Congress blocked DEA action against drug companies suspected of flooding the country with prescription narcotics

“In April 2016, at the height of the deadliest drug epidemic in U.S. history, Congress effectively stripped the Drug Enforcement Administration of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets…
A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills, according to an investigation by The Washington Post and “60 Minutes.” The DEA had opposed the effort for years.
The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns…
For years, some drug distributors were fined for repeatedly ignoring warnings from the DEA to shut down suspicious sales of hundreds of millions of pills, while they racked up billions of dollars in sales.
The new law makes it virtually impossible for the DEA to freeze suspicious narcotic shipments from the companies, according to internal agency and Justice Department documents and an independent assessment by the DEA’s chief administrative law judge in a soon-to-be-published law review article. That powerful tool had allowed the agency to immediately prevent drugs from reaching the street.” (A)

“President Donald Trump said Monday that “we’re going to be looking into” Rep. Tom Marino, the White House’s pick to be the nation’s next drug czar, after CBS’ “60 Minutes” and The Washington Post reported that the lawmaker championed a law that hobbled federal efforts to combat the abuse of opioids….
According to reporting by the Post and “60 Minutes,” Marino was the top lawmaker championing the Ensuring Patient Access and Effective Drug Enforcement Act, legislation that the news outlets said makes it essentially impossible for the Drug Enforcement Administration to freeze suspicious narcotics shipments from drug companies. The DEA had fought against the bill, while the pharmaceutical industry lobbied hard on its behalf.” (B)

“Republican members of Congress Tom Marino of Pennsylvania and Marsha Blackburn of Tennessee promoted the bill as a way to ensure that patients had access to the medication they needed…
“…. the argument that made the bill unanimously pass Congress was that “legitimate painkiller users were not getting their drugs in an efficient manner.”
“There’s nothing in the law that actually changes that at all,” Bernstein said during a conversation on “CBS This Morning.” “The evidence for that was actually sort of anecdotal. Whereas the evidence for the fact that these pills were ending up in the hands of dealers and users was quite substantial.”
Asked whether he feels as though these drug distributors are complicit in the opioid crisis, Bernstein responded, “Well, they certainly have been caught numerous times over, and over and over again, not reporting suspicious orders of these opioid pain pills from doctors and pharmacies.”” (C)

“Rep. Tom Marino, R-Pa., has withdrawn his name from consideration as America’s drug czar, President Trump said Tuesday. Marino is stepping back days after reports that legislation he sponsored hindered the Drug Enforcement Administration in its fight against the U.S. opioid crisis…
Marino was a main backer of the Ensuring Patient Access and Effective Drug Enforcement Act; among other things, the measure changed the standard for identifying dangers to local communities, from “imminent” threats to “immediate” threats. That change cramped the DEA’s authority to go after drug companies that didn’t report suspicious — and often very large — orders for narcotics.
Sen. Joe Manchin, D-W.Va., said he was “horrified” by the story, adding that he “cannot believe the last administration did not sound the alarm on how harmful that bill would be for our efforts to effectively fight the opioid epidemic.”
In a letter to the president, Manchin wrote about the ability of wholesale drug distributors to send millions of pills into small communities:
“As the report notes, one such company shipped 20 million doses of oxycodone and hydrocodone to pharmacies in West Virginia between 2007 and 2012. This included 11 million doses in one small county with only 25,000 people in the southern part of the state: Mingo County. As the number of pills in my state increased, so did the death toll in our communities, including Mingo County.”..
Manchin has co-sponsored legislation that would repeal the changes made by the 2016 law, along with Sen. Claire McCaskill, D-Mo., and Sen. Margaret Wood Hassan, D-N.H. “ (D)

“Mr. Marino’s withdrawal leaves three of the major federal agencies responsible for managing the opioid crisis—the White House drug-control office, the Department of Health and Human Services and the DEA—with no nominees to head them. Mr. Trump’s national opioid commission, led by New Jersey Gov. Chris Christie, is expected to release a final report with recommendations next month.
During his news conference, Mr. Trump said that he would likely make a “major announcement” on the “drug crisis” next week.” (E)

(A) THE DRUG INDUSTRY’S TRIUMPH OVER THE DEA, by Scott Higham and Lenny Bernstein, https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/?utm_term=.76234a485f43
(B) Trump: ‘Looking into’ Marino’s nomination as drug czar after report on opioid legislation, by LOUIS NELSON, http://www.politico.com/story/2017/10/16/trump-tom-marino-drug-czar-opioid-legislation-243827
(C) Washington Post reporter on how Congress may have fueled America’s opioid crisis, by LAUREN MELTZER, https://www.cbsnews.com/news/opioid-epidemic-60-minutes-washington-post-investigation-lenny-bernstein/
(D) Tom Marino, Trump’s Pick As Drug Czar, Withdraws After Damaging Opioid Report, by Bill Chappell, http://www.npr.org/sections/thetwo-way/2017/10/17/558276546/tom-marino-trumps-pick-as-drug-czar-withdraws-after-damaging-opioid-report
(E) Trump’s Pick for Drug Czar, Tom Marino, Withdraws Name from Consideration, by Peter Nicholas, https://www.wsj.com/articles/donald-trumps-pick-for-drug-czar-tom-marino-withdraws-name-from-consideration-1508244954

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Trump vows to rip apart Obamacare piece by piece. (A)

“In a move likely to roil America’s insurance markets, President Donald Trump will “immediately” halt payments to insurers under the Obama-era health care law he has been trying to persuade Congress to unravel for months….
“…. the White House said the government cannot legally continue to pay the so-called cost-sharing subsidies because they lack a formal authorization by Congress. Officials said a legal opinion from the Justice Department supports that conclusion…
Experts have warned that cutting off the money would lead to a double-digit spike in premiums, on top of increases insurers already planned for next year. That would deliver another blow to markets around the country already fragile from insurers exiting and costs rising. Insurers, hospitals, doctors’ groups, state officials and the U.S. Chamber of Commerce have urged the administration to keep paying…
Consumers who receive tax credits under the ACA to pay their premiums would be shielded from those premium increases. But millions of others buy individual health care policies without any financial assistance from the government and could face prohibitive increases. Taxpayers would end up spending more to subsidize premiums.” (B)

“ “Massive subsidy payments to their pet insurance companies have stopped,” Trump said in a Tweet early Friday morning, alluding to the support of Democrats in Congress for CSRs.
But the CSRs are a pass-through from the government through the insurer and directly to the patient. Thus, a single-digit rate increase becomes a rate increase of 20%-25% without the CSRs, insurers have warned for months now.
“These payments are not a bailout – they are passed from the federal government through health plans to medical providers to help lower costs for patients who see a doctor to treat their cancer or fill a prescription for a life-saving medication,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association said in a joint statement Friday morning.
Most insurers, including Anthem, Oscar Health, Centene, Molina and Blue Cross and Blue Shield plans, will still make money if Americans buy their plans because customers will have to pay much higher rates thanks to Trump’s move. The end to CSRs, though, could prevent many from buying the policies in the first place or paying their out-of-pocket costs….” (C)

“The Trump administration is hinting that it will continue to enforce the ObamaCare mandate requiring Americans to have health insurance coverage. An administration document obtained by The Hill that accompanies an executive order signed by President Trump Thursday states that “only Congress can change the law” when it comes to the mandate.
“Will the Administration be enforcing the individual and employer mandates?” the question and answer document asks.
“While HHS has the ability to define a hardship exemption for the purpose of the individual mandate, the tax penalties are contained in the Internal Revenue Code and only Congress can change the law,” the document states in response, referring to the Department of Health and Human Services.
The statement leaves some room for creating more exemptions to enforcement of the mandate, noting that the administration can offer “hardship exemptions.” But it emphasizes that only Congress can change the law that mandates penalties for not having coverage…..” (D)

“The combined effect of cutting off the insurance payments and the executive order will be to destabilize the A.C.A.’s individual market, which is used by nine million people to buy health insurance. Younger and healthier people will be tempted to buy a skimpy short-term policy with low premiums and switch to a policy that complies with the A.C.A. only when they need medical care. Knowing that they will no longer receive cost-sharing payments and that Obamacare policies will tend to attract older and sicker people, insurers will probably jack up premiums or withdraw altogether in sparsely populated counties.
State governments, public interest groups and others will seek to prevent some of the damage from the order. There is some hope that they will be able to shape the regulations during the public comment period. If the final rules are still harmful, some groups will most likely file lawsuits….(E)

