Welcome, everybody, preventive medicine residents especially, to the 11th webinar in the series of webinars offered on public health emergency preparedness and response offered by the American College of Preventive Medicine. Next slide, please. Just a little bit of housekeeping before we move forward. Again, we encourage the residents to attend the webinars and ask questions to our faculty today. Dr. Eduardo Sanchez will introduce himself in just a little bit. We're gonna be posting a feedback evaluation survey during the Q&A session. Please complete the survey. This is a pilot series, so we look forward to your feedback. Of course, you can continue your discussion on this topic on ACPM Pulse. We have a new online platform for our members through which you can continue your discussion on this topic and other topics pertaining to the preparedness and webinars. And of course, this webinar is being recorded and ACPM will share the recording for all preventive medicine residents to access for future use. Next slide. With that, Dr. Sanchez, I turn it over to you. Thank you. So much, Anita. Hi, everybody. My name's Eduardo Sanchez. I serve as the Chief Medical Officer for Prevention at the American Heart Association. I just can't see one of my buddies on one of these slides. I am a family physician by training. I'm also a public health physician by training. I had the great privilege of serving as a physician clinician in a federally qualified health center for a little while and then did some other clinical care in Austin, Texas. And I also had the great privilege of serving as the local health officer in Austin, Texas. And then the greatest privilege of all was serving as the state health officer for Texas from the years 2001 to 2006. And I'm gonna talk to you today about thinking and acting outside the box, healthcare triage and disaster management and planning. And I'm gonna go at this a little bit differently, I think. I do wanna say that I'm a big believer in systems approaches and the framework systems, standards and protocols at the end of the day, whether clinical care, whether it's doing prevention, whether it's about doing any kind of initiative, whether it's about quality improvement, all lend themselves to some degree of standardization, some degree of comparability and some degree of just keeping order. So it's a great privilege for me to be a part of this. I will say that back in the day, I coined, I think, a definition of leadership that was stepping up in challenging situations to help manage dis-ease. And I think that preparedness is part of putting yourself in a position to be able to step up to manage those challenging situations. I'm gonna spend two seconds just talking about what's going on in my life in the last 48 hours where I've had to put some of the skills I've learned around preparedness in a public health sense, preparedness in a population health sense and put it to work in my personal life. Yesterday morning, I got a call from a cousin who's a orthopedic surgeon in the Dominican Republic where my 90-year-old mother went from Pembroke Pines to attend a wedding that took place on Saturday. She was staying for a few more days. And the call from my cousin was that my mother had called him, she couldn't get out of bed. Long story short is that yesterday she was diagnosed with a non-traumatic occult, but very real right hip fracture. And I've had to work with my siblings, work with my cousin, work with what resources I could figure out to put into place to try to get her transported from the Dominican Republic to the United States. And honestly, those of you who are on it, it's just not as simple as that sounds. So a couple of the, a few of the things that I've had to put into play. When you're doing not so much the preparedness, but responding in a situation, staying calm and exuding calmness is really, really important. That's that stepping up in a challenge to help manage dis-ease. Expect surprises. A few of them have come my way in the last 48 hours. And then again, stay calm. Expect missteps. And some of those have happened. Stay calm. Try to figure out if they are things that can be permitted in the moment and make those corrections. And I've done that with a couple of the missteps already. Make the best use of assets that you have. My cousin is a orthopedic surgeon in the Dominican Republic. So he's been able to help me manage that. And on this end, I've been able to leverage relationships through my wife that have afforded me the ability to identify an orthopedic surgeon in an area close to where my mother lives for her care. And then lastly, keep your eye on the prize. Know what the end game is and understand that everything that you are doing, even as you correct, even as you learn as you're going, is about achieving the objective. The objective is to get my mother back to the United States safely so that definitive care can be provided here where she lives and where she can recover from her surgery. And I'm only sharing that with you because those are some skills. And when I go through this, you'll find those are some skills and some opportunities and some practices that become really important in a disaster response kind of situation. I have no disclosures at this time. And so let's get through to it. The learning objectives, these are just sort of to get us through this. Some of the things that I hope you leave with and my sense having seen some of the previous presentations is that this won't be the first time you've heard some of this. Describe at least three components of an incident command system. Describe at least three types of disaster or emergency incidents. And describe differences between triage for individual patients and triage in disasters, pandemics, or terrorist incidents. As