The media and the federal government have warned Americans to be prepared for an anticipated yet unrealized pandemic of avian flu. It all has the hype and horrors of Stephen King's The Stand. In that book some of the first exposures are to an EMS crew at the scene of a car wreck caused by an incapacitated flu victim.

The sentinel event that triggers a massive response from the U.S. Public Health Service may very well be a firefighter or paramedic reporting to a local health district about taking a patient off an airplane who was traveling from Asia with fever and chills. Flu annually kills an estimated 20,000-25,000 people in the United States, or about 22 per 100,000 people annually. Many say it's not a matter of if but when an even deadlier strain of flu will travel the globe, potentially killing millions. Public health officials have been talking about this event for years, and the computer models indicate we're overdue for a pandemic event.

If you're a fire chief in a community that has an international transportation facility, the fire and EMS crews may be the key to containing or slowing the spread of bird flu. The National Flu Pandemic Plan identifies the need for local officials to prepare and plan for the flu; most of the burden for operations will fall on the local public safety organizations.

It's imperative that fire and EMS crews servicing those facilities be educated on the surveillance system, clinical signs and symptoms. They must also develop an attitude that focuses on a high index of suspicion of bird flu. First responders with astute clinical skills can funnel patients who require further evaluation into isolation areas. First priority for equipment, vaccination and training should go to those units. Employees should be empowered to report to the health monitoring systems and act as important monitors for the first patients presenting with suspected flu-like symptoms.

Vaccination has become a hot topic, as there currently isn't a bird flu vaccination. As the president mentioned in an October press conference, first responders will receive first priority for bird flu vaccinations. But will it be produced and ready to be distributed before an outbreak of bird flu occurs and infects first responders in large numbers?

Keep in mind that the federal government has not demonstrated the ability to move quickly in the most recent disaster situations. The federal system depends on regional resources being moved to the location of the emergency. Because it's expected that any disease will appear in many areas at once, those regional resources may be unavailable or delayed in deployment.

The problem with any delay is that the spread of flu outpaces the body's ability to contain it in about two days. This makes it necessary for local stockpiles to be developed or to apply other methods of protection to be in place due to the rapid increase in sick people and limited resources. Getting a regular flu shot may provide some protection because the viruses are similar, but not identical.

First responders and staff should consider getting the Pneumovax II or the Pneumococcal Vaccine. Flu weakens the immune system and allows other opportunistic infections to gain a footing. Pneumonia is a frequent killer of flu victims, and the Pneumovax II provides significant protection for up to five years against the bacteria that is the number-one cause of deadly pneumonia. This strategy should be extended to relatives of first responders such as children, elderly parents and family members with respiratory diseases.

Another option is to purchase antivirals, although you will be lucky to find a significant supply now that restrictions have been placed on shipping. According to estimates, there's only enough antiviral medication for about 5% of the population in the United States. It makes sense to stockpile antivirals for you personnel.

Tamiflu (oseltamivir phosphate) and Relenza (zanamivir) have a seven-year shelf life and are the two antivirals that have been shown to combat the flu. The medication must be taken within two days of exposure or at the first onset of symptoms to be effective. If given two days after the onset of symptoms, the medication won't be effective and may lead to antiviral resistance, leaving no other medications to be effective against the flu.

In a worst-case scenario, a significant staffing shortage may arise in the first responders and hospital staff. In simulations on bio-warfare done by ABC News in 1999, approximately 33% of the first responders became ill or stayed home to care for sick family members. Fire chiefs should consult with command staff on how they would deal with a simultaneous loss of half of their staff and a significant increase in call volume. This is new territory for most emergency responders, and there are few examples to draw from.

One contingency plan is to consider down-staffing fire apparatus for EMS or transport vehicles. If you rely on private ambulance for transport, it's important that your mechanics have a plan to staff transport vehicles if faced with similar sick call-offs. Theoretically, the health departments will limit activities in large venues, resulting in a decline in daily activity and a drop in the number of calls for service that typically require fire apparatus. There will be migrations of people to the rural areas, and small departments will need to prepare for influx of people and limited resources.

Transporting and dealing with an already overcrowded hospital situation will be the biggest challenge faced by EMS. Hospital resources will become overwhelmed very quickly. The “worried well” will flood the system and need to be screened, which may result in extended turnaround time for ambulances and a lack of beds. There's no excess hospital bed capacity in the United States. The idea of moving flu victims to shelters isn't feasible given the nursing shortage and the capacity of the federal system, which again relies on regional resources such as a DMAT and DMORT to pick up patients and move them to another location.

Some form of community quarantine is a real possibility, and fire and EMS chiefs need to look at their supply chain to ensure they can maintain operations. The medical director and the fire chief must create a contingency plan to decide which patients to transport and which ones to leave at home to be cared for by family. For example, is there a pulse oximetry level or set of vital signs that will act as a trigger for a transport? The question has to be asked, is it safer for an immune-compromised person to sit in a hospital hallway exposed to other patients, or will the outcome be better for the patient to stay at home with instructions and periodic checks from EMS workers?

In a worst-case scenario, dealing with the dead could place a strain on resources. Some predications indicate that fatality rates could increase beyond the ability for local coroners and morticians to handle. Contingency plans for cold storage and body removal need to be discussed among chief officers. One trigger for panic or unrest will be the inability to remove a deceased family member from a home. If this process takes days, the spread of other disease and the psychological impact could increase the toll of the flu, creating unrest. It's generally not the role of the fire service to place a victim in a body bag. However, securing the body in a sealed bag could reduce the effects of having a decaying body in the home. This should be discussed with the local coroner or medical examiner to develop a contingency plan and supply the fire service with body bags.

We can only hope that we will be spared the bird flu pandemic. The key is for the fire and EMS chief to sit down, make plans, brainstorm and build contingencies for worst-case scenarios. This scenario will not play out like other disasters and will create logistical challenges. Local municipalities may be on their own to operate without federal assistance. If federal help does arrive, expect significant delays and shortages until the Department of Health and Human Services receives full funding to prepare the country.

As we have see with the Gulf hurricanes, local governments must be prepared to take care of their citizen with local resources. On a brighter note, if nothing happens you have just prepared yourself to service the citizens and built confidence in your ability to protect the public. Peace of mind and faith go a long way in the face of challenging times.

Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.