“White House Chief of Staff John Kelly told reporters that there probably won’t be a new Obamacare repeal bill until the spring and declined to join President Trump in attacking Senate Republican leadership…
“We probably won’t have a healthcare bill until the spring,” he said. “This was a way to take care of as many Americans as he could legally with an executive order.”…”Congress is designed to be extremely complicated, slow-moving part of our government,” he said. “I have nothing but respect for members of Congress and the staffs that work for them.” (F)

“In theory, precipitously ending the payments could lead to catastrophic market failures. Insurers set prices for their insurance this year, assuming the payments would continue to be made, and have no ability to raise them midyear to cover their losses. But, because the president has repeatedly signaled that the payments might cease and we are nearing the end of 2017, many plans set their prices for next year’s products assuming the subsidies would not be paid.
A few months ago, we called those increased prices an uncertainty tax. The uncertainty is gone now. But the conservative planning of the insurance industry means that many insurers can afford to keep offering insurance, even after the president cuts off the funding. Plans that priced for the threat will take a small haircut this year, but they can still make money, even without the payments, next year.” (G)

“Even before Mr. Trump’s decision, Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, were working on legislation to extend the subsidies, paired with other measures to offer states more flexibility regulating health plans offered under President Barack Obama’s health law.
But Republicans in Congress are divided. Some worry that ending the subsidies would hurt their constituents. Others are loath to do anything that could be seen as propping up the health law that they had promised to tear down.
For their part, Democrats are convinced that any blame for rising premiums and shrinking choices will fall on Republicans, who now control the White House and Congress. After spending the year trying to preserve the Affordable Care Act, Democrats did not appear ready on Friday to make major concessions.” (H)

“But there’s another question here, which is the electoral consequence. If health insurance gets worse, will people blame Barack Obama and the Democrats, or Donald Trump and the Republicans?” (I)

(A) Trump vows to rip apart Obamacare piece by piece, http://abcnews.go.com/WNT/video/trump-vows-rip-obamacare-piece-piece-50472671
(B) Trump to issue stop-payment order on health care subsidies, by ricardo alonso-zaldivar, http://abcnews.go.com/Health/wireStory/trump-halt-subsidies-health-insurers-50455624
(C) Trump’s Termination Of Obamacare Subsidies Hurts Patients, Not Insurers, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/13/trumps-end-to-subsidies-hurts-patients-not-insurers/#525cb1444c61
(D) Trump administration hints at enforcing ObamaCare mandate, BY PETER SULLIVAN, http://thehill.com/policy/healthcare/355144-trump-administration-hints-at-enforcing-obamacare-mandate
(E) Congress Can’t Let Mr. Trump Kill Obamacare on His Own, https://www.nytimes.com/2017/10/12/opinion/editorials/congress-cant-let-mr-trump-undo-obamacare-on-his-own.html?_r=0
(F) John Kelly: Obamacare repeal effort likely to return in spring, by Robert King, http://www.washingtonexaminer.com/john-kelly-obamacare-repeal-effort-likely-to-return-in-spring/article/2637332
(G) Trump Is Trying to Gut Obamacare. Here’s Why His Plan May Fail, by Margot Sanger-Katz, https://www.nytimes.com/2017/10/13/upshot/trump-is-telling-obamacare-insurers-he-doesnt-support-the-market.html
(H) End to Health Care Subsidies Puts Congress in a Tight Spot, By THOMAS KAPLAN and ROBERT PEAR, https://www.nytimes.com/2017/10/13/us/politics/trump-congress-obamacare-insurance-subsidies.html
(I) Trump’s Head-Scratching Health-Care Moves, by Jonathan Bernstein, https://www.bloomberg.com/view/articles/2017-10-13/trump-s-head-scratching-health-care-moves

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Trump’s Executive Order: “By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges.”

“President Donald Trump signed an executive order Thursday morning intended to allow small businesses and potentially individuals to buy a long-disputed type of health insurance that skirts state regulations and Affordable Care Act protections.
The White House and allies portray the president’s move to expand access to “association health plans” as wielding administrative powers to accomplish what congressional Republicans have failed to achieve: tearing down the law’s insurance marketplaces and letting some Americans buy skimpier coverage at lower prices. The order is Trump’s biggest step to carry out a broad but ill-defined directive he issued his first night in office for agencies to lessen ACA regulations from the Obama administration…
According to White House and agency officials, , the most far-reaching element of the multi-prong order instructs a trio of Cabinet departments to rewrite federal rules for association health plans – a type of insurance in which small businesses of a similar type band together through an association to negotiate health benefits.
The order will expand the availability of short-term insurance policies, which offer limited benefits meant as a bridge for people between jobs or young adults no longer eligible for their parents’ health plans. The Obama administration ruled that short-term insurance may not last for more than three months; Trump will extend that to nearly a year.” (A)

“In an effort to allow employers to form groups and obtain coverage across state lines, the order directs the administration to consider expanding Association Health Plans (AHPs), which allow small businesses in a similar sector or trade to band together to negotiate health benefits with other states.
This is a controversial measure and some experts predict there could be legal challenges, but supporters say it would increase competition by allowing employers to find the states offering the cheapest plans. It could also give more leverage to small businesses to negotiate policies. Additionally, the order calls for a broader interpretation of the Employee Retirement Income Security Act (ERISA), a law that regulates group plans provided by employers.
While ObamaCare mandated that short-term insurance policies should not last for more than three months, Trump is looking to expand those plans. The order says these short-term limited duration insurance (STLDI) offerings typically cost one-third of the price of the cheapest ObamaCare plans, while featuring broad provider networks and coverage. These plans are also not subject to most ObamaCare requirements…
The administration’s order also directs the government to look into ways to expand the use of Health Reimbursement Arrangements, or tax-free accounts that allow employers to reimburse employees for medical expenses. This measure is intended to give Americans greater control over their finance and health care.” (B)

“Although Mr. Trump has been telegraphing his intentions for more than a week, Democrats and some state regulators are now greeting the move with increasing alarm, calling it another attempt to undermine President Barack Obama’s signature health care law. They warn that by relaxing standards for so-called association health plans, Mr. Trump would create low-cost insurance options for the healthy, driving up costs for the sick and destabilizing insurance marketplaces created under the Affordable Care Act.
“It would have a very negative impact on the markets,” said Mike Kreidler, the insurance commissioner in Washington State. “Our state is a poster child of what can go wrong. Association health plans often shun the bad risks and stay with the good risks.”
They also worry that the Trump administration intends to loosen restrictions on short-term health insurance plans that do not satisfy requirements of the Affordable Care Act.
“By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges,” said Topher Spiro, a vice president of the Center for American Progress, a liberal research and advocacy group. “For older, sicker people left behind in plans regulated under the Affordable Care Act, premiums could increase.”” (C)

“Critics, however, worry that the order may free these association health plans from several key Obamacare regulations and from state oversight, allowing them to sell plans with lower premiums but skimpier benefits. That could draw younger and healthier customers away from Obamacare and send premiums skyrocketing for sicker people left in the exchanges.” (D)

“If Donald Trump signs an executive order as early as this week allowing insurance companies to be able to sell health plans across state lines, it’s unlikely to have any takers willing to prop up medical provider network in new regions.
The trend in insurance is to narrow – not expand – networks of doctors and hospitals.
“Insurance companies have not been very interested because we are moving to these network based plans,” Sabrina Corlette, professor with the Center on Health Insurance Reforms at Georgetown University said last week during a Commonwealth Fund briefing. “Since the 1990s, health insurance has evolved and has been a network driven product.”
It’s unclear exactly what will be in Trump’s executive order, which he mentioned within days after the failure of the latest Republican attempt to replace and replace the Affordable Care Act.
Health insurance companies in some states can already sell health coverage across state lines, but it hasn’t worked in large part because plans haven’t wanted to spend the money contracting with more doctors and hospitals in areas they have no enrollees. Six states have enacted laws allowing health plan sales across state lines and “no state was known to actually offer or sell such policies,” National Conference of State Legislatures said in a new report last week.
“In the states that have tried to do this, there has been zero interest from carriers,” Georgetown’s Corlette, who is also the consumer representative to the National Association of Insurance Commissioners.” (E)

We’re Tracking the Ways Trump Is Scaling Back Obamacare. Here Are 11.,
By HAEYOUN PARK ,, https://www.nytimes.com/interactive/2017/10/12/us/trump-undermine-obamacare.html

TRUMP HEALTH CARE EXECUTIVE ORDER WILL DO WHAT GOP FAILED TO DO: LEAVE SICK AMERICANS WITHOUT HEALTH CARE, BY CHRISTIANNA SILVA
http://www.newsweek.com/trump-health-care-executive-order-will-do-what-gop-failed-do-leave-sick-683614

President Donald Trump’s executive order could take health care insurance away from millions of sick Americans, which was also a criticism of his earlier effort to repeal and replace the Affordable Care Act in Congress. The new plan would roll back some of Obamacare’s protections and coverage, but it could lower premiums for healthy Americans.