I was thinking about preparing for this, I just sat down and wanted to put together an acronym. You won't see this again, but you're gonna see elements of this as I talk through. Prepare is the acronym. Plan, planning is so important. I'm gonna talk about planning as we go along. Research and prepare. So understanding the situation, understanding what it is that you have in front of you, understanding what your charge and responsibilities are before you have to step up and do anything critically important. Engaging stakeholders, and I'll talk about that. Those would be the partners that you might engage in response to an event. Practice, really, really important, and I'll try to make that case as we go along. There's tabletop exercises where you sort of walk through a thing, and then there's real life exercises. That's like a dress rehearsal. Assess, assessment, really, really important. Not only as you're going along, how are we doing? Do we need to course correct in any way? And you always have to course correct. It's just a matter of when, why, and how. And at the end of it all, when you're on the other side of it, doing an after action and asking, how did we do? What went well? What didn't go so well? What would we do differently the next time this happens? Then the actual respond, if you're only in the how are we doing phase, and the recovery when you're in the how did we do phase, and then evaluation is a more formalized version of assessment. And honestly, it was all so I could come up with the seven things that would make up this acronym PREPARE. So an incident command system is an approach for running the show, controlling the assets, the pieces of the organization that you have, and coordinating those pieces as you go along. It provides a means to coordinate those efforts of the individual agencies through a common goal of fixing what's going on, and in the process, providing as much protection to individuals, to property, and to the environment. Five major components, command, operations, planning, logistics, finance, and administration. The most important parts, I believe, are planning, operations, logistics, and then the command component, not to say that finance and administration aren't important, but those are not generally things that you should find yourself doing while you are engaged in a response. Command, control, and coordination, some of the elements, decision-making, and sometimes delegation of authority. You cannot, one individual cannot be making all the decisions. I think everyone would agree with that. How does one figure out how to make the best use of the team that one has? Situational leadership is one way. I'll be talking about that a little bit later. Communication is really, really important, and one of the things that I had the great privilege of learning from a gentleman named Vince Covello was the notion of risk communication in situations where trust is low, risk is high. And what I learned in that process, and I'll come back to this, is that you have three primary goals. To build or repair trust, people have to see that response as being trustworthy, credible, and getting the job done. Inform stakeholders about the risk or risks, whatever those may be. I can recall in the time of COVID, as y'all can, trying to communicate to people the risk of being in crowded spaces, as an example. And then to gain agreement, trying to have consensus about what needs to get done and how one is gonna go about doing it, particularly in a response or in an event or situation that is either geographically spread out, involves many different sectors, or is one that requires lots of different pieces to make happen, and I'll talk about that in a moment. And then continuous improvement is really, really an important element of everything that I've done in my career. When I was in clinical care, continuous improvement was also about quality improvement in the way I took care of my patients, always doing the work I did based on evidence. And I think in the public health realm, in the population health realm, in the preventive medicine realm, that would hold true as well. And after any event, it is worth doing an after-action review. I came across this particular item interestingly enough and ironically enough at the USAID website, which is largely inaccessible as of the day I tried, February 10th. But I found this little bit that I could come to, and I'm sharing it with you because these are words that everyone understands. Sometimes when you look at a continuous improvement paradigm, a continuous improvement protocol, you see words that are just not the words that are commonly used by everyday people. Here we go. What was supposed to happen when we did this thing? What was the reality of the thing we did? What went well? What didn't go so well? And what should be changed for next time? Five essential questions, sometimes encapsulated or communicated with much more intellectual sounding, but not necessarily words that convey understanding to those who were involved. Assessment. I wanna talk a little bit about kind of how things are organized in Texas. And part of that is asking yourself whatever it is that you are charged with being responsible for, is understanding what is in the realm of possibilities of the job that I have. And I'll come back to this, but when I became the Commissioner of Health, one of the things that I became acutely aware of and interested in better understanding was the responsibility of the Texas Department of Health when I started, the Texas Department of State Health Services, which is the organization that I was heading up when I left state public health. I came to realize that one of my charges was to oversee the health and medical response to a public health emergency. And I