Chapter 32 Charles M. Miramonti, Dan P. O’Donnell, Andrew C. Stevens, Elizabeth Weinstein, Josh D. Mugele, Kacy L. Allgood, and Bobby A. Courtney For the last 20 years – from the early days of urban search and rescue teams and the World Trade Center bombing in the early 1990s to the barrage of natural and man-made disasters we witness every year across an ever-shrinking globe – the field of professional emergency management has developed into a science as our knowledge of mass casualty incidents (MCIs) has grown. However, while round-table discussions of far-fetched “what-ifs” have evolved into best practices and doctoral dissertations, the fundamentals of disaster preparedness and response are essentially the same. Knowledge of these fundamentals is necessary for every EMS provider. A medical director who can proactively apply these fundamentals is crucial for effective disaster and MCI response and optimal patient care. Early public safety strategies to bolster surge capacity and mass care centered on the development of extensive stockpiles of equipment. Since 9/11, excessive money has been spent on durable medical equipment, pharmaceuticals, and specialized vehicles and communications systems. Further money has been invested in tabletop exercises and training initiatives designed to support narrow policies and procedures specific to disaster events. This strategy of investing in insular disaster training has been echoed by EMS, hospitals, and other health care entities. Recent studies question the cost-effectiveness of this approach [1]. Many leading health care coalitions now approach disaster management by investing in everyday infrastructure, personnel, protocols, and processes enhancing the health care system’s all-hazards capacity. This approach follows the philosophy that a robust health care system with integrated everyday capabilities will be able to respond more effectively to disaster and surge events. Whether during MCI events or day-to-day operations, command can be used to organize individual assets and personnel or, on a larger scale, to manage a host of participating organizations and assets at the local, state, and federal levels. The National Incident Management System (NIMS) provides a consistent nationwide approach for federal, state, tribal and local government, the private sector, and non-governmental organizations to work effectively and efficiently together to prepare for, respond to, and recover from domestic incidents regardless of cause, size, or complexity. To provide for interoperability and compatibility among federal, state, tribal, and local capabilities, the NIMS includes a core set of concepts, principles, and terminology. HSPD-5 identifies these as the incident command system; multiagency coordination systems; unified command; training; identification, and management of resources (including systems for classifying types of resources); qualifications and certifications; and the collection, tracking, and reporting of incident information and incident resources [2]. Command of individual resources for an event is best performed under the incident command system (ICS) paradigm as outlined by the NIMS. The ICS provides well-defined roles, responsibilities, and terminologies as well as a framework for response and recovery. Public safety personnel are well versed in the ICS. The medical director typically will not have a direct command or patient care function, but rather an advisory or consultant function as provided for by the ICS. The medical surge capacity and capability (MSCC) management system provides for coordination and command of large organizations and interoperability between health care organizations and local, state, and federal entities (Figure 32.1). It focuses on health care response and recovery, integrating public and private acute care providers into a larger architecture in order to support Emergency Support Functions (ESF) 4 and 8 of the National Response Plan (NRP). Figure 32.1 Medical surge capacity and capability management organization strategy. Source: US Department of Health and Human Services, 2007 [2]. The MSCC management system describes an interdisciplinary coordination system that emphasizes responsibility rather than authority. Each medical asset is responsible for managing its own operations, as well as integrating with other entities in a tiered framework. This allows assets to coordinate more effectively than the individual, ad hoc relationships that otherwise occur during a disaster [2]. In everyday operation of an EMS system, the medical director is responsible for such things as protocol development, equipment selection, and education. He or she also serves as a liaison and advocate for EMS within the rest of the health care system. The medical director is more akin to a chief executive or “big picture” thinker than an individual provider or scene commander. The same holds true during MCIs or disasters. The medical director is most effective through the entire disaster cycle – mitigation, preparedness, response, and recovery – by fulfilling his or her day-to-day responsibilities well before the advent of a disaster. During the event itself, direct patient care and on-scene triage are best left to the street-level providers who train in those tasks every day. As described above, the medical director serves in the ICS command structure as a senior advisor and liaison between the scene commanders, health care facilities, and other agencies to facilitate the best care for the greatest number of people (Figure 32.2). Figure 32.2 Incident command system organizational chart for unified command. The physician serves in the liaison or advisor role under the command structure. Source: US Department of Health and Human Services, 2007 [2]. In summary, the