Leroy Richmond was one of the first to enter the war at home, hospitalized with inhalation anthrax Oct. 19. Lying in bed, pumped full of antibiotics and other drugs, Richmond was in serious condition, but his doctors at Inova Fairfax Hospital were cautiously optimistic that they had caught the infection in time.
Medical literature doesn't exactly brim with details about anthrax. What doctors do know is that most victims suffer a rapid decline. Then they die. Richmond and the other, unidentified Brentwood Road postal worker being treated at Inova Fairfax were sick but stable -- nowhere near death.
That's why Richmond and his doctors were astonished when they saw TV reports saying that the 57-year-old Stafford County man was "gravely ill." Watching the wall-mounted television in Richmond's room, he and the doctors saw a news conference in progress with health and government officials expressing concern about what they said was Richmond's downward spiral.
"Hey, are you guys holding back something?" Richmond asked the two doctors at his bedside. "Is there something I need to know?"
There was a problem all right. But it wasn't with Richmond. The news conference confirmed what hospital officials had begun to suspect in the chaotic first few days after the deadly infection surfaced in Washington: Information about the still-mysterious illness was circulating fast and furious without a lot of coordination.
"I couldn't believe it!" recalled Steve Brown, the hospital's administrator. "No one called here. The information was not correct, but where did they get it? . . . We knew we had to take control of the situation."
Not only did the record need to be set straight about Richmond, Brown said, but the hospital had to reassure an anxious public as the Washington area began grappling with the anthrax outbreak. And since then, Inova Fairfax has been at the forefront of a regionwide cooperative effort to prepare for bioterrorism.
The crisis began Oct. 15 when an anthrax-contaminated letter arrived at the office of Senate Majority Leader Thomas A. Daschle (D-S.D.).
As postal facilities and government buildings were shut down for decontamination and emergency rooms began to swarm with panicked flu sufferers, health officials mobilized.
Two confirmed cases of inhalation anthrax were being treated at Inova Fairfax, and people began to question whether the region's health system could deal with such an unthinkable emergency.
"We've always been prepared for plane crashes and train wrecks and chemical spills on the Beltway," said Brown, who likens the first days of the anthrax crisis to walking through a new house in the dark. "We really didn't know what we were facing."
Moreover, there was little time to weigh the options.
Hours after tests confirmed that Richmond was infected with anthrax, hospital officials called in an infectious diseases nurse to brief doctors and staff members about the deadly spores and answer questions about their own threat of exposure. Standing-room-only staff briefings by the hospital's entire infectious diseases team soon followed.
"I heard some of the most basic questions, such as, 'Is this transmissible and contagious?' . . . to very detailed clinical questions about treatment strategies and epidemiological histories," said Dan Hanfling, an attending doctor in the hospital's Department of Emergency Medicine, who has testified about bioterrorism preparation and response before Congress and the Virginia General Assembly since the outbreaks.
Shortly after the first anthrax death, in Florida on Oct. 5, Hanfling distributed anthrax fact sheets to the Inova staff. He now oversees educational materials being used to train them.
Officials said one of their first avenues of information and reassurance was e-mail to Inova Health System staff members. The news spread as doctors and nurses shared the knowledge with worried patients.
Brown talked to a few of the patients himself. One of them was nine months pregnant and scheduled for a Caesarian delivery at Inova Fairfax.
"She said, 'I was afraid about whether I should come in or not,' " Brown recalled. "I told her she had nothing to worry about."
Anthrax is not contagious. But that fact is hard to get across to a worried region where some residents have taken to wearing rubber gloves to empty their mailboxes and where fear about contracting the infection has prompted thousands of people to be tested for exposure to the bacterium.
Doctors have spent a lot of time reassuring the public. During a widely covered news conference late last month, Susan Matcha, an infectious disease specialist who has treated Inova Fairfax's two inhalation anthrax cases, made a point of telling the media that she was not taking antibiotics despite her daily contact with the patients.
Depending on your point of view, it was either good fortune or cruel irony that Inova Fairfax held a massive disaster preparedness drill focusing on chemical terrorism three days before the Sept. 11 attacks on the Pentagon and World Trade Center towers.
When the call came in from the Pentagon that day with news of the attack, hospital officials quickly cleared more than 200 beds for the expected casualties. Volunteers swarmed the emergency room, dressed in gowns and gloves to handle numerous trauma patients. They were prepared for the broken bones, the burns and the fatalities, although it turned out few people needed treatment.
It was the second wave of terrorism, with bioweapons, that officials said proved Inova Fairfax and every other Northern Virginia hospital had work to do to better coordinate disaster planning.
That work started with hourly conference calls Sept. 19 that included Inova Health System medical staff members and executives, officials from the Centers for Disease Control and Prevention and the state health department.
Soon after anthrax surfaced in the Washington area, Hanfling, who headed Inova's disaster preparedness task force, was asked to help lead -- along with key members of the Northern Virginia Emergency Medical Services Council -- a disaster preparedness committee among Northern Virginia's hospitals.
Hanfling has been keeping notes on the committee's progress in yellow steno notebooks. The experience of managing the spread of anthrax and preparing for trouble was so new that Hanfling found himself scribbling the words "reinventing the wheel."
"Then I crossed it out and wrote 'inventing the wheel,' " Hanfling said. "That's really what we're doing, writing the book as we go along."
Later this month, a case study of Inova's two inhalation anthrax cases -- written by the team of doctors who participated in the patients' care -- will be published in the prestigious Journal of the American Medical Association. As of Tuesday, Richmond and the other postal worker still were being treated at Fairfax.
Hanfling said that in the wake of the attacks, health officials realized disaster preparation had to be a "front-burner, high-priority" item not only at Inova's seven acute-care facilities but regionwide to create an entity that would allow all the hospitals to cooperate and share information and so avoid inconsistencies and duplication in service.
"What we recognized as the anthrax cases unfolded was that there was a lot of information that needed to be shared and dissected," Hanfling said. "Up until now, there has been no effective means to do so."
Not only would communication with other Northern Virginia hospitals have to be beefed up but so would coordination with health departments and governments across the region, Washington area health officials said. New equipment, such as protective gear, would have to be purchased to safeguard the hospitals, and anxious staff members and visitors would need to be reassured that it was okay to work and visit a place where two patients -- perhaps more -- were sick with a frightening infection.
For the first time, area officials said, they are mapping out the future together. The emergency preparedness committee has brought together representatives from all of the Northern Virginia hospitals: clinical and administrative decision-makers as well as state and local health departments and the emergency medical service community.
The group has begun identifying must-have safety and communication equipment, as well as which drugs and supplies to stockpile. Plans are being drawn up to stagger the shifts of staff members and trained volunteers. Security has been modified at some hospitals -- including Inova Fairfax, which now issues visitor badges and has closed some entrances. Additional training is in the works.
"The hard question now is, what happens if something comes around that we don't know more about?" Brown said. "We learned about anthrax by doing. You can't prepare for everything."