wanted to get my arms around what that meant, what responsibilities I had, what assets I had to bring to bear, how I might go about doing that. And I spent time bringing all pieces of the department to understand what those roles might be and anticipate that in any moment, one can get a call from their cousin saying that their mother has a broken hip. So the organizational construct. In Texas, there is a division of emergency management that coordinates Texas Emergency Management Program. What is the equivalent for whatever it is that you might be doing, whether that's at a local level, whether that's working in a health plan, how do they manage emergencies when and if they happen and how do they manage emergencies that affect members, the people who are in the health plan, employees, the people who work for the health plan and the facilities that the health plan might have. It's a way to think about this notion of assessing and understanding what it is that is expected and what it is that you're supposed to know about. So it's intended to ensure the Texas Division of Emergency Management that state and local governments respond and recover from emergencies and disasters and they implement plans and programs to prevent or lessen the impact of any given emergency or disaster. Anticipating and being prepared. In a place like Texas, anticipating hurricanes, probably a good idea. In a place like Texas, anticipating outbreaks of disease is probably a good idea and you are on another planet if you don't know that Texas is in the midst of a measles outbreak right now. Anticipating heat-related kinds of issues in a state like Texas, very, very important and part of how you should think about the work that you do. The Texas Division of Emergency Management defines a comprehensive emergency management program as including pre and post disaster mitigation of known hazards to reduce their impact, preparedness activities such as emergency planning, training and exercises, provisions for effective response to emergency situations and recovery programs for major disasters. That division lived in the Texas Department of Public Safety until 2019 when that was transferred to the Texas A&M University System, that is the Texas Division of Emergency Management. Very quickly, one pre-disaster mitigation would be to know that a hurricane is potentially gonna hit a part of the state and being able to, on the one hand, have people evacuate certain areas that might be very adversely affected and also to be prepared to, post disaster, have pre-positioned supplies and other things that might be needed for recovery. I'll keep going. The Texas Department of State Health Services has a public health emergency preparedness unit. It works with local health departments to improve their ability to respond to public health threats, not limited to infectious diseases, natural disasters, biological, chemical, nuclear and radiological events. Texas has 64 established local health departments, 45 of them participate in the public health emergency preparedness program. Begs the question, what about the other 19? Which works to build more resilient communities prepared to deal with and rapidly recover from disasters. And this is done through federal funding that comes to the state and the state helps assist with planning, training and exercise efforts. The Texas Department of State Health Services disaster response and recovery happens at the state medical operations center. It serves as the ESF-8 public health and medical lead to support the Texas state operations center. That's responding to an emergency, all those other things that are not public health and medical transportation, et cetera and so on are happening out of the Texas state operations. And I'm sharing this with you, not so that you understand Texas necessarily, but that you think about what is it that you know and or don't know about what constitutes emergency response and the emergency response system where you might have some leadership and or responsibility. The state medical operations center provides operation support and coordination of those response activities during disasters, provides four basic functions in emergency response. I'll show you those in a minute within 17 core functional areas. And those four basic functions, coordination and control, communications, resource allocation and then recovery. Those look very similar to the elements of incident command because indeed they are overlapping. Types of disaster emergency incidents. I named a few of these and some of these you will recall. Hurricanes, tornadoes, wildfires, winter storms, mass casualty events, public health emergencies, COVID was one, Zika, Ebola, and I mentioned measles just a moment ago. And then some major activities that at least the state of Texas is involved in include evacuation support for persons with medical needs, providing patient care, support for medical and actually some support for non-medical shelters for that matter, repopulation of persons with medical needs, immunizations, medical supplies, mass fatality support, and also health surveillance. That health surveillance is the activities that take place among the activities that take place in non-medical shelters but that come into play. So I'm gonna shift and talk a little bit about leadership. And what that is, and as I mentioned earlier, some of that is the ability, the responsibility to step into and be that person or among those persons in a uncomfortable set of situations because there's a disaster that's occurring for a number of reasons and provides the leadership to manage dis-ease and the consequences of that dis-ease. I came across this model a few years ago when I was researching the idea of leadership. And situational leadership is a flexible