Homeland Security Medicine with Dr. Dominique Wong

In this episode, we interview Dr. Dominique Wong, an expert in the intersection of homeland security and emergency medicine. 

Dominique Wong M.D. is an emergency physician with expertise in disaster, event and tactical medicine, and a particular interest in the nexus of medicine and homeland security. She serves as chair of her hospital's Medical Readiness Committee, works extensively in hospital disaster preparedness and mass casualty planning, and has experience as a tactical physician and law enforcement high threat medicine educator.
Dr. Wong is active nationally in disaster and tactical and law enforcement medicine and also contributes to public health and biodefense initiatives as a consultant for wastewater surveillance for biothreat detection. She is a co-facilitator and speaker for the Naval Postgraduate School, Center for Homeland Defense and Security and holds degrees from Cornell University and The Ohio State University College of Medicine.

Transcript

Unknown: 1:03

Hello, I'm Captain Matthew Turner, and welcome to another episode of the GSA SEP podcast. In this podcast, we interview Dr. Dominique Wong. Dr. Wang is an EM physician with expertise in disaster event and tactical medicine, and a particular interest in the nexus of medicine and homeland security. She is the chair of her hospital medical readiness committee, and works extensively in hospital disaster preparedness and mass casualty planning, and has experience as a tactical physician and law enforcement high threat medicine educator. Dr. Wong is also active nationally in disaster, tactical, and law enforcement medicine, and also contributes to public health and biodefense initiatives as a consultant for wastewater surveillance for bio threat detection. She is also a co-facilitator and speaker for the Naval Postgraduate School Center for Homeland Defense and Security, and holds degrees from Cornell University and the Ohio State University College of Medicine. So, Dr. Wang, what first drew you to emergency medicine, and how did that evolve into an interest in homeland security medicine? Well, a quick, a quick description of how I ended up in emergency medicine, because the details are only interesting to me, probably, but I think the impactful part is I came about emergency medicine in a bit of a circuitous route through a lot of other experiences. I was certain I wasn't going to be a physician, and then I did a lot of horrible other jobs for a while, and then I finally ended up as a high school teacher, which convinced me that there had to be something easier to do, and I loop back around, and at the time I knew probably four different jobs, you know, teaching, nursing, fireman, or doctor, and so I picked doctor, and as I went through medical school, and then residency, it became more of a personality match, more than what you think you know about the day to day, it's what does your, what is your personality like, and so if you like some of the action and if you're a little bit, you know, have a little short attention span, and you like problem solving, and you feel challenged by problem solving with relatively little information, and if you like being a stopgap, and hopefully someone there who can make a difference in someone's lives, then emergency medicine might be a good fit for you. Again, there's a lot of different paths that lead to the same place, and if you're a trainee or a med student, then there isn't one perfect right path or the right set of letters to put behind your name, and I also want to kind of point out, conversely, if you're in a leadership or executive role, consider sometimes those unconventional candidates, they may bring something to the table that you're not fully expecting. Yeah, and then the Homeland Security medicine was also a little bit just serendipitous, so that was emergency medicine was my interest, and as I had more free time, I started to look into ways that I could expand that outside of the emergency department, I got involved with law enforcement tactical medicine, and then I worked as the EMS director for the Boy Scout Jamboree World Jamboree, you know, a huge event in an austere environment, and that all piqued my interest, and then I literally just stumbled on something online, which was the Naval Postgraduate School Center for homeland defense and security, and signed up for their executive leaders program, and ended up getting into that, and that was a fabulous opportunity to learn more about homeland security, and it, it literally was like a drink of cold water after a big workout, it was like everything I was wanting to know about all the threats, you know, whether they're natural or man-made, you know, futures thinking about these threats, innovative, creative ways to address them from a systems point of view to an operational point of view. The instructors were terrific, the guest speakers were great, and my cohort was just like fabulous, so they came from all different parts, essentially all government-related sectors, and I could, I learned a lot from them, but what I kind of recognized is like medicine's kind of missing because it's private sector, right, the majority of our healthcare in the US, like 95% is private sector, but to me it seemed to be a natural flow, because when you look at all these homeland security threats, whether you're looking at like a hybrid warfare or a bio threat or a natural disaster or whatever, all these disasters, all of our homeland security concerns involve human casualties of some sort or another, right, or else. They're just economic threats, or threats to structure, or whatever. Those all end up in hospitals somewhere, right? All those human casualties end up in a hospital somewhere, and yet none of the physicians that I work with, none of the physicians I interacted with, really were fully aware of these homeland security threats outside of, like, what you get on the news, and conversely, Why was Homeland Security not aware that ERs are boarding patients across the country, and we are not ready to absorb more casualties on the regular, or we're deeply impacted by supply chain issues, to the point of having someone in front of me, and not be able to treat their basic chest trauma if I don't have my supplies, and how could they not know that? How could they not be interested in the medical side? I think you explained that really well. It's a bit