During catastrophic disasters, government leaders must decide how to efficiently and effectively allocate scarce public health and medical resources. The literature about triage decision making at the individual patient level is substantial, and the National Response Framework provides guidance about the distribution of responsibilities between federal and state governments. However, little has been written about the decision-making process of federal leaders in disaster situations when resources are not sufficient to meet the needs of several states simultaneously. We offer an ethical framework and logic model for decision making in such circumstances. We adapted medical triage and the federalism principle to the decision-making process for allocating scarce federal public health and medical resources. We believe that the logic model provides a values-based framework that can inform the gestalt during the iterative decision process used by federal leaders as they allocate scarce resources to states during catastrophic disasters.

The events of September 11, 2001, set in motion the broadest emergency response ever conducted by the US Department of Health and Human Services. In this article, some of the nurses who deployed to New York City in the aftermath of that horrific attack on the United States offer their recollections of the events. Although Public Health Service Commissioned Corps (PHS CC) officers participated in deployments before 9/11, this particular deployment accelerated the transformation of the PHS CC, because people came to realize the tremendous potential of a uniformed service of 6,000 health care professionals. When not responding to emergencies, PHS CC nurses daily serve the mission of the PHS to protect, promote, and advance the health and safety of the nation. In times of crisis, the PHS CC nurses stand ready to deploy in support of those in need of medical assistance.

Part I of this report summarizes findings from a literature search on end of life in people with genetic disorders. There is a paucity of research on this topic; thus this article includes descriptive studies, clinical reviews, and case presentations. Part II describes the proceedings of a workshop to discuss end-of-life issues in people with genetic disorders. The workshop brought together clinicians, researchers, and people living with genetic disorders to discuss this topic. The purpose of this article is to summarize the literature and workshop proceedings to provide directions for future investigation in this important area.

BACKGROUND: A deficiency of alpha-1 antitrypsin (AAT) can lead to pulmonary disease in middle-aged adults in whom dyspnea management can be a significant issue. OBJECTIVE: The research addressed whether short-term oxygen (O2) administration during activities might decrease dyspnea and improve exercise performance in nonhypoxemic patients with emphysema caused by a deficiency of alpha-1 antitrypsin. METHOD: This was a double-blind, randomized crossover study of 31 subjects with a deficiency of AAT (mean + SD, age = 47 +/- 7), moderate emphysema and a resting PaO2 > 70 mm Hg. Oxygen saturation (SpO2), 6-minute walk distance, and end of walk dyspnea were measured during three practice walks and during walks with nasal cannula administration of O2 (intervention) and compressed air (control). RESULTS: Repeated measures analysis of variance (ANOVA) showed significant differences across the walks for SpO (F= 18.9, p = 0.0001), 6-minute walk distance (F= 6.07, p = 0.004), and dyspnea (F= 4.44, p = 0.016). Using post hoc contrasts, SpO2 was the only variable that differed between 20, and compressed air (p < 0.0001). There was, however, an interaction effect of gender with O2 for dyspnea (F= 9.85, p = 0.004). Mean values showed that men did not benefit from O2 (p = 0.87). However, women experienced less dyspnea when receiving O2 as compared with compressed air (p = 0.0025), and although not statistically significant, the lower dyspnea with O2 corresponded with an increased walk distance of 79 feet. CONCLUSIONS: O2 administration may be useful for reducing dyspnea during exercise in selected populations.

In twenty-one patients ventilated for > or = 3 days, we compared similar levels of partial support provided by synchronized intermittent mandatory ventilation (SIMV) and pressure support ventilation (PSV) in terms of breathing comfort. On a single day, eligible subjects experienced, in random order, both SIMV and PSV weaning protocols (sequential 20% reductions in support at timed intervals) separated by a 1 to 3 h rest. Breathing comfort was defined by subjective ratings of dyspnea and anxiety. Subjects reported significant levels of preweaning dyspnea and anxiety despite resting for at least 6 h. Dyspnea and anxiety were not significantly different between the two methods at any level of support. Our findings suggest that dyspnea and anxiety are higher than expected on "full" ventilator support, and that comfort may not differ between PSV and SIMV during active withdrawal of machine support.