Discussed in Chapters 2 and 3, raising the alarm that a potentially catastrophic event has occurred is just the first step in the prehospital system. The following sections examine the participants' discussion of the effect of specific resource deficiencies facing rural communities, underdeveloped communication between responding authorities, and the effect of inconsistent professional education on preparedness and response strategies preceding victims' arrival at a hospital. Attendees offered strategies to combat these obstacles to improve local and regional coordination, while remaining mindful of current fiscal constraints. (Summarized in Boxes 4-1 and 4-2.)
DISCERNING AND ADDRESSING LOCAL CHALLENGES
Norm Dinerman, medical director of LifeFlight of Maine began by citing Democracy in America in which Alexis de Toqueville described how geography is destiny. If geography is destiny, Dinerman asked, is it determinative of the outcome of health care?
A primary challenge facing the prehospital system is the acquisition, allocation, application, and coordination of assets and resources. This includes recruitment, retention, training, and education of emergency medical services (EMS) human resources. Another challenge for response planning in rural America is risk analysis, which assesses the likelihood of the occurrence and subsequent consequences of an event, and then defines the metrics or markers on which a successful preparedness strategy hinges. Other challenges include
- Leadership (someone who can work their way through the political process to secure the necessary support and resources),
- Physician participation or lack thereof (e.g., in medical direction at the scene or hospital),
- Sustaining commitment to disaster preparedness and planning (which is most intense following a disaster, and wanes over time),
- Political and cultural landscapes (where disaster preparedness fits as a priority),
- Existing statutes, and
- Contingency planning.
Dinerman also described the “rural-urban paradox” of prehospital care: the most highly trained responders are in urban America where the transport times to hospitals are short and the need for in-depth prehospital care is limited, while in rural America, responders must sustain patient management for miles and hours, and may need to address complex medical issues that require specialized training they may not have.
Behavioral paradigms add to these challenges, Dinerman said. Altruism is a great motivating factor for prehospital care providers in all of rural America, as are the values of community service and heroism. Rural America also has a strong sense of independence and is proud of its resourcefulness. The incorporation of this mindset into strategies to improve preparedness is discussed in the following sections.
Applying What Works: Identifying Best Practices
Dinerman recognized the importance of identifying “best practices” through experience, but he drew participant attention to the equally important task of adapting best practices from other industries, such as vehicle tracking, crash notification, weather reporting, or “preferred corridors” for tour buses (comparable to a ground-based “flight plan”). He similarly emphasized nimbleness and agility, both politically and operationally, in sharing identified metrics for contemporary risk management methodology and contemporary scaled disaster response, in the form of available strike forces. There are a myriad of disaster preparedness models and approaches to contemporary preparedness education, Dinerman explained, such as those used by the Federal Emergency Management Agency (FEMA), the National Aeronautics and Space Agency (NASA), and the military, that can prove valuable as guides. EMS statutes should be principled, reciprocal, and situationally flexible, Dinerman said. He added that to optimize air medical capability and safety, night vision goggles and local air traffic control should be used. Sophistication must exist at all levels of response, and there must be a focus on local provider needs.
Many strategies were discussed that leverage creativity and inclusive planning to address these challenges. Myra Wood, director of Vital Link Ambulance in Arkansas, related how Vital Link avoided an interruption in service despite the destruction of its dispatch headquarters on February 6, 2008, by an EF-4 tornado that touched down in Atkins, Arkansas. Wood explained that the ability to survive an unexpected event, that itself killed 23 people along its 123-mile trajectory, was a direct result of preplanned surge capacity. Vital Link is an active participant in regional preparedness planning and practices and continuously updates its mass casualty incident (MCI) plans. Vital Link maintains extra ambulances and employs almost as many part-time staff as full-time staff, from which it draws crucial increases in personnel during an MCI, as full-time staff.
While Vital Link was able to creatively integrate surge capacity with its traditional organizational infrastructure, 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., drew participants' attention to untraditional sources of surge capacity during an MCI. CVC Training provides first aid and CPR training to first responders in Sublette County, Wyoming. Spanning 3.2 million acres, portions of three mountain ranges, and 7,900 residents, Sublette County also contains a large natural gas field, which adds between 3,000 and 5,000 people to the county's workday population. In May of 2000, 382 students and 45 adults required triage after a hazardous gas leak was suspected at an excavation site near a local school. Binning described resourcing personnel from all local venues: EMS was in charge of the triage, law enforcement handled traffic and crowd control, and the county emergency manager was in charge of publicity and communications. Local radio stations assisted by disseminating information of the incident to parents, the majority of whom worked on rural ranches and would otherwise have been unaware of the situation or known where to collect their children. Churches were used as triage facilities and a local, large swim club served as a secure location for individuals deemed nonsymptomatic.