“Republicans in Congress should take President Donald Trump’s hint about working with Democrats on health care as motivation to follow through with their own promises, Mick Mulvaney, director of the White House Office of Management and Budget, said on Sunday’s “Meet The Press.”
Mulvaney’s comment comes on the heels of a Saturday morning tweet from Trump, stating: “I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!”
When asked what Republican lawmakers should take from that tease, Mulvaney responded, “Keep your promises.”
“The president wants to get something done,” he said. “He sees and understands what Obamacare is doing to folks back home, and he really doesn’t like it very much. So he’s looking for folks who will work with him to help change that. We had hoped it would be the Republicans in the Senate. They failed twice to do that. And can you blame the president then to sort of step back and say, ‘Okay, if my own party can’t deliver what I need, can I work with the other side?’ That’s not an unreasonable position.”” (F)

“Republican Sen. Ron Johnson said Sunday he believed Congress could reach an agreement on health care that includes continuing the funding of a key set of Obamacare subsidies to keep down insurance premiums.
The conservative Wisconsin senator said in an interview on CNN’s “State of the Union” that he understands some of his Republican colleagues are against funding the cost-sharing reduction — or CSR — payments. But he said the government should keep making the payments to prevent the cost of insurance skyrocketing.
President Trump has not committed to paying insurers the cost-sharing subsidies, which reduce deductibles and co-pays for low-income Obamacare enrollees. This has prompted many insurers to raise their premiums for 2018 to make up for the anticipated loss of the subsidies. The 2018 rates have already been finalized.
Johnson added that any such move to support continuing those payments would come with strings attached. “We should get something in return for that,” he said. For example, he said, Congress should make it so anyone has the option to purchase a “catastrophic plan” — insurance with relatively low premiums but high deductibles that provides fewer benefits. Johnson also said they should make health savings accounts more usable.” (G)

“Local and state groups that help with ObamaCare enrollment say they will likely have to reduce their services following funding cuts from the Trump administration.
Funding for the “navigator” groups, which provide outreach, education and enrollment assistance, was cut in half this year for being “ineffective,” Trump officials have said.
Now most of the navigator programs say they will have to limit their services this year, according to a new survey from the Kaiser Family Foundation (KFF).
Among programs that got reduced funding this year, 45 percent of statewide programs and two-thirds of regional programs said it is “somewhat or very likely” they will have to limit the territory their program will serve, according to the survey.
This could primarily impact consumers living in rural areas.
Some 55 percent of statewide navigator programs and 72 percent of regional programs expect to limit services to rural residents this year, KFF found. “ (H)

“New Jersey will lose more than 60 percent of the federal funding it expected to receive this year to help enroll vulnerable citizens in health insurance plans, a new report found, a change advocates fear will make it harder to reach those most in need of affordable care.
Officials at the federal Centers for Medicare and Medicaid Services announced more than $26 million in funding cuts in September that will impact the Affordable Care Act navigator programs in all but three states (Delaware, Kansas, and West Virginia); more than a dozen states lost at least half their funding.
New Jersey saw support drop to nearly $721,000 from the roughly $1.9 million received last year, according to a detailed analysis of these cuts released Wednesday by the nonprofit Kaiser Family Foundation. The money is distributed among five nonprofit programs that will see between 10 percent and 86 percent less funding this fall than they had to work with in 2016, the foundation determined.” (I)

What scares the members of Congress who for decades have collected hefty donations from the insurance and health-care industries and then used their positions of public trust to sustain and protect profiteering by those industries?
The threat of a single-payer “Medicare for All” health-care system.
By replacing the bureaucratic profiteers with an efficient system that would guarantee care for every American—and fair compensation for doctors and nurses—single payer would not merely make health care more accessible and more affordable. It would also make politics more honest and responsive to the will of the people.
House Speaker Paul Ryan has, through the campaign committees and political action committees that he guides, collected millions of dollars from Wall Street interests, insurance interests, pharmaceutical interests, private hospital and nursing home interests, and “health products” interests over the course of a political career that has seen him go to the mat, again and again, in defense of Wall Street interests, insurance interests, pharmaceutical interests, private hospital and nursing home interests, and “health products” interests.
So is it any surprise that Ryan keeps trying to “repeal and replace” the Affordable Care Act with measures that benefit his crony-capitalist campaign funders?
Single payer is a bad idea for senators whose political survival is based on banking checks from health-care profiteers. But it is a very good idea for America.” (J)

(A) Trump signs executive order to scale back Obamacare insurance rules, Amy Goldstein, http://www.chicagotribune.com/news/nationworld/politics/ct-trump-health-care-executive-order-20171012-story.html
(B) Trump’s health care order: What’s in it?, By Brittany De Lea, http://www.foxbusiness.com/politics/2017/10/12/trumps-health-care-order-whats-in-it.html
(C) Foiled in Congress, Trump Moves on His Own to Undermine Obamacare, By ROBERT PEAR and REED ABELSON, https://www.nytimes.com/2017/10/11/us/politics/trump-obamacare-executive-order.html?_r=0
(D) Trump begins Obamacare dismantling with executive order, by Tami Luhby and Kevin Liptak, http://www.cnn.com/2017/10/12/politics/trump-obamacare-executive-order/index.html
(E) How Narrow Networks Doom Trump’s Plan For Insurance Sales Across State Lines, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/08/how-narrow-networks-doom-trumps-insurance-sales-across-state-lines/#5b1ce52335f9
(F) Mulvaney on Trump’s Message to GOP: ‘Keep Your Promises’, by KAILANI KOENIG, https://www.nbcnews.com/politics/congress/mulvaney-pres-trump-s-message-gop-keep-your-promises-n808821
(G) Sen. Ron Johnson suggests compromise on health care, By Eli Watkins, http://www.cnn.com/2017/10/08/politics/ron-johnson-healthcare-cnntv/index.html
(H) ObamaCare enrollment groups likely to decrease services after Trump funding cuts, BY JESSIE HELLMANN, http://thehill.com/policy/healthcare/354879-obamacare-enrollment-groups-likely-to-decrease-services-after-trump-funding
(I) NJ LOSES FEDERAL FUNDING TO EXPAND ACA ENROLLMENT, by LILO H. STAINTON, http://www.njspotlight.com/stories/17/10/11/nj-loses-federal-funding-to-expand-aca-enrollment/
(J) Why Do Republicans (and Some Democrats) Vilify Single Payer?, by John Nichols, https://www.thenation.com/article/why-do-republicans-and-some-democrats-vilify-single-payer/

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CDC deactivated its emergency response center for Zika.. The first probable locally acquired Zika case in 2017 has been confirmed in Texas….

