8Needs and Opportunities

The challenges facing response to mass casualty incidents (MCIs) in rural settings reflect the broader challenges of national policy for rural health care in general. As highlighted throughout the workshop, MCIs in rural settings are not rare and, due to limited resource availability, health systems can quickly be overwhelmed. Therefore it is critically important that rural communities be provided the necessary guidance and resources to prepare and respond to an incident, commented workshop chair Robert Bass. Outcome measures and the ability to acquire the necessary data are needed to evaluate the magnitude of threats and to guide planning. An assessment must take into account both the risk of an incident occurring, and the capability and capacity to mount an effective emergency response. Complicating such an assessment is the lack of defined metrics.

Despite their geographic, topographic, and demographic differences, rural and frontier areas all face similar barriers in planning for and responding to MCIs noted Bass. But funding for technology, supplies, and preparedness activities (e.g., training, travel to training, planning and coordination meetings, exercises) is limited. As there is no dedicated direct federal funding for emergency medical services (EMS), support is often cobbled together from various grants, local and state support, and Medicare reimbursements (for which there are many restrictions). Panelist Aimee Binning, a member of the board of directors of the National Association of Emergency Medical Technicians (NAEMT) and owner of CVC Training, Inc., commented that many EMS organizations are entirely staffed by volunteers, which is not a sustainable model. In addition, several participants observed that rural areas must often contend with limited or nonexistent infrastructure, especially with regard to communications (e.g., lack of 9-1-1 access, cell phone service, 800 MHz two-way radio, broadband, satellite).

Workshop participants also highlighted that federal grants programs are not guided by any coherent, unified policy. Moreover, distribution of funds remains discretionary at the state level, where it subject to the whims and political vagaries of state governments. Because most of the funding is not dedicated, it must be applied for by EMS in competition with other responder agencies and security interests.

Workshop participants offered a broad range of suggestions and strategies for improving response to rural MCIs going forward, including (but not limited to):

  • Ensure an adequate day-to-day response capability at a minimum;
  • Conduct broadly inclusive planning and exercises;
  • Train in and consistently use the incident command system;
  • Identify and share best practices across services and sectors (e.g., military battlefield trauma care, private industry communications capabilities, distance education);
  • Develop demonstration projects to assess the capability and feasibility of using telemedicine technology as a potential means to improve emergency medicine services in rural communities;
  • Establish formal mutual aid agreements and cross-jurisdictional coordination;
  • Strengthen the standing of EMS in the federal government and ensure coordinated and dedicated EMS funding;
  • Develop realistic regionalization strategies with local input;
  • Develop strategic partnerships (public/private/nonprofit) to achieve goals; and
  • Leverage existing federal programs and grants to bring enhanced communications (including Next Generation 9-1-1, broadband, and telemedicine) to rural areas.

Relationships were a thematic hallmarks of participants' discussion over the course of the workshop. Filtering its way into multiple discussions were the importance of individual and federal leadership, and mechanisms to build trust among local, state, and regional coalition partners that can survive transitions in that leadership. Alluding to participants' discussion during the panel on rural health systems “regionalization is not centralization,” several participants concluded that through attitudes of inclusion, in which notions of a zero-sum power structure have little or no place, improvements in rural preparedness for and response to mass casualty incidents from all causes can steadily achieve the goal of mitigating and better treating injuries, and saving more lives.