While community teamwork proved effective to combat the threat, funding and staging challenges persisted. Sublette County does apply for federal grants, but Binning noted that volunteer staff are generally not familiar with the grant process. Binning advocated educating EMS volunteers about finding and applying for appropriate grants. While both Wood and Binning demonstrated the difference creativity in leveraging community resources can make during MCIs, Binning cited the problem of limited and decentralized EMS funding as an inescapable traditional obstacle.
Both Binning's and Wood's experiences during respective MCIs spoke to Dinerman's previous point on the challenge of behavioral paradigms. Their common solution was to expend considerable funds in favor of staff dependability: all staff at Vital Link and Sublette County have been transitioned from unpaid volunteers to both paid volunteers and full-time EMT employees.
RETHINKING AND RETASKING AVAILABLE RESOURCES
Gloria Tavenner Dow, a firefighter-paramedic for the Gwinnett County Department of Fire and Emergency Services in Lawrenceville, Georgia, described her system-focused planning approach that incorporates nontraditional EMS system components, nontraditional use of traditional components, and planning for barriers. Dow advised participants to think about available resources in a very broad sense, beyond their traditional roles or capabilities. She emphasized the need to plan. In considering resources and system components, for example, she advised participants to think not only of the transport vehicle, but of the expertise of the providers associated with the vehicle and the equipment that they bring. When the weather is bad or aircraft cannot be used for some reason, the air medical team can still assist at the scene, as was done during the Mexican Hat incident response. But there needs to be planning for how best to bring and utilize those air medical resources to the scene in the absence of the aircraft. There are also specialty care components of the prehospital setting that should be included in planning exercises. Pediatric hospitals and regional trauma centers, for example, likely have specialty care assets and expertise to share, perhaps through remote medical direction technology during the incident or a specialty team that can come to the scene.
Communications and Incident Command Systems
Robust and redundant communications systems are crucial to an incident command system (ICS) in the prehospital phase of an MCI response. An incident command system is a tool box that expands a department's capacity to respond to an incident, Dow explained. It aims to create a common language, define roles and responsibilities, and develop a preparedness and response plan among all potential responders. Thus, it can adapt standardized strategies to meet the specific needs of an MCI response. A strong prehospital communications strategy is the cornerstone of a reliable ICS, a fact that should be taken into account when attempting to strengthen and adapt ICS strategies. Although many rural communities will not have the capacity of a robust mobile communications unit, existing resources can be better used to coordinate the flow of resources to the incident, facilitate information sharing between first responders, and survey hospitals' availability to accept patients. For instance, most critical care systems have a communications component that could operate as a point of contact within the communications incident management system as needed. However, where there are gaps, existing communications assets should be creatively leveraged to support and strengthen ICS, Dow commented.
Alternatives to Telephone and Radio Communications
Because real-time communication can drastically increase response efficiency, it is important to identify alternatives to telephone and radio communications, contested Glenn Mitchell, chief medical officer of the Sisters of Mercy Health System. Glenn Gaines, deputy U.S. fire administrator for FEMA, reminded participants of the strategy in which an EMT or paramedic is stationed on a landline at a nearby house and someone on site uses a talk-around channel direct to the paramedic. It is not ideal, he admitted, but it is a plausible alternative to transmit situation statuses. Roy Alson, medical director of disaster services for the North Carolina Office of EMS, directed attention to a valuable tool when Internet access is available: the web-enabled emergency management communications system, WebEOC. He pointed to WebEOC as a potential tool to improve situational awareness during an MCI. He suggested the need for health systems to become more facile in utilizing Internet-based tools to help manage large-scale incidents, adding that his hospital is converting to VoIP (Voice over Internet Protocol), but existing land lines are being left in place so there is a redundant system. Systems like WebEOC could serve as repositories of real-time information, allowing a continually dynamic MCI response. Yet despite the discussions' focus on improved technology, Ken Knipper reiterated the value of local ham radio operators as a resource, as well as traditional cellular service, which can be mobilized in the form of a mobile cellular tower, to disaster sites.