County health officials on Thursday reported the case involves a Laguna Heights resident who sought testing at a county clinic. The individual is believed to have contracted the virus through a mosquito bite.
“Based on the information that we have, the source of the transmission appears to be mosquito-borne that took place several months ago. Clinical test results show that this person may have had the virus 2-3 months ago and it is no longer active in her system,” said Dr. James W. Castillo, Cameron County Health Authority. “In addition, there is no evidence of any other mosquito transmitted cases related to this one.”
Health officials conducted an “epidemiological investigation of the index case household” and provided residents in the area with information on eliminating mosquito breeding areas.” (A)

“The first outbreaks of contagious disease are beginning on the island of Puerto Rico 10 days after Hurricane Maria strafed the U.S. territory with a direct hit, according to The Daily Beast, even as the federal response lags and President Donald Trump attacks Puerto Rico and its elected officials on Twitter….
Mayor Julia Navarro of Loiza, a city half an hour’s drive from San Juan, said residents are showing signs of Dengue fever, Zika virus and a runaway epidemic of conjunctivitis that has infected more than 300 people.
“I’m here because there are still murky waters clogged on my streets and residents have been showing symptoms of Zika, Dengue and conjunctivitis virus,” she said. “If I didn’t come here personally, I wouldn’t get any help.”…
The lack of running water means that opportunities for proper hygiene have largely disappeared, Ramos said, leaving the population vulnerable to cholera, hepatitis A, meningitis, and salmonella. “Without water supply, residents rely on stocking water to wash their mouth and do the dishes. This water is often stored incorrectly and this gets infected rapidly,” he explained.” (B)

Statistics from the Ministry of Health of Costa Rica confirm today 307 Zika cases in the first 38 weeks of 2017, while notifying 2,124 people likely to carry that dangerous arbovirus.
The weekly bulletin of the Directorate of Vector Control and the Costa Rican Institute for Research and Teaching in Nutrition and Health reports that among the confirmed cases are 60 pregnant women and four are likely to carry the disease. So far this year, four confirmed cases of a congenital syndrome associated with this condition were reported, as well as four other probable cases. (C)

“More than six dozen sentinel chickens, living in coops dotted around Los Angeles, make up one of the first lines of defense in this sprawling county’s fight against West Nile virus. The disease has been a background threat for years here, but cases have spiked this fall to worrisome levels. Six deaths have been reported by Los Angeles County this year — including three just last week.
And the cases are alarmingly severe: Of 98 reported infections here this year, 79 have led to serious neurological side effects, and 87 have required hospitalization. Because it’s still peak mosquito season, more deaths are expected….
West Nile virus causes no symptoms in 8 of 10 infected people, according to the Centers for Disease Control and Prevention. But some, particularly the very young and very old, can get fevers, fatigue, and flu-like symptoms. (Dr. Lyle Petersen, the director of the CDC’s division of vector-borne diseases, experienced that misery himself back in 2003, when he was infected with West Nile virus after going out to pick up his mail without insect repellent.)
The virus has caused more than 2,000 deaths in the U.S. since it first appeared in New York in 1999. States hit hardest in recent years include California, Arizona, Texas, Colorado, Oklahoma, Nebraska, and South Dakota. This year, 22 states have already reported 49 deaths and 658 of the most severe cases, known as “neuroinvasive,” which can involve meningitis, encephalitis, and paralysis.” (D)

“A mutated version of the decades-old Zika virus has been causing severe birth defects in countries like Brazil since 2015, and scientists are still trying to understand how it became so dangerous so fast.
As of early September, there had been 523 travel-related cases of the virus reported in Canada and four sexually transmitted cases, including 37 pregnant women.
In its most recent public health notice, issued on Sept. 13, Health Canada advised all travellers heading to countries where Zika has been identified to continue to take precautions — especially if they are pregnant or planning to get pregnant.
These hot spots include, but are not limited to, popular winter getaway destinations like Cuba, the Dominican Republic, Mexico, St. Lucia, Brazil, Costa Rica, and several other South/Central American and Caribbean nations.” (E)

“Scientists have started to unravel a key mystery about the Zika virus. And the findings are almost unbelievable.
“When I first started reading the study, I said, ‘Oh, my gosh, that’s amazing,’ says molecular biologist Alysson Muotri, at the University of California, San Diego, who wasn’t involved in the study.
The study — published Thursday in the journal Science — demonstrates how an obscure virus may have transformed into a global threat almost overnight.
For decades, Zika had been a relatively innocuous disease. Since its discovery in 1947, the mosquito-borne virus had been circulating around Africa and Asia, almost undetected. It caused only a mild illness — a fever, a rash and joint pain. About 80 percent of people had no symptoms at all. And outbreaks tended to be small.” (F)

“The U.S. Food and Drug Administration today approved the cobas Zika test, a qualitative nucleic acid test for the detection of Zika virus RNA in individual plasma specimens obtained from volunteer donors of whole blood and blood components, and from living organ donors. It is intended for use by blood collection establishments to detect Zika virus in blood donations, not for the individual diagnosis of Zika virus infection.” (G)

“Massachusetts Institute of Technology researchers have developed a paper-based test that is able to diagnose the presence of Zika virus in 20 minutes.
The MIT-developed test is a cheap, portable and easy-to-use diagnostic test that could be used in countries where Zika is prominent, but tests that measure viral RNA in the bloodstream are not.
“It’s important to have a single test that can differentiate between the four serotypes of Dengue and Zika, because they co-circulate. They’re spread by the same mosquito,” Kimberly Hamad-Schifferli, associate professor of engineering at the University of Massachusetts at Boston and co-senior author of the paper, said in a press release….
Zika virus is spread through the bite of an infected mosquito. According to the CDC, there have been 288 reported cases of Zika in the U.S. this year as of Oct. 4.” (H)

“In September 2017, the development of the US Army’s Zika vaccine—once a leading candidate in the Zika vaccine race—came to a halt after almost all federal funding for Zika R&D was cut short. This happened less than a year from the end of the global public health emergency. Funding will now resume only if the Zika epidemic re-emerges.
That R&D on diseases like Zika is not attractive to pharmaceutical companies is a well-known phenomenon. It usually takes a major public health crisis to shake up the playing field. With Ebola, for instance, funding for R&D increased 258% in 2015. The Zika outbreak had the same effect, and so will future outbreaks of similar diseases.
But funding spikes triggered by outbreaks are short-lived. They fuel an accelerated R&D race, with multiple pharmaceutical companies and research institutions jumping in. As soon as the fear factor begins to decline, so does the support for R&D. The looming possibility of another outbreak guarantees that some drug development will still occur, but only at a residual level.” (I)

“The U.S. Centers for Disease Control and Prevention deactivated its emergency response center for the Zika virus, as it seems the worst of the outbreak has passed…
On Jan. 22, 2017, the EOC was activated in response to Zika, which can have devastating effects during pregnancy. The CDC began its transition back to normal program operations Sept. 29.
In 2009, the EOC was activated for the H1Ni influenza pandemic. It was also activated for the 2014 Ebola outbreak.
Although the center is closing, the CDC will continue to work to protect people affected by Zika and coordinate with federal, state and local governments to help families touched by the virus. In its announcement, the agency emphasized that Zika is still a risk in the U.S.A.” (J)

(A) Zika case first in 2017, by LAURA B. MARTINEZ, http://www.valleymorningstar.com/news/local_news/article_74135444-aa47-11e7-b2eb-b799afd87eb8.html
(B) Disease outbreaks begin in Puerto Rico even as Trump attacks its citizens on Twitter, by David Ferguson, https://www.rawstory.com/2017/09/disease-outbreaks-begin-in-puerto-rico-even-as-trump-attacks-its-citizens-on-twitter/
(C) Costa Rica Confirms 307 Zika Cases, http://www.plenglish.com/index.php?o=rn&id=19007&SEO=costa-rica-confirms-307-zika-cases
(D) Deadly West Nile virus cases are spiking in LA. The first line of defense: chickens, by USHA LEE MCFARLING, http://www.pbs.org/newshour/rundown/deadly-west-nile-virus-cases-spiking-la-first-line-defense-chickens/
(E) Planning a winter getaway? Zika warnings remain in place as travel season looms, byy Monique Scotti, https://globalnews.ca/news/3789212/zika-virus-warnings-canada-travel-season-looms/
(F) How Zika Became So Dangerous For Babies, by Michaeleen Doucleff, http://www.npr.org/sections/goatsandsoda/2017/09/28/554054047/how-zika-became-so-dangerous-for-babies
(G) FDA approves first test for screening Zika virus in blood donations, https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm579313.htm
(H) This paper-based test quickly diagnoses Zika, by Danielle Kirsh, http://www.medicaldesignandoutsourcing.com/paper-based-test-quickly-diagnoses-zika/
(I) No Vaccines Before the Next Zika Outbreak?: A Case for IP Preparedness, by Dennis Crouch, https://patentlyo.com/patent/2017/10/vaccines-outbreak-preparedness.html
(J) CDC shutters Atlanta-based Zika emergency operations center, by Ellie Hensley, https://www.bizjournals.com/atlanta/news/2017/10/04/cdc-shutters-atlanta-based-zika-emergency.html

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Trump: “I want to focus on North Korea not ‘fixing somebody’s back’,…Let the states do that.” As “synthetic repeal” of ObamaCare is underway.

