Caring for the living: Bringing out the dead

A bioterrorism scenario deployed during a major economic summit in Denver in 1996 showed little that was comforting: Hospitals were overwhelmed, equipment was scarce, and there was no obvious place to put the multitudes of dead. And that was a best-case scenario. "Assume for a moment that there is a shopping mall in Denver and anthrax is let into the ventilation system by a terrorist," said Randy Culpepper, MD, MPH, a bioterrorism expert with the U.S. Army Medical Research Institute of Infectious Diseases at Fort Detrick in Frederick, MD. "Of the 10,000 people shopping in that mall that day, 9,000 became exposed to the anthrax spores enough to have made them ill."

The terrorists announce the attack 24 hours after the release to draw attention to their ideological cause. "By the end of the second day — now this is a best case scenario — the public health infrastructure is able to get chemoprophylactic antibiotics to 90% of those that were exposed," he said. " I think that’s a pretty ambitious event, but, nonetheless, we assume that’s what happened. Ten percent of the people could not be found initially."

Looking at the resources required to manage this "small event," Culpepper estimated that about 5,000 patients — despite chemoprophylaxis — would still need to be hospitalized over the next two or three days. "They were all exposed the same moment so they’ll all get sick within a couple of days of each other," he said. "Do you think Denver can handle an influx of 5,000 patients being hospitalized all of a sudden? Not very easily."

Some 3,000 would be sick enough to need intensive care beds. "Denver only has 300 ICU beds of which half are already filled," he said. "So we had available 150 ICU beds for a need of 3,000 patients. We figure we would need about 2,600 ventilators. Do you think Denver has 2,600 ventilators? No, of course not."

Fortunately — given the aforementioned numbers — the scenario predicts that all but 855 people survive. "Anthrax has a case fatality rate of about 85%, but remember [that] we got chemoprophylactic antibiotics out to the individuals by the end of the second day," he said. "So we don’t have as high of a death rate — only 9% in this scenario. But, even with 855 casualties, where is Denver going to put them? How many beds or spaces do we normally have in our morgues in our hospitals? About six. Denver doesn’t have enough spaces for 855 fatalities. Where are they going to stack them? Where are they going to hold them? Where are they going to refrigerate them?"