framework. It's a framework that enables leaders to tailor how they go about leading the members of their team or individual members of their organizations. Developed in 1969, and it is something that I have come to realize I used but didn't know what it was called. And you will find that that happens. You do a thing and you find, oh, there's people who write about this and have given it a name. I didn't know I was doing the thing, situational leadership, but it is indeed the way I generally do leadership. And I'm saying that more generically than actually. Here's a diagram of situational leadership. And I'm only putting this in front of you because I'm gonna tell a story in a little bit about situational leadership. If you look at the source, that's the reference, it has a perfect little phrase that I think is what situational leadership is about. It's the right leadership at the right time. And I will say to you that it applies not only about how you lead, but it also applies in how you might put people into leadership positions when situations arise. What this tries to capture in a somewhat complicated way is it's starting at the right, where it says telling. There are basically four styles of being a leader. And S1 is where you have somebody who has not had a lot of experience yet. And the leader makes the decisions and basically tells the follower what to do. So the leader makes the decisions, the follower does what he, she is told. In the next box, there is some maturation on the part of the follower where the leader still makes decisions, but there is some input solicited from the follower that may modify how that direction is actually executed. In the next frame, that very evolved follower or the more evolved follower is now making decisions, but soliciting input from the leader about how the follower might modify what he, she is doing. And in the last section, there's very little directive behavior. That is, the follower makes decisions and basically offers what I might call updates to the leader as opposed to seeking guidance on how to take step A, B, or C. Now, that's important, I think, because sometimes you have folks who come into a work environment who are very ready to get the work done. And you might be leading them in a participating or delegating mode as opposed to a selling or telling mode. And the selling, the telling or selling might be where you have hired somebody or somebody joins the team who appear to be very capable. They haven't been around very long. They might be somewhat inexperienced and you might feel that very appropriately that they might need some good guidance, some good observation as you watch them evolve. The reason this is important is that in emergency settings, what I found is that I sometimes moved people into a different kind of leadership role in this incident command system. Again, I'll talk a little bit about that in a more concrete way in a moment. Again, preparedness. I believe that the ESF-8, the public health and medical response, the players, the sectors that make up and need to be a part of that preparedness response include, of course, public health, but include the healthcare delivery system and its providers, and then the emergency medical services as distinct from the healthcare system and its providers. And I will share again examples of how those are essential to think about emergency response. In some instances, there may be very little that's EMS or healthcare and a lot of public health, and there may be other situations where the sizes of those pieces might alter in terms of influence as reflected by the size of the wedge. So I was charged with talking about triage. And I do wanna say that triage in this sense, which is triage, which happens in clinical care settings. I'm gonna use the example of emergency departments. When you go back and think about this triumvirate, this three parts of the circle is largely in the hands of healthcare and EMS. It's very, very important so that folks get directed to the right places. But this is a situation where when you are trying to figure out who does what and roles and responsibilities, healthcare and emergency medical services are best equipped to be driving triage and triage decisions. So again, it originates from the French word, trier, used to describe the processes of sorting and organization. It's utilized in the healthcare community to categorize patients on the severity of their injuries or their conditions, and by extension, the order in which multiple patients require care and monitoring. Who goes first? Who do you take care of first? In an emergency department setting, here is one index, the emergency severity index, five levels, is the patient dying? And can we do something about it? That's level one. That person in this environment is gonna get taken care of first. Second, is the patient in a high risk situation, confused, lethargic, disoriented? Is the patient in severe pain or distress? That's level two. Level three, does the patient require two or more hospital resources, whether that's internal critical care bed, which actually is gonna be much more than two hospital resources. Do they need to be on the floor with nursing care? Does the patient just need one hospital resource? And level five, the patient doesn't need any hospital resources at all. I would say to you, we were talking about, I was talking about my mother. I would say my mother is at a level four plus, four minus, somewhere between three and four, probably more like four. Because she's a 90-year-old woman, things can happen fairly quickly, particularly in the setting that she's in right now. Now I'm gonna transition to preparedness. In a preparedness setting, what does triage look like? And that's a little different, I would say. In