“President Trump praised health care block grants on Saturday, saying they allow the states to focus on health care, but said he would rather focus his energy on tensions with North Korea than “fixing somebody’s back or their knee.”
“You know in theory, I want to focus on North Korea, I want to focus on Iran, I want to focus on other things. I don’t want to focus on fixing somebody’s back or their knee or something. Let the states do that,” ….
“The block grant concept is a very good concept, and if you have good management, good governors, good politicians in the state, it’ll be phenomenal,” he continued. (A)

“The Trump administration issued rules Friday that immediately carve broad exceptions to the Affordable Care Act’s promise of no-cost contraceptive coverage, touching off fresh lawsuits and renewed debate about the proper scope of religious liberty.
The rules significantly widen the range of employers and insurers that can invoke religious or moral beliefs to avoid the ACA requirement that birth control pills and other contraceptives be covered by insurance as part of preventive care. Administration officials and their allies on the right downplayed the impact of the change on American women, while women’s rights and civil liberties groups portrayed it as a massive, discriminatory act.” (B)

“Stymied in his efforts to repeal the Affordable Care Act, President Trump is poised to issue an order that could ease some federal rules governing health insurance and make it easier for people to band together and buy coverage on their own, administration officials said Saturday.
One official said the directive could move the president a step closer to one of his longstanding goals: allowing consumers to buy health insurance across state lines. Conservatives say that interstate sales could expand options for consumers, increase competition in the insurance market and perhaps lower costs.
The order, which the administration officials said was likely to be announced in the coming week, would instruct three cabinet departments to take actions to help individuals and small businesses join together to buy insurance through arrangements known as association health plans. Such plans could be sponsored by trade and professional groups and community organizations.” (C)

“Legislation to rescue the Children’s Health Insurance Program sailed through a Senate committee on Wednesday, but touched off a partisan conflict in the House, diminishing hopes that the popular program would be quickly refinanced.
Funding for the program expired on Sunday, and state officials said they would soon start notifying families that children could lose coverage if Congress did not provide additional money. It was impossible to say when Congress might pass a bill and send it to President Trump…
But in the House Energy and Commerce Committee, lawmakers brawled Wednesday over a similar bill to provide money for the children’s health program. Democrats strongly support the program, but complained that Republicans would take money from Medicare and the Affordable Care Act to offset the cost.” (D)

“President Donald Trump said on Saturday that he had talked with Senate Minority Leader Chuck Schumer to see if Democrats want to help on a “great HealthCare Bill” — but Schumer separately indicated the conversation didn’t exactly go smoothly.
“”I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!” the president wrote on Twitter Saturday morning.
Schumer, in a statement, said Trump had suggested another Obamacare repeal-and-replace effort, which the New York Democrat said was a non-starter.
“The president wanted to make another run at repeal and replace and I told the president that’s off the table,” Schumer said. “If he wants to work together to improve the existing health care system, we Democrats are open to his suggestions. A good place to start might be the Alexander-Murray negotiations that would stabilize the system and lower costs.”” (E)

“”All of the things Trump and his administration have done on health care — not just pushing for repeal-replace, but independently cutting off enrollment outreach, keeping insurers in limbo about their payments, reportedly putting the kibosh even on Republican governors’ efforts to stabilize their markets, all of it — cuts in the exact opposite direction of anything Schumer would want or could abide.”” (F)

“Andy Slavitt, a former top health-care official in the Obama administration, warned on Twitter Thursday that the administration’s “sabotage” of the law added up to what he called “synthetic repeal,” meaning a range of small steps that add up to repealing ObamaCare even if Congress doesn’t act.” (G)

(A) Trump: I want to focus on North Korea not ‘fixing somebody’s back’, by JULIA MANCHESTER, http://thehill.com/homenews/administration/354419-trump-on-health-care-block-grants-i-would-rather-focus-on-iran-north
(B) The Trump administration just changed the rules on contraception coverage, by Amy Goldstein, Juliet Eilperin and William Wan, https://www.washingtonpost.com/national/health-science/trump-administration-could-narrow-affordable-care-acts-contraception-mandate/2017/10/05/16139400-a9f0-11e7-92d1-58c702d2d975_story.html?utm_term=.a5c305026020
(C) Trump Poised to Sign Order Opening New Paths to Health Insurance, by ROBERT PEAR, https://www.nytimes.com/2017/10/07/us/politics/trump-association-health-plans.html?_r=0
(D) Bill to Rescue Children’s Health Program Hits Snag in House, by ROBERT PEAR, https://www.nytimes.com/2017/10/04/us/politics/children-health-insurance-program-congress.html
(E) Trump reached out to Schumer to work on ‘great HealthCare Bill’, by BRENT D. GRIFFITHS and SEUNG MIN KIM, http://www.politico.com/story/2017/10/07/trump-says-that-he-has-reached-out-to-schumer-on-health-care-243560
(F) Trump phones a friend on health care, by Jonathan Swan and Mike Allen, https://www.axios.com/trump-confirms-his-phone-call-with-chuck-schumer-2494036970.html
(G) Critics see Trump sabotage on ObamaCare, by PETER SULLIVAN AND RACHEL ROUBEIN, http://thehill.com/policy/healthcare/354308-trump-sabotage-seen-on-obamacare

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‘This Is Like in War’ – Lessons Learned about Hospital Hurricane Preparedness

“Failing infrastructure, the increasing density of cities and the growing frequency of extreme weather events create public health risks on a massive scale. In Houston, improperly maintained Superfund sites ― that is, profoundly polluted hazardous-waste sites ― could not withstand the waters that rose as high as streetlights in some areas. Drainage systems failed. Poisonous chemicals and dangerous bacteria spread via floodwater through residential areas. In the wake of a flood, mold can bloom inside devastated structures, putting people at risk of allergies, asthma and other respiratory problems.
As with Houston, overdevelopment in Florida is making people more vulnerable to hurricanes and flooding, as precious swampland and marshland is encased in concrete and high-density residential zones are built in risky areas like barrier islands. Hurricane Irma, which made landfall in Florida on Sept. 10, knocked out power for between 60 and 80 percent of residents across the state, underlining the need for more diverse kinds of energy infrastructure.” (A)

“All hospital systems maintain emergency plans of action for a looming crisis such as Irma…
Hospitals have electrical generators in place if needed, are tied into their local government’s emergency operations response centers, and have preselected and specially trained administrators and medical staff at the ready, along with their relief teams. Non-critical surgeries and routine patient checkups are postponed, and clinics and physician practices closed…
Systems with multiple locations have specific plans for each “based on hazards,” such as proximity to the ocean or river, said Karen Ketchie, Baptist Health’s director of emergency management services. That’s how they were prepared to move patients when conditions at each site warranted it, she said…
“The hospital … was built to enable a defend-in-place strategy. This is due to the high acuity of our population of patients, and removing them from the building might be dangerous,” he said. (B)

“After an estimated 215 people died in hospitals and nursing homes in Louisiana following Hurricane Katrina in 2005, policy makers realized that the nation’s health care institutions were ill-prepared for disasters.
One of the rules they created after years of discussion looked especially prescient in light of the tragic deaths on Wednesday of eight nursing home residents in Florida’s post-hurricane heat. But the rule, regarding power supplies and temperature control, will not be enforced until November, and even then, some patient advocates are concerned that it does not go far enough…
The new federal rule will require that nursing homes have “alternate sources of energy to maintain temperatures to protect resident health and safety.” But the rule does not specifically require backup generators for air-conditioning systems — the nursing home in Florida, Rehabilitation Center at Hollywood Hills, did not have such a generator — and now some are questioning whether the rule should.” (C)

Escalating a legal and regulatory fight, Gov. Rick Scott’s administration issued an emergency suspension of the license of a Broward County nursing home Wednesday after the deaths of nine residents following Hurricane Irma.
The license suspension was another step after the state Agency for Health Care Administration last week placed a moratorium on admissions to The Rehabilitation Center at Hollywood Hills and suspended the facility from the Medicaid program. The nursing home late Tuesday filed a lawsuit challenging the admissions moratorium and the Medicaid cutoff.
Eight of the residents died Sept. 13, three days after Hurricane Irma shut down the nursing home’s air-conditioning system. The license suspension alleged that four of the residents had body temperatures of at least 107 degrees when they arrived at a nearby hospital or when they died.
“Respondent (the nursing home) failed to maintain safe conditions in its facility; failed to timely evacuate its facility once conditions were no longer safe for residents; and failed to timely contact ‘911’ during a medical emergency,” said the emergency suspension order, signed by AHCA Secretary Justin Senior. (D)