Utilizing Resources to the Fullest Potential
Dow also encouraged participants to consider all of the different ways medical support resources could be used. If there is a trauma team available, is it possible to activate just a component of it? Perhaps a trailer usually used to transport patients on a portable ECMO (extracorporeal membrane oxygenation) machine could instead be used as a surgical suite, if the ECMO equipment was left behind. When conducting preplanning with local critical care services, Dow urged participants to think about interoperability, compatible supplies, and cross-jurisdictional agreements. She cites, as an example, a mutual aid agreement in which an EMS agency agreed to support the staff of a one-bed emergency room with advanced life support ambulance personnel during MCIs that would otherwise overwhelm the small emergency room.
In developing innovative MCI response partnerships, members of the community must not be forgotten. First responders have numerous responsibilities during an MCI, from communications and triage to shutting down roads and directing helicopter landings. Dow suggested, for example, that local service groups such as the civil air patrol or the local flying club could be trained to take over landing zone command during MCIs.
Similarly, the first helicopter to arrive will often have three qualified people on board; therefore, one could be assigned as a triage officer, one as a medical officer, and the pilot as the ground officer for the landing zone. This helicopter could eventually be used to transport the last patient from the scene. Rather than viewing this retasking negatively, because the helicopter is not immediately used to transport a patient, Dow pointed out that the delay could be a better allocation of expertise; in preparing patients for transport by other air medical personnel, the overall response efficiency could be increased. Dow also pointed out that an aircraft coming in to pick up a 200-pound patient has about a 200-pound capacity to bring something or someone with it, such as a Hazmat expert, a trauma surgeon, or someone with another specific skill that could aid the response effort. Thus, communications incident management systems and thorough planning are all the more crucial.
THE HUMAN RESOURCE
Barbara Quiram, director of the USA Center for Rural Public Health Preparedness at the School of Rural Public Health, Texas A&M Health Science Center, noted that nearly 190 of the 254 counties in Texas are rural. People in rural America wear many different hats, which can be both a strength and a weakness, she said. An individual who is the emergency management coordinator may be the fire chief and also the mayor. Which role do they play at any given point in time during an emergency? Roles need to be clarified from the beginning of an incident.
Strengthening the Personnel Pipeline
Recruiting and retaining first responders, Quiram noted, is a major challenge. Rural communities often find themselves in the frustrating position of having made a large financial investment in hiring and training responders, only to have them recruited away by a neighboring community or an urban center. How do we develop the pipeline of practitioners and responders? One option is to recruit at undergraduate programs and professional schools, such as colleges of nursing, medicine, public health, pharmacy, and dentistry. These individuals likely have training in the life sciences and may be interested in working part time for EMS.
Continuing education also poses unique challenges to rural communities that can not afford to have staff absent for extended periods of time. Therefore the Center for Rural Public Health and Preparedness and other programs are developing distance education programs using interactive video conferencing and online course work, both as continuing education and for graduate credit. For instance, the center produces thousands of CD-ROMs every year with complete programs that are eligible for continuing education credits.
Quiram encouraged participants to convene all of the stakeholders, including the faith-based community, healthcare providers, funeral home associations, extended care organizations, school nurses and principals, and others who may never have engaged each other on MCI response issues, and discern the community's preparedness level and improvements they can make together. Response is local, Quiram concluded, so communities must come together to identify the assets and resources they have and need to ensure they will be able to respond and recover.
Value-Added Community Paramedicine
In contextualizing the takeaway message from his panel, Nels Sanddal, President of the Critical Illness and Trauma Foundation, began with the importance of expanding the roles, but not the scope of practice, of rural paramedics to ensure continued community prioritization of rural EMS. Without the daily case load of urban EMS, rural paramedics can take on greater public health responsibilities to improve the systems' ability to handle day-to-day care. The importance of maintaining such daily efficiency to adequate surge capacity will be discussed in greater detail in Chapter 5; however, a community can meet its MCI preparedness requirements by establishing a workforce of people with emergency skills to provide a service every day to meet rural health requirements.