disasters, pandemics, or terrorist incidents. In disasters, sorting, prioritizing, and allocating scarce resources sometimes comes down to doing the greatest good for the greatest number. Now, that doesn't need to be done in a crass sort of way. It is done in a way that says, how do I make use of the resources I have, and how can I make that stretch for the most number and do the most good? Protocols should be used for triage. That's true in an emergency department as well. Those protocols can provide a decision support aid in a time of crisis to improve performance. What does that mean? You really don't wanna be trying to make a decision without a decision support tool to just help you know, if this, then that, if that, then this. And in those situations where there's some indeterminateness, then you have to do the best you can, still trying to operate with the decision support tool. They also help improve consistency of decisions that are made as well as improve outcomes. So that as staff changes, or as your ability to make smart decisions is challenged by the time and intensity of what you're doing, those decision support tools can help you stay consistent in how it is that you're making decisions about triage. And they've gotta be designed in a way that helps distinguish between those who are most in need to benefit from a particular therapy. Some disaster triage considerations, the likelihood of survival at a high level, quality of life kinds of issues, and resource consumption. Will this action result in having much less that can be used for others or for a longer period of time? And some, and this article suggests really important to find, have a triage officer, somebody who's helping provide that. They might benefit from extensive clinical experience, from the experience of leadership, from being effective communicators, and people who can make decisions in tough situations. So I'm gonna talk a little bit about communication, and I'll tell a little story. And communication is really, really important. And it's important, particularly in situations where there's low trust and high risk. Low trust, high risk might be characterized by what was going on during the pandemic. It might be characterized if there's a different kind of outbreak or disaster situation where it was the result of inattention to unknown possibility. And those effective risk communications, as I said before, three primary goals, to build or repair trust, to inform stakeholders about risk, and to gain some consensus about what needs to be done. One of the things that I learned in training from Vince Covello, which has served me to this day, is how to think about the construct of risk communication. And that, I'm gonna share one example of where I used this particular framework, this particular rubric. It was when the first case of West Nile virus had caused, when the first death from West Nile virus had occurred in Texas. The case was in Houston, Texas. We felt that there was a press conference that needed to be held. And that press conference started with an acknowledgement of what had happened, an expression of condolences for family members and friends. And then the three affirmative statements were maybe along the line of, we know what we need to do to protect people in Texas. They include the following things that would be statement number two. And number three is we have a plan that is going to address this statewide now that it has reached the state, caused a death in the easternmost part of the state. We were prepared for this. We knew that this was going to eventually happen. And we had the pieces one, two, three ready to communicate, but they needed to be prefaced in the event of this particular situation where someone died, starting with an expression of condolences. That expression of condolences builds some trust and sense that you are empathetic and caring, and that buys you the attention to then communicate the three affirmative statements. I'm gonna shift now, and I'm gonna come back to these questions that I mentioned earlier. Continuous improvement. I have been, I said this earlier, I have been a practitioner of continuous improvement through my entire career, as a clinician, as a clinician in training, as a public health doc. And after every incident that I was involved with, I sat down with others and put these five questions in some form or fashion in front of us. What was supposed to happen? What did happen? What went well? What didn't go well? What do we change for the next time? One of the times that we did an after action where the answers were mostly in the affirmative just because I had smart stakeholders around me to help me figure some things out. At a time early on, when I was a local health officer, we had a number of meningitis cases among persons who were HIV positive. And it became clear that although these people resided in very different places, they were spending social time in clubs and other places in very densely mixed and populated places. I will tell you that it took some convincing to the CDC that while this didn't look like a typical meningitis outbreak situation, what we had when you considered the zone where people were all lending some of their, spending some of their time, that we indeed had a meningitis situation. This was in the early years of the HIV epidemic, in the years of very low trust of the public health community on the part of folks with HIV and fear of persons with HIV by the general community. And what we did, again, working with many stakeholders, is that we went to the clubs and we did vaccines and we did immunoglobulin injections at the time in the clubs before the dancing started and in the early part. And as we did these things at club after club, A, the word got out about what was supposed