to shortages of tank ventilators).

9. Pessimist Globalisation Catastrophic terrorism Trained staff: absent 25% Absences 8 days ICU beds postcode lottery: asynchronous with need. Problems: staff and equipment Space and cost Number of victims, duration, O2 Rent additional ventilators Stockpile (USA Strategic National Stockpile) Children

10. Great Thinkers Trigger factor recognition Cancel elective list (dismayed Divisional Director and managers) Library of equipment and early mobilisation Log non critical care resources

11. Lateral Thinker Cancel elective lists Use recovery and operating theatres to ventilate Use Recovery nurses and ODPs Log negative impact Post pandemic period

12. Even more laterally Can’t apply figures to all situations Pop of 100,000 and 150,000 in St Albans. Week 5 >900% rise in bed occupancy! 54 pts, 23 ventilated 35% attack rate 84 pts, 36 ventilated

13. MMC and MTAS urgent meeting….s

14. Solutions

16. I C U admission Old, confused, hypotensive, tachypnoec, with uraemia. CURB 3-5: pO2 0.6) Rising Pco2 Severe acidosis pH<7.26 Septic shock

17. So what will we do? Close schools Wear masks Quarantine No large gatherings Make tough decisions World may change forever!

18. Issues A] Micro: Equipment Personnel Space B] Meso: co- ordination C] Macro: DOH

19. Micro:Equipment HHGH SACH 3 theatres +3 Anaesthetic rooms= 6 ventilators A&E resus= 1 oxylog /4 bays ITU= PB, 5+2, 1 oxylog= 8 ventilators Recovery: 4 bays and 1 ventilator SACH: 5 theatres and 5 anaesthetic rooms: 10 ventilators ??BUPA Harpenden: 3 theatres and 3 anaesthetic rooms = 5 ventilators Potentially 30 ventilators/ 36 patient bays

20. Micro: Personnel ITU nurses Recovery nurses Theatre scrub nurses SCPs ODPs Anaesthetists : 13 trainees/ NCCG and 9 FT consultants Medical students, Unemployed doctors or official bag squEezers (OBE)

21. Micro: Space ITU Theatres Recovery A&E Acute medical ward

22. Micro: Cost No idea

23. Meso Issues Liase with Watford General Hospital L&D Hospital East and North Herts Cambridge EBS etc

24. Macro: No idea but contingent upon effective coordination

25. Questions

26. Acknowledgements/ Bibliography Diane, Library, HHGH Dr James Ferguson Google Thorax Jan 2007 Anaesthesia 2005 BMC Health Nurses Sci Q Biosecurity, Bioterrorism 2006 Journal of Critical Care Sep 2003 Journal of Intensive care 2003 Critical Care Nursing clinics of North America 2007