Gary Wingrove, director of Government Relations and Strategic Affairs for Mayo Clinic Medical Transport, drew participant attention to a successful example of EMS integration into the broader healthcare system in Nova Scotia, Canada. After the lone physician on a small island retired, the only way for its inhabitants to receive even routine care was to visit the closest hospital, a 45-minute ferry ride away. In response, the local ambulance providers, recently consolidated to improve response time, suggested paramedics staff the clinic, providing a range of services including at-home visits to manage the chronically ill. Over the five years following the establishment of the Nova Scotia community paramedic system on the island, there was a 40 percent reduction in emergency room visits. Wingrove noted that this decrease was significant not only to residents, who had to travel much less, but to local hospitals on the mainland.
Standardizing and Strengthening Paramedical Education: Community Paramedic Programs
To better standardize paramedic education, Nebraska, Minnesota, Nova Scotia (Canada), and Brisbane (Australia), formed the Community Healthcare and Emergency Cooperative. Its goal is to homogenize existing educational programs to make one, comprehensive curriculum available to ambulance services throughout the countries (CHEC, 2009). Pilot educational programs have been conducted in Minnesota, Colorado, and Wisconsin.
The first part of the curriculum takes about 100 hours and involves the paramedics learning social service skills, conducting assessments of their community to identify where the gaps are, and developing care strategies. This is followed by 15 to 146 hours of clinical skills development, depending on the individual (CHEC, 2009). The curriculum orients community paramedics to their breadth of public health responsibilities. It expands their purview beyond acute emergency response to serve patients at all entry points to care, roles many rural community paramedics say they already fill in their clinician-short environments, said Wingrove. Taught as distinct modules, the course builds on the specific experience and knowledge level of paramedics, lending it the flexibility to adapt to each community. Wingrove noted that though the programs are tailored to rural environments, the same principles could apply in an urban setting. The program is meant to be set up for designated underserved areas, and should be approved by the community. Funding arrangements should similarly be addressed locally.
Wingrove noted the program is provided free of charge to any accredited college or university in the world. It is not provided directly to ambulance services or other entities however, because the model is intended to continually evolve and improve, a process best fostered by an academic environment.
One of the major benefits of the community paramedic program is that it keeps rural and remote health issues on the radar of policy makers and community leaders. It also addresses health issues specific to rural populations. However, Wingrove cautioned participants to remember that paramedics are surrogates, not independent care practitioners, and it is essential that there be oversight by a physician or other care provider.
Six State-Adapted Strategies: The North Dakota Example
Tim Wiedrich, chief of the Emergency Preparedness and Response Section of the North Dakota Department of Health shared six specific strategies that North Dakota has employed to enhance response. These are not necessarily applicable nationally, he said, but they are the best fit for the state. The strategies are built around integrated command centers, standardized communications, flexible authority to alter the scope of practice, targeted training, maintained supply caches in anticipation of a surge response, and established quality improvement mechanisms.
The first strategy was the establishment of an incident command and control system that integrates local, state, and federal emergency response using a common operating structure. The state emergency operations center establishes communications and incident command with local centers (including the local public health, hospital, and EMS emergency operations centers), which then link to the incident command at the scene. This creates the ability to share information and needs assessments with the entire state simultaneously.
The second strategy was the construction of a safe, secure, and redundant communications system that can function without the commercial power grid or commercial communication networks. There are 32 radio communications towers spread throughout the entire state, each connected to centralized dispatch point in Bismarck. For the redundant system, a fiber-optic network was laid out throughout the state in a figure eight. This affords the ability to link technologies such as video conferencing, management information systems, and patient tracking across all hospitals. Every hospital and public health unit in the state, and about 250 other sites ranging from local government to the K–12 and university education systems, are connected to this network. The fiber-optic network is self-healing and redundant, able to function despite failures in the power grid or commercial communication networks.
The third component was to establish the framework and authority to enter crisis standards of care in order to ensure fair and equitable patient care during situations of scare resources. During large-scale emergencies it is often not possible to stay within predefined standards of care and scopes of practice (IOM, 2010). Wiedrich noted that this concept is somewhat controversial. However, transparency has been used to manage public expectations. Officials, for instance, attempt to explain the realistic difference between receiving life-saving medical care in emergency settings and the traditional best-available, office-based care to which people have become accustomed.