to happen, what the reality was, what went well. We learned a couple of things about what didn't go well. We changed those for the next time. And I will say to you that by the end, we had people lining up and we had people inviting us to stay and dance at least one or two dances after we put our tables away. I'm gonna walk you through this towards this. I'm gonna hopefully spend just about eight minutes about what I think might be a way to put real world experience, more real world experience around planning to response from 2001 to 2006. I was named commissioner of health three days after 9-11. I started the job on November 2nd, 2001. Between 9-11 and my start was when the anthrax events took place. So it was very clear when I started that a focus on bioterrorism was gonna be part of the job. There was no budget for bioterrorism preparedness. The department before I joined had put in front of the legislature a request for funding to put together a bioterrorism, not only a plan, but response capability. And that didn't happen. It wasn't even authorized with no funding. There was just no budget and there was no program. So when I came on board, I was trying to figure out with the rest of the persons working at AHA, what do we do? The one thing is, the plan existed. It was the work that had been put in front of the legislature. So we figuratively took it off the shelf. We created something called the Bioterrorism Workgroup, where we brought every single part of the department, every single unit of the Texas Department of Health at that time and went through an exercise where we tried to determine what assets they brought to bear that might help support a bioterrorism unit, or if they just were not relevant to the bioterrorism unit. And in that process, we created, we cobbled together through this Bioterrorism Workgroup, a bioterrorism unit. The bioterrorism unit, in subsequent months, was provided some funding that came from the federal government that was the result of the actions and the legislation that was passed to support bioterrorism preparedness nationwide. The other thing that happened when I joined the health department is that as I looked over what were those health and medical responsibilities, roles and responsibilities of the health department, it seemed to me that 90% of the assets that one might bring to bear or one might need to bring to bear during a public health emergency response were not in the hands of the public. They were not government property. They were not government assets. They were indeed in the private sector. And there was no appetite then, and even less appetite now, to give the commissioner of health the ability to commandeer resources to do a response to a public health emergency. So in trying to figure out what to do and how to do it, I, with others, had this thought of creating the Preparedness Coordinating Council. It started as somewhat of a kitchen cabinet where I invited persons representing different sectors that seemed to me to be very important in health and medical response. If you think about the pie that I put earlier with the three pieces, some of those pieces are comprised of physicians, so Texas Medical Association, nurses, Texas Nurses Association, hospitals, Texas Hospital Association, the Pharmacy Association, the ACLU, and knowing that there might be a need to think about public health that might involve quarantining, mental health presence, behavioral health, other behavioral health presence. And there were two tasks of the Preparedness Coordinating Council at first. One was to also review the legislation that authorizes the response, and if they had any thoughts about how that might be tweaked that we might take to the legislature, but also what might be a way that we could create a structure, an organizational construct that could respond to an emergency, including decision-making and distribution of assets. So that got put into play, and it served Texas well. I will make the case in a moment. In 2005, as a result of the work that had been done around bioterrorism, Texas conducted the largest strategic national stockpile exercise that had ever been conducted anywhere in the United States. And when that happened, that was one of the times where situational leadership—I had to exercise what I thought was a situational leadership decision. The person who might ought to, on a org chart, be thought to be in charge of the strategic national stockpile exercise was somebody who was a deputy—excuse me, public health officer. But the person who I thought had the operations skill and the ain't-no-way-we're-gonna-fail sensibility about him for this exercise was the chief operating officer of the department. And I chose to put that person, the COO, in charge of this national stockpile—strategic national stockpile exercise, where we did pretty well. We got an A-minus. I believe that's how they scored them. The governor's office was angry that we didn't get an A+. But the truth is, when we did our after action, there were some lessons learned, but a lot of it went well, and a few things didn't go so well. That was situational leadership. I had to deal with the deputy health officer who was not too happy with me. And I had to, I think, convey that the important thing was success. And I thought that that other person was the most likely to deliver success, because that was really an operations exercise and not a public health response exercise, if you will allow me that. In 2005, when half a million Louisianans came to visit Texas because of Hurricanes Katrina and Rita, there were a few things that had to be addressed. One, there were dozens of shelters for non-medical care and for non-medical sheltering that required some of that health surveillance and public health oversight. But