Just before the July 4 holiday this past summer, as National Guardsmen with sniffer dogs monitored the nation's bridges and airports, Jerome Hauer, an assistant secretary at the Health and Human Services Department, dispatched a technician to Atlanta to set up a satellite phone for the new director of the Centers for Disease Control.

If smallpox broke out, if phones failed, if the federal government had to oversee mass vaccination of an urban center, Hauer would have a way to communicate with the CDC director, who since last fall has worked with him on health crises, particularly bioterror. It was one of many precautions that might make the difference between a manageable event and full-scale disaster.

But at the same time, an attempt at crisis management of a more immediate kind was unfolding 2,500 miles to the west. As the FBI chased reports of potential new threats, including a possible attack on Las Vegas, Dr. John Fildes, the medical director of Nevada's only top-level trauma center, watched helplessly as a real medical disaster developed, one that had nothing and everything to do with the problems that Hauer was working to solve.

Faced with a dramatic spike in the cost of their malpractice insurance, fifty-seven of the fifty-eight orthopedic surgeons at University Medical Center in Las Vegas resigned, forcing the state's only trauma center that could treat it all--from car crash, burn and gunshot victims to potential bioterror casualties--to close for ten days.

With Las Vegas a potential target, a quarter-million tourists at the gaming tables and the closest high-level trauma center 300 miles away, the crisis barely registered in the federal government. Nevada's Office of Emergency Management called to inquire about a backup plan, which, as Dr. Fildes later recounted, was to dissolve the county's trauma system, send patients to less prepared hospitals and take the critically injured to Los Angeles or Salt Lake City, both about eighty minutes by helicopter.

During that anxious week Hauer's satellite phone and Fildes's resignation letters formed two bookends of the nation's disaster planning. Hauer--whose Office of the Assistant Secretary for Public Health Emergency Preparedness (ASPHEP) was created by the department Secretary, Tommy Thompson, after the anthrax attacks--can get a last-minute satellite phone, a crack staff and even the ear of President Bush on public health concerns.

But Fildes, whose trauma center is the third-busiest in the nation and serves a 10,000-square-mile area, struggles to keep his staff intact and the doors of his center open. And this is in a state with no appointed health director, few mental health facilities, no extra room in its hospitals and the nation's only metropolitan area, Las Vegas, without a public health laboratory within 100 miles. In the event of a public health disaster, like a bioterror attack, Fildes says, "we're prepared to do our best. And I hope our best is good enough."

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