of a passion of mine as well, that intersection between medicine, healthcare, and homeland security medicine, so working at the intersection of healthcare, emergency response, and public safety, was there a defining moment that really shaped that path for you? No, you know, again, I think it boils down to problem solving, and then over the course of a career in emergency medicine, what I found for myself is that I became much less resilient to a concept of potentially preventable deaths. I came across that term in some active shooter studies, and it kind of coalesced things for me. This death should not have happened. First, my mind went to, we could have prevented it if EMS had done this, so the 18 year old kid who's transported from a very rural area and doesn't have a turner get placed and bleeds out through the course of an hour long transport to our hospital, right, and it was a very preventable death, but those are the easy ones, right, then you start looking at systems, well, what about that EMS system, what is it about rural EMS? What is it about active shooter incidents that creates not just people who have died, but a core component of them that shouldn't have died because we couldn't get medical care in quicker, because it's a high threat situation. Then you can even back it up, another, another step, culturally, mental health wise. Where are we at that would have perhaps prevented that active shooter incident from happening in the first place? There's all these levels of potentially preventable death, but nonetheless, on no matter what level you take it at, those are the most heartbreaking things to me. And again, directly operationally, I can do what I need to do in the emergency department, and sometimes that's the best you can do, but other times we could have done a lot more to prevent any of this from happening in the first place, and prevent all of all of the suffering and sadness that go along with it. One defining moment, but rather this, like, I just found myself less and less resilient, bouncing back less quickly when there were preventable deaths, or even now to the point where I read about them and think, God, why can't we fix that? We really should be able to fix that. I completely agree. There's so much you can do as a person, but when it comes to adjusting the very systems that we work within, I think the potential for really addressing that sort of thing is even greater. Absolutely, and of course, this is it's complex and takes finesse, and it takes leadership, but the part of me that has seen it, and probably similar for you, part of the part of us that has actually been face to face at the implications of a preventable death, it wants to sort of drive through the logistics of getting to a system that actually works, or to solving the problem, because it feels like such a serious ramification if we don't fix the problem. Absolutely, focusing more on a tactical level, so your career expands medicine and law enforcement. What do most physicians misunderstand about the realities that officers face in the field on a tactical level? So it is interesting. It is the one time in my experience that medicine doesn't come first. So in the ER, you know, remember we had to adjust when COVID happened, and you had to stop and put your PPE on when they're wheeling somebody very sick back. That's not our MO. We, we go in, we go in typically without checking to see if the scene's safe, and it is the one time where tactics have to take precedence over medical, so we have to understand that that they work in a different world and that preventing deaths by being tactically sound is really key. I think there's a lot that can be learned in communication between both sides. Some of the other projects I'm working on are, I just recently did a review of after-action reports for active shooter in. Residents with a couple of people that I work with, and it's a limited number of after-action reports that have medical information, but of the ones that we were able to review, hands down, police provided the most immediate critical medical care over Rescue Task Force and Thames, and we're seeing it kind of over and over, where police are getting in there, they're doing what they're supposed to do, what they recognize they need to do, also beyond the tactical side of, and looking at the after-action reports are saving lives by doing something that is out of their normal sphere. So I think that training police officers, or at least having some cross training, there is pretty critical. I also think that medicine has a lot that maybe police don't understand we can offer them, right, an awareness of what the conditions are in the hospitals. I'm like, hey, we have a bed shortage. Yeah, matter of fact, we're working on things like IFAC recommendations for police now, because, and we're balancing the medical necessity with the with the physician or a police tactical reality, right? You get, we can't give them a paramedic bag, and we can't expect a non-medical person to learn and retain effectively complex medical skills, that's an unreasonable expectation, and along with preventable deaths, another worry would be that someone walks away thinking that they actually injured somebody or caused somebody's death by doing the wrong thing or doing it incorrectly. So we're trying to balance that with the clearer set of recommendations, so every officer knows here this is what I need at a, at a minimum, we can tailor it to our particular situation, but this is what we need evidence-based. So, let's talk about another project of yours that I'm interested in. Could you tell us about your work with wastewater surveillance and how it relates to homeland security medicine? I'm probably like most emergency physicians, a little bit of an action person, a little bit of an adrenaline junkie, as they call us. What I've come to realize is that, like, you know, the Hulk - there's like, as a banner, the scientist, and then there's the Hulk, and sometimes, honestly, the scientist is way more effective than the Hulk, and across my work in Homeland Security, you know, how it's always kind of typically that the quiet person that flies under the radar that has the most impact and is has the most to offer, really. Wastewater surveillance has been a really fascinating shift for me. So we started with COVID, we had no tests, we thought it was about a 5% mortality, or one in 20, and it turns out I