think about this. You have half a million people come into a state. Any of them who left immediately might have need for medications. And because of the Preparedness Coordinating Council, it was easy, easy, put in quotes, to convince the Texas Pharmacy Board that for 90 days, Texas would honor any and all prescriptions that were coming from Louisiana. The Texas Renal Coalition that was part of the Preparedness Coordinating Council stepped up and took on a large part of the responsibility of assuring that people who needed dialysis, who came among those 500,000 Louisianans, would be welcomed and taken care of in the dialysis centers in the state of Texas. The Texas Education Agency, not a part of the Preparedness Coordinating Council, but having done what we did with the Texas Pharmacy Board, we approached them and said, wouldn't it make sense to waive the proof of vaccination for kids who are from Louisiana, assuming that probably our neighbor state requires vaccines for their students? They did. And we were able to accommodate students. We were able to take care of people's medical needs. And we were able to provide dialysis by thinking ahead, on the one hand, and acting quickly and in an anticipatory way. In 2005, some folks came to me. This is in the middle of hurricanes, actually as Hurricane Rita that came right after Hurricane Katrina. And Hurricane Rita came into Texas, and all of those shelters and all of those people that had left Louisiana and were in Texas coastal counties needed to be moved. So it was like a double sheltering kind of situation. And there were people who needed medical care who were going to have to be moved, and there was less capacity to take care of them. Folks from Texas A&M came to me and said, hey, Commissioner, we have a large animal veterinary hospital facility that has not been used yet. We're opening in a month. We believe we could take care of patients there. My staff went and visited and said, it's safe, but we don't think we should do that. And my response, and not unilateral, was, you know what, that makes really good sense. There's capacity, there's equipment. We did it. The after action was exceedingly positive, up to and including engaging a part of the state to respond. Two more things, and then I'll be done, Anita, and we'll wrap it up. I was asked during, and I would say to you, that was a triage question. The question about the large animal veterinary hospital, if you go back to the two slides about triage, that was indeed about triage. And it was a way to use resources that we had in the best possible way that would not result in expending other resources in other places and stretching ourselves too thin. And it brought a whole bunch of volunteers, not vets, these were practicing physicians who took care of patients. And oh, by the way, large animal veterinary hospital equipment, at least at that time, was just basically adult equipment that's used on animals. We were requested to set up a field hospital in Houston in the midst of, in the aftermath of the hurricane, where a part of Texas north of, north and east of Houston had been ravaged. And Houston had been largely spared. Houston hospitals were providing the emergency care for people from that part of the state. The Texas hospitals wanted to open up and start providing elective surgery and elective care and wanted me to open up a field hospital in Houston so that folks could be taken care of there. Honestly, the answer was no. And what we did was set up a, we set up field hospitals in, in the part of the state that got ravaged. And lastly, we spent the time and money from 2005 to 2006 on an after action report on what we did to determine how we might do better if there was another big hurricane or another big public health event. This slide is just to show you that the preparedness coordinating council that started as an idea in my head has actually been codified. And here are the members and the different parts that are represented and some takeaways. This is really hard work. And it, and just admit it to yourself and be prepared to do the hard work. Preparation absolutely matters. And it makes a difference. When it's done well, it doesn't mean the disaster doesn't happen. It doesn't mean that it's not hard. It means that you are prepared and you can manage those tough situations better and more effectively. You should make use of framework system standards and protocols. I tried to speak to some of those. Real-time tracking of progress and performance are critical. So we did every day kind of how did things go so that we could make those changes. And I would say that in this day and age, information technology, IT needs to be in the room, at the table, helping to make that tracking better. Course corrections are key. We weren't always doing the right thing at a particular time. And being able to know that and make those course corrections is really important. Constant communication, also key. You cannot over-communicate during these kinds of emergencies. And then lastly, I repeat myself, continuous performance improvement and monitoring are very, very important. My favorite quote, I'm not an optimist. I'm a very serious possible list. And I say to you, this is not about being optimistic. This is about using the skills to anticipate, to plan, to put people around you, to monitor performance, make course corrections, improve performance. The pieces are there. The possibilities are endless. And so with that, thank you very much. Thank you, Dr. Sanchez. We do actually have a couple of questions come in. So if you don't mind, do you mind taking a couple of questions? Of course, I don't. Of course. Wonderful. So the first question is, if in an after-action report, you realize that you made a significant mistake, how do you