Bioterrorism Expert Develops Best Medical Response to the Unexpected

OAKLAND, Calif. — It was Saturday night ride-alongs with the Harlem paramedics during medical school that first piqued Kristi Koenig’s interest in the way we respond to emergencies in the United States. A systems-oriented thinker from the start, she wanted to more clearly understand why people call 911, how they are transported for care, and what constitutes an emergency. The only person in her medical school class at Mount Sinai Medical School to specialize in emergency medicine, Koenig went on to complete a residency in emergency medicine at Oakland’s Highland Hospital.

Today Kristi Koenig, MD, is a much-in-demand expert on bioterrorism and speaks worldwide on topics of disaster triage, terrorism management, and the coordinated medical response to events many would prefer not to think about bioterrorism attacks, among other scenarios. She is professor of emergency medicine, director of Public Health Preparedness, and co-director, EMS and Disaster Medical Sciences Fellowship, at UC Irvine School of Medicine.

Q: What aspect of bioterrorism concerns you the most in terms of our ability to respond?

A: One of the potential results of a bioterrorist attack would be mass casualties on the order of 100,000 patients or more which would severely stress our response capabilities. If terrorists released an agent such as aerosolized anthrax through the air, and if it were “weaponized” or altered and then spread over a large geographic area, many people could be exposed. There are other agents tularemia or plague that could also be aerosolized and released. The World Health Organization has done modeling of this, and looked at the potential number of casualties we could expect. Compared to the things we’ve already experienced such as the anthrax letter attacks in the fall of 2001 an aerosolized release is the one of most concern.

Q: How well equipped is our emergency response system to a scenario of mass casualties?

A: Emergency departments are crowded on a day-to-day basis, so we don’t have room for another 100,000 people. We would still have our regular emergencies, and putting a bioterrorism attack on top of an already stressed system would be a real challenge.

In the case of an aerosolized release, it would take several days to know about it since there is an incubation period before people start getting sick. It’s possible the terrorists could announce that they had released anthrax in a shopping mall or stadium, but more likely, it would be a covert attack and people would start getting sick days later. Most of these agents give people non-specific flu-like symptoms, and you would need to have a high index of suspicion if you were an emergency department clinician. All of a sudden, you see a bunch of “flu patients” coming in, and it’s not flu season. An epidemiological investigation would need to be done to see if these people were all in the same location a few days before. EMS might be able to detect that something has happened through tracking call volume and call type to see if there was a blip over the prior year in number of “flu patients.” The sooner we detect an event, the sooner we can give prophylactic treatment to anyone who has been exposed.

If we’re successful communicating with the public, people would get information about how to protect themselves without coming to the ER. People get concerned even though they’re not exposed. We saw this, for example, after 9/11 with the anthrax letters. Everybody who saw white powder whether it was from your donut or whatever was worried that it could be anthrax and coming to the hospital or calling 9/11. It is totally understandable as it is a fear of the unknown type of situation but people need to get good information.

Q: What can non-medical professionals do to ensure a greater level of community preparedness?

A: When I first started in this business many years ago, the government was sort of saying “Don’t worry about it. We’ll be there in a few hours to help you out.” Now they’ve become more realistic and say if you’re going to be on your own for a period of time perhaps 72 hours personal preparedness has become absolutely crucial. So people need to think if they didn’t have assistance for 72 hours, what would they need?

Q: How are we as a country doing in this area, and who have you been able to learn from?

A: That is such a difficult question. We don’t have good benchmarks or measurements to determine whether we’re prepared. We can’t study disasters like we can other things in science where you take a double-blind randomized study and say, “OK, I’m going to put you in the earthquake and you not in the earthquake.” It just doesn’t work that way. It’s a more qualitative-type research and it’s really complex. So we’re trying to put some science behind it, looking at things that are very difficult to conceptualize, like surge capacity, for example. How would we manage a sudden influx of casualties from a disaster?

Another area I’m very heavily involved in is what I call “crisis standard of care.” What do we do if we really don’t have enough resources to take care of patients? How do we optimize population outcomes as opposed to what we normally do which is to optimize individual outcomes?

These are very difficult issues to even think about.

LJ Anderson writes on health matters every Wednesday. She can be reached at

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