work in a group of 20, and one of the guys said,"Hey, it looks like one of us is not going to make it through this pandemic, and again, we didn't have any tests for patients, or, you know, or for staff, and my husband's a scientist, and I don't know if he just got a little tired of hearing me, kind of, you know, hand ring about not having any testing. He went to the university, which was shut down, met a couple other scientists. They called the CDC, and the CDC gave them the recipe to make the viral transport medium, and they made the state's first several 1000 COVID tests, so we finally had a way to test, and then it became like it's very hard to test individuals, and there was a proposal to do group testing or community testing, so wastewater surveillance came about, and so you can detect or trend COVID, you can trend flu, you can trend RSV measles, you can have an early detection. There have been cases through history where we, we found polio before the first clinical case happened, so there weren't, there wasn't that paralytic disease as a result was able to stop that, identify the community, isolate them, vaccinate, treat, whatever, and of course it's expanded then into my concern for homeland security, like the early identification of biologic weapon in the environment, and then the potential to trend for it in the community would certainly save lives. You don't have to wait for clinical cases, you don't have to, you know, wait weeks for a send out lab for an unusual pathogen, and you can use sequencing on it to even potentially identify agnostically whatever's in there. So that means bioengineered pathogens can now be detected, and so you look at it for the war fighter, right? If you can push this technology out there, it can be simple field-ready equipment that you can push out there and be monitoring or surveilling environment or the community for pathogens, whether they're natural or man-made, and give some early warning, even wastewater. Can be very exciting, right. That's my interest in it. We did a joint exercise with the National Guard Surf P team, or their C Bernie team, their Chem Bio team, and they had, we rolled it in so that it was a stadium biologic exposure, and they rolled out their samplers, they put it into their lab, they were able to try to get a quick ID, and then we worked in a system to continue monitoring the community for disease through the wastewater surveillance system, and we use smallpox as a proxy for a biologic event. It's pretty cool stuff, I think. Identifying the invisible, you know, making the invisible visible is pretty cool, because for me, you can see a bullet, you can see a bullet hole, you can do your thing with your hands on a macroscopic level, but not being able to see the invisible is concerning. Wastewater surveillance, I did not think it would be that fascinating, but you did a great job explaining it. It's pretty cool. I know that. Actually, the military is doing quite a bit on this too. We had gotten through a couple rounds, but we just couldn't quite get the technology to be completely field rugged. A sequencer the size, literally, of an iPhone now really plugs into a laptop. Yeah, you remember the whole Human Genome Project? Yeah, it like 10s of millions of dollars. Wow, yeah, it's fascinating. Where it's going to be, it's like a couple $1,000 size of a cell phone plugs into a laptop. What leadership qualities would you say matter most during a rapidly evolving emergency? There are a lot of leadership qualities that I think you really have to explore and try to incorporate and practice. Ultimately, one that I think has stood the test of time in my experience is the ability to keep showing up. You keep showing up for your team. You don't weigh the success of the team as your success, and if it's a failure, or if there were problems, you don't walk away from it. You keep showing up and building and supporting that effective team is so critical. What an effective team can do is really amazing compared to a number of trained bodies that fill roles. I also think the ability to red team yourself is critical. So, the ability to accept a challenge or a criticism and incorporate that into what you're thinking or what you're doing is important, not just for you, but also for your team. Rapidly evolving emergencies are something that we're fairly used to in the emergency department. You're working on very little information, and yet you have to make decisions. You can't, you are, you can't opt out. And so the ability to rapidly absorb and adjust as you need to, but to be decisive is also an important quality during an emergency. I always like to end on a little bit of a positive note. So, best case scenario, looking forward over the next, say, 10 years, what kind of healthcare and emergency response system do you hope we build here in the United States? On the homeland security front, if I'm speaking about that, I think it's an organically collaborative system where we're bringing experts in their fields to the table to have open exploratory discussions, problem solving, and then the authority to actually act on them. I don't know how that looks. Part of me thinks it works a bit like an ESF, right? Like you say, this - we're on in, we're solving this problem, we're handling drone warfare, we're handling how we absorb soldiers, we're handling what the next pandemic is going to look like, that we can use teams of experts, experts on all fronts, not just subject matter experts, but experts who can put this together, who can sort through the material, who can appropriately weigh and balance that material and put it into the bigger context. I like not to be cynical, because I run into good people all the time. I like not to be cynical and think there are too many incentives and disincentives in our current system, and sometimes I think our current system looks is too retrospective and looks at disasters in the past and not forward thinking enough, but I think there are enough good people in this world to say that if given an avenue we could solve a lot of problems. I do hope we can come up with a system that's as nimble as the threats we're facing. I like that. Anything else you'd like to discuss before we wrap this up? No, I hope you keep up the good work. I think part of breaking down these silos or connect. Our worlds is is education and communication just like what you're doing, so I hope you keep up. Thank you.