High school senior Julie Casani was walking home, less than a block from her Staten Island, N.Y., home when she and a friend saw a commuter collapse after getting off the train. They had no emergency medical training, didn't even know CPR. They could only pull the fire department alarm at a nearby box.
The firetruck soon arrived, but the man died, probably from a heart attack.
"I said, 'That'll never happen to me again,'" Casani recalled last week, 38 years later. "I didn't want to be unable to do anything to help."
A few weeks after the commuter's death in 1971, Casani signed up for the volunteer ambulance squad in her community and launched a career that would take her to some of the nation's most chaotic emergency rooms and the center of two of its most frightening public health crises. She helped lead North Carolina's handling of the most recent of those scares, the H1N1 flu outbreak.
Casani has captained the state's incident command system for the past two weeks, a war room on the fifth floor of a brick state office building. It's a conference room transformed by the addition of portable cubicle walls, desks and a platoon of staffers in logo-emblazoned forest green polo shirts tapping away on laptops and working the phones. They form the hub of a constant stream of communication with 85 local health departments. Casani was at the helm when the first probable flu cases came in, and she sat at the table with State Health Director Jeff Engel when he placed the conference call to Onslow County officials to confirm the first of seven cases in the state so far.
Casani was walking familiar turf. She headed Maryland's bioterrorism program in the aftermath of the Sept. 11, 2001, terrorist attacks, directing that state's response to anthrax cases and preparedness for the possibility of a terrorist-induced smallpox outbreak.
Two Fridays ago, she attended a game for the high school lacrosse team on which her son is manager. North Carolina had confirmed its first H1N1 flu case, and the federal government had issued a public health emergency declaration. When the national anthem played at the lacrosse game, Casani said she flashed back to those post-9/11 days and asked herself, "Is this it again?"
Her experience ranges from the street to the nation's elite medical centers. She couldn't ride on ambulance runs until she turned 18, but she worked as an emergency medical technician through college. Casani earned her medical degree at New York University and, later, added a master's in public health from Johns Hopkins University. In 1990, she shifted from an emergency physician at Baltimore City Hospital to the same role at Johns Hopkins Hospital. The relentless pace and severity of trauma at a big city hospital wore on her.
She was treating a 13-year-old for his second or third gunshot wound and asked how he could deal drugs when he had so much to look forward to.
"He turns to me and says, 'What do I have to live for? All my friends have either been shot, are hooked on drugs or have AIDS,'" Casani recalled. "There was just a hopelessness."
During her years as a doctor, Casani also worked in disaster planning for the city of Baltimore and other organizations. So she welcomed the break from emergency room life when she took the job of creating Maryland's first bioterrorism response program in 1999. It was a quiet office job with no pager and no weekend work -- until Sept. 11.
Maryland officials quickly saw how Casani's front-line work in emergency medicine enabled her to communicate easily with doctors and nurses across the state. Fran Phillips, deputy secretary for public health in Maryland, said Casani assembled much of the training for post-9/11 public health crises in that state.
"She'd explain, 'What is a smallpox rash? What does it look like? How does it differ from chicken pox?'" Phillips said. "She could transfer the clinical data to real-world guidance. She could put up two chest X-rays and say, 'One of these people has pneumonia, and one has anthrax, and walk us through the difference.' "
In 2006, Casani moved to Raleigh, ready to leave the stress of the D.C. area behind but still an adrenaline junkie for public health emergency preparedness.
As the state's director of public health preparedness, she focused extensively on training that has paid off during the current flu outbreak. She made sure local health departments have the anti-viral drugs and protective equipment they need. The county departments are trained on how to investigate a possible case of the disease and how to respond to a confirmed case, all the way down to the legal orders to isolate the patient.
The current flu scare, which originated in Mexico, confirmed for state officials that many of their preparedness steps pay off, but they also learned lessons. Their communications systems showed gaps, such as reaching smaller child care centers, and the state quickly developed logistics for reaching migrant Mexican farm workers and the growers that hire them.
North Carolina was prepared, Casani said, "but you're never as prepared as you will be tomorrow."
Does she relax now that the threat of a flu epidemic seems to be subsiding? She recounts how the deadly 1918 influenza pandemic was preceded that year by a small outbreak that faded.
"We're all a little nervous," she said, "about what will happen in the fall."