communicate that mistake? What do you say that you will do differently? Gosh, I mean, I am somebody who believes you come clean. And you figure out how you come clean, how you admit that maybe errors were made in a way that, A, doesn't disparage people and is about learning, because we learn when things don't go right. You know, in the world of business, they talk about, I don't know, what is it, only one out of 10 businesses survive, or one out of 10 startups. That means nine failed. And all I'm saying is that not having everything succeed is a normal part of everything we do. So I think the other thing is just know and convey that this is how we do better the next time. One of the things that I used to say, we're doing better today than we did yesterday, and we're going to do better tomorrow than we did today. Maybe if you did something not—so I find that that's a nice mantra. Accentuate the positive. Focus on what you're going to do. And if you are in a position like a Department of Health or something like that, what I learned was to go talk to the elected officials that might not like what they hear. And I would arrange one-on-ones or, you know, two-on-ones, have private conversations where I'd say, listen, I need to come clean with you. And what I found time and again, that was, A, respected, B, welcomed, and C, resulted in me not getting put in an embarrassing situation when I was testifying in front of them. So I would say transparency, really, really important. And then making sure that that transparency turns into, what are we going to do different so this doesn't happen again? Great. Thank you, Dr. Sanchez. A couple of more questions. So the second question is, what happens when the public health response is in conflict with what the health system wants to do? Treat fatally ill patients versus use resources to try to prevent future populations from having the exposure. So I would say to you, the way to OA, one of the methods about trying to mitigate those situations is to be involved in the planning and preparedness early on. The situation that you just described is one where I feel like, with the Preparedness Coordinating Council, there would have been a way to have the conversations, because the Texas Hospital Association was involved in the work that we were doing, and the emergency medical services folks were involved in what we were doing, and try, and try, try is the operative word. You can't always know how things are going to work. But I would say to you that if this happened without there having been some conversations in the past about what-ifs, then that's the missed opportunity. And what I would say to you is that now is the time, as I started, make an assessment of what are the likely kinds of situations that will arise, and how do you begin having the conversations that begin to talk about what are the ways that we would respond to this, and what will we, if you're talking to leaders, what role will we play as leaders to be able to manage the resources and the circumstances in a way that doesn't put us in conflict, but puts us in a complementary support mode. Thank you, Dr. St. Justin. My final question is, how do you deal with the situation when your non-medical public health supervisors, especially in government, want to stop what you're doing or won't allow your responses, et cetera? They're tough. And I will be, I will say to you, I was fortunate in that I never had a significant situation where that happened to me. So I think that just comes back to what I said before, is establishing relationship. Sometimes it's organizational relationship. Sometimes it's relationship with people. And it's not always, it at times, trying to avoid the negative, it at times is not going to go, it at times will go in ways you weren't expecting. So I will say in this communication scheme, one thing I missed is not only that you express condolence and then, or acknowledgement, but that your messages are communicated in the affirmative. And if you think about the example I gave, it was the things we were going to do as opposed to non-things that we were going to do. You know, the last question is really, really tough. And that last question is one that in these times, in these political times, has become more and more a reality where the public health imperative sometimes does not align with the imperative of others. And all I could say is do what you can to anticipate those kinds of situations. And actually, if you think about the idea of a tabletop exercise, even to go through the role modeling exercise of what if, I think what ifs are worth doing. They're not hokey. And it really is about how do we lead in times where people are apprehensive, worried, scared, and how do we together lead in a way that engenders confidence and a sense of hope about what's going to come tomorrow as opposed to where we are today. I hope that was helpful. I still think thinking about what ifs, but more importantly, engaging in the work to be able to manage those what ifs, whether it's having those conversations, doing the exercises, engaging in stakeholder relationships, creating your equivalent of a preparedness coordinating council, making sure that that operations person is in the room with you, that non-public health person is also in that room might be critically important. So with that, thank you so much for your time. Thank you for inviting me. I hope this was of help and a benefit. Absolutely. Thank you, Dr. Sanchez. I'm just going to stop recording here for just a second.

public health emergency preparedness

disaster response

systems approaches

situational leadership

strategic national stockpile

communication in crises

triage methodologies

cross-sector collaboration

after-action reviews

emergency response strategies