The fourth strategy, Wiedrich explained, was to determine the necessary knowledge, skills, and abilities needed for a large-scale response, and to provide training when appropriate using just-in-time strategies. This approach favored targeted training, as opposed to an attempt to persist at a constant state of readiness, exemplified by a pervasive and overarching education program. Wiedrich explained that a wide variety of formats have been put into place for delivering just-in-time training, including live and archived web and video conferences. In addition, the military's use of modeling and simulation for scenario training has started to be used by civilian universities, for both EMS and physician training.
North Dakota's fifth strategy was to amass the necessary surge assets, including personnel, communications equipment, durable medical equipment, and medical supplies. Wiedrich explained that there is a state medical cache of about 3,000 pallets of supplies (roughly 30 full semi trucks) housed in a 20,000 square foot warehouse. Regional EMS surge equipment, such as backboards, bandaging, and other necessary materials beyond normal EMS supplies, has been placed throughout the state. There are prehospital stabilization and staging kits, medical shelter kits, and tactical communications kits, ready to be mobilized. Finally, there are 2 ambulance buses that can each hold 16 patients. Everything except the buses was funded through either hospital preparedness funding from Health and Human Services or CDC preparedness funding. The ambulance buses were purchased with utility DHS grants. It was noted that the absence of EMS-dedicated federal grant funding has created multiple challenges, discussed in detail hereafter.
The sixth and final strategy was to establish a quality improvement process that reviews the system based on actual or exercised response, gauging successes and identifying areas in need of improvement. As a condition of provided contracts and funding, the state is required to provide feedback to the quality improvement process through the submission of after-action reports.
THEMES IDENTIFIED BY WORKSHOP PARTICIPANTS
Participants noted that the environmental challenges facing the prehospital care component of response to an MCI in a rural area include geography, long distances, and weather. The prehospital system is also affected by communication gaps and a lack of resources in rural areas, including equipment, funding, and personnel. Participants discussed the “rural-urban paradox” of prehospital care: the most highly skilled and highest-level providers are generally in urban areas where there are short transport times to care facilities, while in rural areas, with long transport times and limited health care resources, there are fewer providers that can address complex care issues en route. Panelists described a need for multidisciplinary involvement in both planning and response beyond EMS and hospitals. It could include law enforcement, public utilities, and others they suggested. It was noted that there are political and cultural challenges to disaster planning. However several participants stated that while “geography is destiny,” it is not determinative, and there are creative approaches to addressing its challenges.
The primary response is local, and states should play a supportive role, such as by coordinating resources or replenishing supplies. Strategic partnerships between local agencies and the state are needed to develop infrastructure such as safe, secure, and redundant statewide communication systems. Training in advance is important for overall preparedness, but there is also a role for just-in-time training (e.g., via live and archived web and video conferences).
One approach to filling gaps in health care is the concept of community paramedicine. Community paramedics have expanded roles (but not expanded scopes). They might assume a broader public health or healthcare function within their rural communities, such as by staffing a local clinic in the absence of a physician, or providing home-based chronic disease management (e.g., for patients with congestive heart failure or diabetes). Many of these activities could be preformed by a basic EMT with appropriate medical oversight, helping to reduce hospital recidivism.
An underlying theme of the discussion was that for a service to be able to step up in the face of an MCI or other disaster, it must first be able to provide adequate care on a daily basis for routine emergency calls and transports. Some participants also emphasized the importance of planning.
Another model discussed was a county-supported, tax-supported rural EMS agency that pays EMTs for responding to calls. It was suggested that pay varies according to certification and whether the responder was on call or at the station, or responded from home.
Participants raised concerns about the general fragility of the current rural EMS infrastructure. Many rural EMS agencies struggle to meet the basic community needs. Collapse of one component of the prehospital system, suggested workshop chair Robert Bass, will affect others in the community, such as the local rural hospital, and will place more stress on neighboring agencies. Limited resources as well as limited coordination between and within jurisdictions limits a prehospital system's capacity to respond. As described previously in the chapter, several participants suggested that improved collaboration and alignment of resources will strengthen rural EMS.
National Academies Press (US), Washington (DC)
Institute of Medicine (US) Forum on Medical and Public Health Preparedness for Catastrophic Events. Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary. Washington (DC): National Academies Press (US); 2011. 4, Challenges Facing the Prehospital System.