First, the nursing home, called the Rehabilitation Center at Hollywood Hills.
Yes, it experienced a partial loss of power after Irma. But the real problem appeared to be that the staff didn’t act quickly enough after the air conditioning failed and patients became overheated and dehydrated, according to police, emergency responders, and family members of patients.
By the time emergency responders got there, the facility’s second floor was “extremely hot,” some patients were already dead, and others were near death, Hollywood Police Chief Tom Sanchez told reporters.
Also, help was just a few steps away. Memorial Regional Hospital, which is right across the street, had power and a fully functioning emergency room when the deaths occurred.
When the hospital finally learned what was happening, dozens of workers rushed over to help, says Randy Katz, an Emergency Medicine specialist at Memorial. (E)

The first call from the Rehabilitation Center of Hollywood Hills to Florida Power & Light was placed about six hours after Hurricane Irma made landfall in Cudjoe Key on Sunday.
Irma had knocked out power to the center where 141 elderly and frail patients lived, and the following morning FPL said it would be there to restore electricity to the air conditioning units, according to a time line provided to the Miami Herald on Friday by officials of the nursing home who asked not to be identified.
The allegations in the time line — that the facility called both FPL and the governor’s cellphone for help that didn’t come, along with comments from the state and the governor’s office denying the nursing home’s version of events — added confusion Friday to a case that includes a criminal investigation into the deaths by Hollywood police.
According to the nursing home time line, FPL didn’t show up as promised on Monday, or on Tuesday, and by the time the utility arrived on Wednesday morning to repair a transformer that powered the nursing home’s air conditioners, all of the patients had been evacuated and eight elderly residents were dead. (F)

“The Texas Hospital Association this week estimated that as many as 75,000 hospital employees experienced losses and damage from Hurricane Harvey, both the storm and subsequent flooding. The association, which is based in Austin and represents more than 85 percent of the state’s acute-care hospitals and health care systems that combined employ some 365,000 health care professionals, announced Sept. 5 that it is contributing $1 million to a special assistance fund for the affected employees….
“Throughout the storm and the days following, we witnessed firsthand the dedication of our health care workforce,” said Ted Shaw, THA’s president and CEO. “Many of these individuals stayed committed to their work, knowing their families and property were at risk. While hospital administrative personnel, nurses, and other staff train for unspeakable disasters like Hurricane Harvey, their preparation and focus ensured the safety and continued operation of facilities even as the waters rose and the lights went out. Now, it’s time for us to take care of the caregivers.” (G)

“Patricia Ney was a nurse. The 56-year-old worked in the obstetrics department at Cape Coral Hospital for more than three years. In total, her career spanned more than three decades. Until last week…
The hospital system’s emergency preparedness plan in case of hurricanes is called “Code Brown.” During hurricanes, essential employees are grouped into two groups — A and B. Group A staffs the hospital during the storm and Group B takes over after to relieve the first staff workers.
Ney was part of Group A, but the day after Labor Day she went to Pennsylvania on a previously planned trip. At the time, Irma was forecasted to hit the east coast of Florida, but the cyclone surprised all by going west instead.
Under the previous guidelines for Code Brown situations, employees who did not go to work were placed under corrective actions and in some circumstances fired.
But because Irma was so remarkably unpredictable and affected large swaths of the state, Briggs said the guidelines will be tweaked allowing those employees to return to work. (H)

Local emergency management officials and state public health officials dodged a bullet with Hurricane Irma. They must do a better job of coordinating with local hospitals the care of hurricane evacuees who have been deemed “medically needy” because of serious health issues.
Emails obtained by this newspaper showed that as Hurricane Irma bore down on Chatham County, the three local hospitals initially flinched and backpedaled on their previous agreements to house 48 fragile members of the community, and that only Memorial University Medical Center eventually lived up to its commitments, but only after Chatham Emergency Management Agency Director Dennis Jones did some serious arm-twisting with top Memorial execs.
Candler accepted none of the evacuees it was assigned and St. Joseph’s, Candler’s sister hospital in the two-hospital system, accepted three “last minute” cases. (I)

“Furniture damaged by floodwater during Hurricane Irma that’s now sitting in front of people’s homes has started attracting people looking to salvage metal from it. But there is a hidden danger that could lead to infection if you aren’t careful.
On Jacksonville’s Northside, which saw a lot of flooding, two men were seen salvaging materials from soaked furniture…
“E.coli is the most common bacteria that can cause a variety of different problems,” Ashbaugh said. “Also, people with staph and strep — that can become a big problem with cellulitis, different abscesses and skin diseases.” (J)

“Nancy Reed, 77, died on Sept. 15 of flood-related necrotizing fasciitis, an infection that spreads quickly through muscle tissue and can cause organ failure…
According to the Centers for Disease Control and Prevention, necrotizing fasciitis is a serious bacterial skin infection that kills the body’s soft tissue, spreads quickly and can be fatal in a short time. Prompt diagnosis and treatment with antibiotics can prevent death.
The infection is not considered a reportable disease in Texas, meaning doctors or laboratories who diagnose it are not required to alert health authorities. But they are required to report many of the organisms that cause the disease — streptococcus, E. coli, vibrio vulnificus and certain types of drug-resistant staphylococcus.
Strep is the most common cause of flesh-eating bacteria. Vibrio is the most common in salt water. (K)

“The major general hospital for the Caribbean island of Dominica has already taken a major beating from Maria. It’s too early to tell just how much damage there will be to the Puerto Rican health system; but medical facilities on the island have historically been underfunded, putting even more strain on health care providers in the midst of an economic crisis in the region. And widespread power outages are expected for the foreseeable future, which will force patients to rely on backup generators and aid organizations.” (L)

“Health and safety are always concerns after such a disaster, but Puerto Rico must try to address those with the island largely devoid of electrical power and with a severely damaged communication system…
There are immediate needs of making sure hospitals can continue to run on generators, which require fuel that is in demand. It’s unknown how many people are trapped in homes that can’t get to a hospital or need some kind of health aid, such as a nebulizer, medication or assistance with getting around…
Jaime Pla, president of the Puerto Rico Hospital Association, told NBC News that hospitals have been able to operate normally for the past 48 hours because they have been on generator power.
“The issue we’re going to have is accessibility to diesel,” said Pla, adding that most generators operate on diesel tanks that last between three to five days…
All of this comes after Puerto Rico’s medical system already was strained as doctors have been leaving the island because of the economic crisis, as NBC News reported last month.” (M)

“The hospitals have been crippled by floods, damage and shortages of diesel. The governor said that 20 of the island’s hospitals are in working order. The rest are not operational, and health officials are now trying to determine whether it is because they lack generators, fuel or have suffered structural damage. All five of the hospitals in Arecibo, Puerto Rico’s largest city in terms of size, not population, are closed.
Making matters worse, 911 still does not work, officials said…
So far, seven regional hub hospitals are taking in patients. The island’s dialysis patients are also getting care. But none of it is easy. Hospitals should be required to have backup generators, diesel, a stockpile of medication and satellite phones, the doctor added. Even with those precautions, problems could arise. There is enough diesel on the island, but a shortage of gas tanker drivers — some cannot get to their jobs — and working gas stations. In Lares, the mayor, Roberto Pagan, said the municipal hospital almost had to close yesterday because it ran out of diesel fuel.
“We have been putting out fires,” Dr. Rodríguez-Mercado said. “The hospitals call you and say, ‘I have two hours of diesel left.’” (N)
.
“Coast Guard planes are flying in fuel, food and water from Miami and Jacksonville. The Navy hospital ship, U.S.N.S. Comfort, with 1,000 beds and 12 operating rooms, is also headed to the island. And the Department of Defense announced that U.S. Northern Command will have a commander on the ground in 24 hours.
“The issue in responding on an island is that you can’t drive trucks in like you can on mainland U.S.,” said Will Booher, a spokesman for FEMA…
At Centro Medico in San Juan, the main hospital on the island, power went out again Tuesday, forcing staff to switch to generators that have to be constantly refueled, said Jorge Matta González, the hospital’s executive director of medical services. (O)

“Aid is finally reaching the islands—fuel for generators, water, medical supplies, food—but disasters always breed disasters. And that might be what’s about to happen in Puerto Rico, too. “The first impact is people who were directly injured,” says Nahid Bhadelia, medical director of the special pathogens unit of the National Emerging Infectious Disease Laboratories at Boston University. “Then you have an entire group of people who are critically ill, facing health care systems that are overwhelmed.”
If things don’t get fixed quickly, the third wave comes. The islands are dealing with standing water, little clean water, and high heat. Those are perfect conditions for waterborne and mosquito-borne diseases—diarrheal diseases, and things like chikungunya, Zika, and dengue.” (P)

