A bomb explodes. An airliner crashes. Fire engulfs an office tower.
The list of calamities that could send hundreds of casualties to Maryland hospitals is limited only by the human imagination.
As their counterparts elsewhere cope with earthquakes and tornadoes, the Marylanders charged with planning for the unimaginable say the state's emergency response infrastructure, communications networks, first-responders and hospitals are much improved since the events of Sept. 11, 2001.
But worrisome vulnerabilities remain, they concede. A radioactive "dirty bomb," a bioterrorist attack or even an outbreak of pandemic flu would add huge numbers and complexity to the management of our worst nightmares.
Infectious isolation rooms and burn-unit beds are not abundant here. And radiation decontamination facilities are slow. All could quickly be overwhelmed by a major disaster.
"What do you do when profoundly more people need health care than we can provide? ... We've never had to face that," said Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services, which manages statewide emergency medical services day-to-day.
Of course, a truly cataclysmic event, such as the detonation of a small nuclear device as envisioned in recent testimony before the U.S. Senate Committee on Homeland Security, would likely overwhelm state and local plans and demand a federally-led response.
Cham E. Dallas, director of the Institute for Health Management and Mass Destruction Defense at the University of Georgia, told the committee that such a blast near the White House would kill 100,000 people, seriously injure and burn another 150,000, and put 100,000 in immediate need of decontamination.
Dallas told the committee that we "only have a fraction of the potential health care and security personnel that we'll need. A lot of people ... will be on their own in the first 24 hours. There won't be anyone there to help them."
Short of a calamity on that scale, Maryland's disaster planners say their plans are flexible enough to deal with the most likely events the future may throw at them.
Outside experts largely agree.
"Maryland has long been regarded as probably the exemplar in the country for understanding, valuing and organizing emergency medical services ... and, very significantly, the state has not backed off from that commitment," said Dr. Arthur L. Kellerman, associate dean for health policy at the Emory University School of Medicine.
That does not minimize the state's challenge, Bass said. "A mass-casualty, major incident is a scary deal. But in terms of our ability to handle it, I feel comfortable. We're probably as prepared as any state, and I would argue better than a whole lot of others."
Even so, he said, "we've got to continue to look at scenarios and at how to improve things, and we've got to do that every day."
Maryland's safety net is a complex web of state, county and local agencies, hospitals, private companies and nonprofits. Bass' agency -- known as MIEMSS - plays a central role. Staff in its downtown Baltimore control center already gather information from incident scenes and waiting hospitals, then coordinate the dispatch and destinations of ambulances and MedEvac helicopters.
Maryland pioneered the system in the late 1960s. The state has tested, improved and used it every day since then, Bass said. "You have to be able to function well day-to-day to be able to ramp up when something bad happens."
The nexus is a communications system that has seen important enhancements since Sept. 11. Staffers watching the disasters unfold in New York and Washington that day began to poll Maryland hospitals, via voice and fax channels, to see if they were ready for more mass casualties in the region. The volume of communications soon choked the system.
"We needed more information, more quickly, about what their status was, and they wanted more information about what was going on, and what was expected from them," Bass recalled.
Since then MIEMMS has developed and deployed an all-digital, Web-based network called "Facility Resources Emergency Database," or FRED. Today, controllers can poll every hospital in the state for readiness and occupancy in 90 minutes, compared to the 24 hours the task once required.
MIEMSS can alert emergency rooms to incoming ambulances or helicopters, or warn hospitals and health departments of emerging threats, from flu to tainted heroin. "The amount of information, and the number of folks we can send out to, went up exponentially," Bass said.
MIEMSS is also working with the state on a new, statewide communication system using 700 MHz frequencies that TV broadcasters will vacate next year when they switch to digital transmissions.
Coupled with a statewide network of microwave towers and computer-controlled "trunking" technologies, Bass said, the new channels will allow Maryland to link the incompatible radio systems used by law enforcement, fire departments, hospitals, public health services, public works and highway crews.
