Northeast, the city described in the anthrax scenario (Inglesby, this issue, pp. 556-60) is actually Baltimore, a metropolitan area of 2 million population, with a football stadium that holds 74,000. Route 95 would be where the anthrax dispersion took place. My test case started on February 13 at 6 a.m. when I went to the emergency room at Johns Hopkins University Hospital and asked to see the physician in charge. I described the typical case and asked what the procedure would be if a patient came down with these symptoms. The physician in charge had actually taken the specialized 8-hour training course on bioterrorism (one of five physicians in Maryland to have completed this course entitled ?Train the Trainer?). Nevertheless, she confessed that the typical early case of inhalation anthrax would have a presumed diagnosis of flu, and the patient would probably be sent home. Despite the emphasis on emergency room physicians as the ?early response team,? the actual diagnosis would be made after hospitalization. Many seriously ill patients arriving at the same time might arouse suspicion, but the initial cases would likely be isolated events or would be dispersed in multiple emergency rooms. There was a further problem. At the time of my visit, the emergency room was on ?blue alert,? meaning that all 28 beds were filled; the hospital was also filled. Furthermore, the whole city was on blue alert, probably because of the flu epidemic. Hospitals routinely run on marginal excess capacity. The pressures of managed care have resulted in a health-care system that has minimal elasticity, so on February 13, there were no beds for an anthrax epidemic. I then went to radiology; I showed the radiologist a classic case of inhalation anthrax and asked him how he would interpret the X-ray. He said that he would read it as widened mediastinum; the differential diagnosis did not include anthrax
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