‘About 90 patients evacuated from Puerto Rico and the Virgin Islands are receiving kidney dialysis at Florida International University in Southwest Miami-Dade under a hurricane recovery response program coordinated by the state’s Department of Health.
Among the most urgent patients evacuated from Puerto Rico were the three infants with heart defects, who were born in August and September…
For transportation, Nicklaus Children’s turned to its LifeFlight program, an air ambulance service that flies jets packed with advanced life-support equipment for transferring critically ill newborns from the Caribbean, and Central and South America to Miami for medical care.” (Q)

“Evacuees from Puerto Rico and the U.S. Virgin Islands are being transported to mainland hospitals to receive care for critical medical conditions caused or impacted by Hurricane Maria.
In South Carolina, more than a dozen evacuees have arrived at the Columbia Metropolitan Airport by C-130 or private jet to be transported to various medical facilities around the state’s capitol…
In Puerto Rico, 59 out of 68 hospitals are open but not considered fully functional. Troy and her team from Fort Jackson are a part of the National Disaster Medical System, N.D.M.S, and Federal Coordination Center, F.C.C, which were activated in cities within the southern states of Louisiana, Mississippi, Georgia, and South Carolina in an effort to provide free medical assistance to those suffering from life threatening issues.” (R)

“Texas hospitals canceled surgeries, evacuated patients, and closed for days because of Hurricane Harvey. They sank millions of dollars into not caring for patients as a measure of precaution.
More than a month after Harvey made landfall, administrators at the roughly two dozen hospitals that evacuated in the eastern part of the state have now reopened their doors to patients. But some may feel the financial burdens of the storm for months to come — both caring for more patients who can’t afford treatment, while also seeing patients postpone the more lucrative elective surgeries that are many hospitals’ moneymakers.” (S)

“Hurricane Maria took almost everything from Rodriguez save for what he could fit into a backpack: the medical school he attended on the Caribbean island nation of Dominica and his family’s home in Puerto Rico. But he vows it won’t take his future — indeed, it has helped him find it.From his uncle’s house in Homestead, Florida, Rodriguez calls his experience surviving Maria “life-decisive.” In an interview by phone, he told CNN it has pushed him to pursue a new career path in his final semester at Ross University School of Medicine — emergency medicine.It was a decision born in the midst of a crisis.” (T)

“With Hurricane Irma menacing Florida, the leader of a state university campus decided on her course of action: Flee. As the storm approached earlier this month, Sophia Wisniewska dashed off an email to her boss. It included a description of the campus and indicated all was quiet at the University of South Florida at St. Petersburg.
It did not include any indication that Wisniewska was decamping for Atlanta…
Now, Wisniewska is out of her job as regional chancellor at USFSP, forced to negotiate her resignation. USF officials this week released a copy of the resignation agreement to The Washington Post, as well as a draft of a scathing termination letter from USF System President Judy Genshaft. (U)

(A) How Houston Can Become Stronger After Hurricane Harvey, by Anna Almendrala, http://www.huffingtonpost.com/entry/houston-hurricane-city-infrastructure_us_59c019f0e4b093cfe7761771
(B) Hurricane Irma: How Jacksonville-area hospitals responded to latest weather crisis, by Beth Reese Cravey, http://jacksonville.com/news/metro/2017-09-15/hurricane-irma-how-jacksonville-area-hospitals-responded-latest-weather-crisis
(C) Nursing Home Deaths in Florida Heighten Scrutiny of Disaster Planning, by NEIL REISNER and SHERI, https://www.nytimes.com/2017/09/14/us/nursing-home-deaths-irma.html?_r=0
(D) State suspends license of nursing home where 9 died after Hurricane Irma, by Jim Saunders, http://www.orlandosentinel.com/news/breaking-news/os-hurricane-irma-nursing-home-suspended-20170920-story.html
(E) When Irma Arrived, Most Florida Health Care Facilities Were Ready, by JON HAMILTON, http://www.npr.org/sections/health-shots/2017/09/19/551920301/when-irma-arrived-most-florida-health-care-facilities-were-ready
(F) Nursing home says calls for help went unanswered but state disputes claims, by DANIEL CHANG, http://www.miamiherald.com/news/weather/hurricane/article173630881.html
(G) Harvey Affected About 75,000 Hospital Employees in Texas, https://ohsonline.com/articles/2017/09/22/harvey-hospital-employees.aspx?admgarea=news
(H) Lee Health fires then rehires its essential employees who did not work during Irma, by MELISSA MONTOYA, http://www.news-press.com/story/news/local/2017/09/21/lee-health-fires-then-rehires-its-essential-employees-who-did-not-work-during-irma/687117001/
(I) Editorial: Come up with better plan for medically needy evacuees, http://savannahnow.com/opinion/editorial/2017-09-23/editorial-come-better-plan-medically-needy-evacuees
(J) Storm debris, floodwater-soaked furniture pose health risks, doctors warn, by Erik Avanier, https://www.news4jax.com/weather/hurricane-irma/storm-debris-floodwater-soaked-furniture-pose-health-risks-doctors-warn
(K) Kingwood woman confirmed as Harvey death from flesh-eating bacteria, by Cindy George and Todd Ackerman, http://www.chron.com/houston/article/Kingwood-woman-confirmed-as-Harvey-death-from-12230105.php
(L) Hurricane Maria Could Devastate Puerto Rico’s Underfunded Health System, by Sy Mukherjee, http://fortune.com/2017/09/20/hurricane-maria-puerto-rico-hospitals/
(M) Puerto Rico Attempts Recovery Amid Escalating Crisis and Dam Failure, by SUZANNE GAMBOA, https://www.nbcnews.com/news/latino/puerto-rico-precarious-situation-hurricane-recovery-begins-n803926
(N) The Crisis at Puerto Rico’s Hospitals, by OLGA KHAZAN, https://www.theatlantic.com/health/archive/2017/09/the-crisis-at-puerto-ricos-hospitals/541131/
(O) ‘This Is Like in War’: A Scramble to Care for Puerto Rico’s Sick and Injured, by LUIS FERRÉ-SADURNÍ, FRANCES ROBLES and LIZETTE ALVAREZ, https://www.nytimes.com/2017/09/26/us/puerto-rico-hurricane-healthcare-hospitals.html?mcubz=0
(P) https://www.nytimes.com/2017/09/28/opinion/puerto-rico-hurricane-maria.html?mcubz=0, by AM ROGERS, https://www.wired.com/story/puerto-rico-health/
(Q) Stranded in Puerto Rico after Hurricane Maria, infants flown to Miami for heart surgery, BY DANIEL CHANG, http://www.miamiherald.com/news/health-care/article176662251.html
(R) Hurricane Maria victims airlifted to mainland hospitals from US Virgin Islands and Puerto Rico, by Terace Garnier, http://www.foxnews.com/health/2017/10/04/hurricane-maria-victims-airlifted-to-mainland-hospitals-from-us-virgin-islands-and-puerto-rico.html
(S) Texas hospitals feeling the long-term financial strains of Harvey, byy MAX BLAU, https://www.statnews.com/2017/10/03/harvey-hurricane-texas-hospitals/
(T) Hurricane Maria took everything, but it gave med student a calling, by Paul P. Murphy, http://www.cnn.com/2017/10/06/us/hurricane-maria-survivors-story-future-trnd/index.html
(U) This university leader fled Florida during Hurricane Irma. Now she’s been ousted, by Sarah Larimer, https://www.washingtonpost.com/news/grade-point/wp/2017/09/20/this-university-leader-fled-florida-during-hurricane-irma-now-she-has-been-ousted/?utm_term=.88fe8b891f6d

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As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save.