Meanwhile, local disaster planners and hospitals are bringing emergency operations into conformity with state and federal guidelines. If a high-rise building collapses in downtown Baltimore, city police and firefighters would establish a command structure at the scene, while MIEMSS would instruct hospitals to launch their emergency plans.
"You empty the beds that you can" and prepare to expand treatment areas into hallways, cafeterias and even nearby schools if necessary, said Frank Monius, assistant vice president for administration at the Maryland Hospital Association..
At the same time, the Maryland Emergency Management Agency (MEMA) would activate its Emergency Operations Center in Reisterstown, providing a central location for state and local agencies, utilities and the Red Cross. MEMA could also manage the acquisition of cranes, bulldozers and other heavy equipment needed to deal with wreckage.
If local departments are overwhelmed, the state agencies can call in more ambulances, rescue teams, police and fire fighters under an interstate aid agreement.
"In the span of a day, we could activate 500 ambulances," Bass said. Volunteer medical teams mobilized under the National Disaster Medical System could be transported to Baltimore with their equipment within 48 to 72 hours.
The state Department of Health and Mental Hygiene would open its command center on West Preston Street. Its job might include ensuring sufficient cold storage for bodies and mental health support for first responders as well as vaccines, respirators, power and water for hospitals.
The department also is continuing to enroll and train doctors, nurses, pharmacists, radiologists and other providers for the state's Medical Resources Corps, which would deploy full-time, part-time, retired, or on-leave personnel as needed.
The federal government has insisted that hospitals throughout the United States re-evaluate and address their vulnerabilities in the wake of Sept. 11.
"We weren't as prepared as we thought we were," said Susan K. Dohony, vice president for performance improvement at Calvert Memorial Hospital in Prince Frederick.
Last fall, Calvert Memorial completed renovations to its emergency department, including a dedicated entrance where people injured in a nuclear accident at the Calvert Cliffs nuclear power plant can be decontaminated before treatment.
The hospital has stockpiled radiation detectors and drugs and improved training. The first drill with the new decontamination room was held in December.
Franklin Square Hospital, in eastern Baltimore County, has focused on catastrophes that could arise from nearby interstate highways, the Amtrak rail corridor, Baltimore's chemical plants or the Aberdeen Proving Ground.
"Decontamination equipment, and personal protective equipment for our staff is key," said Christine Hughes, the hospital's emergency preparedness coordinator.
Disaster planners acknowledge they still face vulnerabilities. For example, Bass worries about the limited capacity of negative-pressure isolation rooms, designed to prevent the escape of toxic or infectious agents.
"Candidly, that is one of our Achilles heels," he said.
Another is crowded emergency rooms that back up regularly under normal conditions because there are too few beds available to receive patients admitted through the ER.
Although ER crowding and the resulting diversion of ambulances away from the nearest hospital remain a problem here, data released last summer suggested it's no longer getting worse, at least in Baltimore. That is not the case nationally, said Emory University's Kellermann.
"By and large ... hospitals are in an aggressive state of denial about access to emergency care, crowding and diversions," he said.
Franklin Square is considering additional negative pressure and decontamination capacity a new patient-care tower scheduled for completion in 2010, Hughes said. It also has portable equipment available to convert existing space to such purposes.
Mass burn casualties from, say, a plane crash or a terrorist's bomb are another worry, Bass said. Improved fire safety engineering has reduced the number of burn cases, but also the number of available burn unit beds.
"A lot of those patients might have to be distributed to other [more distant] burn centers," he said. Hospitals without burn units might be asked to improvise space for burn care.
The challenge would be far greater if the disaster struck during an outbreak of seasonal flu. "We might not have any ICU [intensive care] beds in Baltimore," Bass said. Plain hospital beds might be scarce, too.
When disaster strikes, hospitals may have to convert space inside the hospital or in nearby schools or hotels to provide patient care. Some people may be have to be cared for at home.
"I believe emergency planning is a never-ending loop," Bass said. "There's always a bigger 'what if.' I think we do well.
"But ... you can't have a plan for everything. You try to identify the most likely scenarios, and plan for those."