“The Las Vegas University Medical Center looked like a war zone when trauma surgeon Jay Coates arrived just after 11 p.m. PT to care for the scores of wounded victims of the largest mass shooting in U.S. history.
“We started divvying them up, taking them to the operating room and doing what’s called ‘damage control surgery,’ where you’re not definitively repairing everything,” Coates, a medical profession of two decades, recalled. “You are just stopping the dying.”
That’s exactly what medical staff did. John Fildes, trauma center medical director, said UMC received more than 45 trauma patients Sunday night. Although some died before they reached the hospital, “the patients who arrived alive have all survived,” Fildes said.”
As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save….” (A)

University Medical Center is the only level-one trauma center in Nevada and one of only a few free-standing trauma units in the nation. That means it is fully staffed with surgeons and trauma nurses day and night to handle injuries and mass casualties, from vehicle crashes that bring in 10 patients at a time to a 2015 episode in which a woman drove onto the Las Vegas Strip, sending 17 patients to the medical center. Last week, there had been 15 trauma cases in one night.
But even with 11 trauma bays, three operating rooms, a CT scanner, a trauma intensive care unit and a pediatric intensive care unit all under one roof, the trauma center had never faced a torrent like this. For two or three hours, the patients came nonstop. The radio at the clerk’s desk blared with transmissions from paramedics. With the frequency overburdened, other paramedics resorted to calling in patients by phone. Many patients simply arrived in cars or, in one instance, several in the back of a truck.
To an outsider, “it would look like a disaster zone, a chaotic scene, very chaotic,” Ms. Mullan said. “If a nonmedical person were to be sitting there watching this, they would think nothing was being accomplished.”
But in fact much was being done. It had been a busy day, which meant some of the day shift was still present and stayed to work alongside the night shift. Pagers went off with a be-beep be-beep each time a severe trauma case was identified. Patients, most of them with gunshot wounds, were doubled up two stretchers to a trauma bay. At one point, beepers screeched as five trauma cases were clocked in at the same time. “We couldn’t hear each other talk, it was that crazy,” Ms. Mullan said…
“The patients who arrived alive have all survived,” Fildes said. (B)

to read about my experiences with mass casualty events, We don’t know what we don’t know”…The challenge to emergency preparedness…..highlight and click on http://doctordidyouwashyourhands.com/2017/08/we-dont-know-what-we-dont-know-1-the-challenge-to-emergency-preparedness/

Dr. Jay Coates, a trauma surgeon at UNLV School of Medicine, said it was a night of non-stop surgeries.
“It was a little bit of controlled chaos. We’ve had mass casualties come through this trauma center but nothing of this magnitude,” he told Las Vegas station KTTV.
To save as many lives as possible during a tragic event like this, first responders and emergency room doctors must act quickly and make difficult decisions.
“It’s an ethical and moral dilemma that all physicians and health care providers go through because we try to save everyone, but unfortunately that’s not the case,” Dr. Robert Glatter, an emergency room doctor at Lenox Hill Hospital in New York, told CBS “This Morning.”
On the scene, he explains, there is a tagging system that prioritizes wounded patients based on who needs to be seen first.
People who have life-threatening injuries and need immediate attention, such as those with a collapsed lung, are tagged red and are brought in for treatment right away.
Those with severe, but less life-threatening injuries are ranked a tier lower with a yellow tag.
Unfortunately, doctors must also decide when a patient cannot be saved.
“Say there’s a person with a head injury who’s barely breathing. We try to open their airways but if there’s not much chance of saving them we have to move on,” Glatter said. (C)

“…. 100 extra doctors were called in to work Sunday night, along with another 100 people including nurses, technicians, and support staff.
“We have a relatively large emergency department. We were able to triage within our emergency department,” he says. “We used the hallway space to see patients, so it’s a lot fuller than it normally would be and it feels a lot more chaotic.”
At University Medical Center, patients were being triaged in the ambulance bays, Cohen told CNN. The hospital has an 11-bay trauma center, with three operating bays, as well as regular surgery suites, which they likely used in this situation.
“We can get patients from an ambulance into the OR [operating room] in one minute,” Cohen says.
As reports of the gunfire emerged shortly after 10:30 p.m. PST Sunday, the city’s trauma centers began calling in extra personnel.
People working in trauma centers train for such emergencies and would know they’re likely to have to report to work as soon as they heard about the shooting on the news or social media. But still, the scale of this incident may have been surprising. “When you think of more than one hundred shooting victims, ballistic injuries, that is an absolute giant number,” says Bruno Petinaux, the chief medical officer and co-chair of emergency management at the George Washington University Hospital in Washington, D.C.
“When you’re talking about a mass casualty incident like this, this is where you call in the backup, and you call in the backup to the backup, and you may have to message the rest of your medical staff that you may need their help,” he says. (D)

The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation.
Most major cities have such a plan, says Ian Weston, executive director of the American Trauma Society, which advocates for victims of trauma and the trauma care system.
“Hospitals are prepared to build capacity,” he says. “They’ll get the most critical patients into surgery quickly, they’ll stabilize more in the ER and some will even be treated in the lobby.”
He says hospitals determine exactly how many people they can care for in such a situation, even taking into account how many people they can fit into hallways, at least temporarily.
Hospitals across the Las Vegas area were inundated Sunday evening when hundreds of people injured in the mass shooting at a country music festival on the Strip arrived at their doors by ambulances and private car.
And hundreds of doctors, nurses, and support personnel were called into work to help handle the patients that were lined up in ambulance bays and hallways, officials say…
The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation. (E)

“All hospitals in North Carolina have a common agreement for mutual aid. We also have, through our disaster planning, some teams which are available that can be shared between areas,” she said.
Bisset said WakeMed regularly plans emergency response training and drills to practice for a major disaster of any kind, including infectious disease outbreaks, like Ebola, or a chemical attack. However, mass shootings with military-style weapons pose a special set of problems for critical care responders.
“We have the good fortune that a number of our trauma surgeons have served in the military and so they are very well trained with war wounds, because this is what we’re really talking about when you have many of these weapons,” she said.
Bisset said that, on any given day, WakeMed could already be at capacity. In such an event, plans are in place for moving non-critical care patients to other facilities. (F)

In moments like these, doctors, nurses, and technicians lean on their training for most of the required actions. But in every calamitous circumstance—and this is a calamitous medical emergency—there are intricacies that could never have been predicted. And that’s where improvisation comes in. Things that would never be done under normal circumstances can end up saving lives—police cars broke protocol after the 2013 Boston Marathon bombing and put bleeding victims into the back seats of their units and drove them to the hospital themselves, rather than waiting for ambulances. This move, which had also occurred after the Aurora, Colorado, shooting, likely lowered the death toll.
After each catastrophe, leaders such as my colleague Eric Goralnick, medical director for emergency preparedness at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School and the T.H. Chan School of Public Health, share experiences, both domestically and internationally. Paris learns something from Boston: Tourniquets, long out of fashion, had turned out to be helpful in the field. In turn, Boston had learned something from Aurora: Mass casualty drills in Boston had never accounted for such a large number of victims until officials realized in the wake of Aurora that they needed to prepare for circumstances that had previously seemed too remote to train for.
Emergency departments like the ones that treated victims from Las Vegas are forced to develop their protocols based more on anecdote than evidence.
Man-made mass casualty incidents seem increasingly common. But are medical teams actually learning enough from them? Are we really getting any better? (G)

(A) LAS VEGAS STRIP SHOOTING, AT LEAST 50 DEAD, by Brett Kellman, https://www.usatoday.com/story/news/nation-now/2017/10/02/las-vegas-shooting-hospital-you-just-stopping-dying/725466001/
(B) Controlled Chaos at Las Vegas Hospital Trauma Center After Attack, by SHERI FINK, www.nytimes.com/2017/10/02/us/vegas-shooting-hospital.html?_r=0
(C) ‘It’s not a matter of if, it’s when’ How Las Vegas hospitals prepared for a massacre, by Dan Mangan, https://www.cnbc.com/amp/2017/10/02/las-vegas-hospitals-dealing-with-hundreds-of-mass-shooting-victims.html
(D) Las Vegas Hospitals Call For Backup To Handle Hundreds Of Shooting Victims, by Alison Kodjak, http://www.npr.org/sections/health-shots/2017/10/02/555044797/las-vegas-hospitals-call-for-back-up-to-handle-hundreds-of-shooting-victims
(E) Las Vegas Shooting Update: At Least 59 People Are Dead After Gunman Attacks Concert, by Bill Chappell and Doreen McCallister, http://www.npr.org/sections/thetwo-way/2017/10/02/554976369/section-of-las-vegas-strip-is-closed-after-music-festival-shooting
(F) Response to Las Vegas shooting offers lesson to local trauma centers, by Allen Mask, http://www.wral.com/response-to-las-vegas-shooting-offers-lesson-to-local-trauma-centers/16989905/
(G) Hospitals Aren’t Fully Prepared for Mass Shootings, and It’s the Gun Lobby’s Fault, Jeremy Samuel Faust, http://www.slate.com/authors.jeremy_samuel_faust.html

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