principles that should guide a medical director’s approach to disaster management are investment in everyday infrastructure; integration into both individual asset command structure as well as the interagency structure; and adapting to a less operational and more advisory role. The remainder of this chapter focuses on applying these principles during the four phases of the disaster cycle. Mitigation and preparedness strategies are daily activities that health care facilities and personnel undertake prior to a disaster event that enable an effective response to and recovery from the event. Mitigation activities involve reducing the potential for a disaster to occur or reducing the potential impact of a disaster. Seat belt and other highway safety laws are examples of mitigating activities. Preparedness refers to activities that enhance an organization’s capabilities to respond and recover if a disaster does occur. Examples include mass casualty training drills in hospitals. Both mitigation and preparedness involve similar principles. Historical events demonstrate that during true disasters, fundamentals such as communications systems, resource distribution, and organizational structure are common points of failure. Effective mitigation and preparedness strategies should focus on reinforcing these factors through enhancing these daily capabilities before the occurrence of an MCI. The EMS medical director is responsible for his or her agency’s mitigation and preparedness strategy, which should focus on the following three areas. Effectively implementing these areas in daily operations will affect multiple downstream components such as mutual aid agreements, hospital integration, patient distribution, and on-scene command, and will help prevent overwhelming on-scene and hospital resources during an MCI. Poor coordination between the multiple agencies affected by an MCI, as well as difficulties presented by resource sharing, lead to breakdowns in MCI response. As part of their mitigation and preparedness strategy, EMS medical directors should build collaborative and supportive relationships among the agencies that will be responding to or affected by MCIs. Under the auspices of patient care, the medical director is an ideal bridge-building envoy between agencies that rarely interact or sometimes compete in daily operations. In his or her role as a regional preparedness advisor, the medical director should identify and collaborate with every component of the patient care chain such as: Similarly, the medical director should identify local or regional resources and infrastructure that are operationally available on a day-to-day basis and that can be appropriately redistributed in the case of a disaster. He or she should collaborate with agencies responsible for these assets during daily operations so that the relationship can be called on in the case of a disaster. Mass casualty incident planning should also account for appropriate distribution of these resources. Classically, distribution has been defined either as a “push” or a “pull” model. In the push model, resources are distributed to the community at large, as in the case of using postal workers to distribute vaccines during a biological attack [3]. In the pull model, resources are centralized and patients are pulled toward the central infrastructure, as in the centralized makeshift facilities that saw the majority of patients during the Joplin tornado. We advocate a hybrid approach, using components of each model to address community-specific needs, based on the relationships established with various agencies. Establishing protocols for response activities during an MCI is key to preparing an organization to respond effectively and uniformly during an event. Protocols establish key criteria, define roles, and establish best practices that can often be forgotten in the heat of the moment. Protocols should account for varying levels of training, amounts of available resources, and interoperability of accountable agencies. A well-designed MCI protocol should reinforce a first responder’s ability to recognize and escalate an MCI, establish clear roles within the command structure, and appropriately allocate transportation resources (often resources are consumed immediately by lower-acuity patients, and thus transport of the sickest patients is delayed). Protocols and policies should address the following. Medical directors should also consider and account for rare, but extremely disruptive events such as chemical, nuclear, or biological attacks, mass fatalities, or extreme weather events. Figure 32.3 shows an example of a standard operating procedure utilized by on-scene providers that defines levels of MCIs and how responders can initiate a response system. Figure 32.3 MCI protocol. Source: Indianopolis Fire Department. Reproduced with permission of the the Indianopolis Fire Department. Once protocols are in place, the medical director is responsible for awareness and education of the protocol for all key providers, not only various first responder agencies and personnel responsible for implementing the protocols but other stakeholders as well, such as hospitals, law enforcement, and public health agencies. As with any new protocol, buy-in by the stakeholders is key and the education component also serves a relationship-building role. Finally, the medical director must provide for training and drilling for first responders on the implementation of MCI protocols. Because of the infrequency of real-life events, we recommend using the daily multipatient events that EMS responds to as a substitute for large-scale events. Events such as multivehicle collisions requiring transport of multiple patients will likely not escalate to the regional, state, or national level, but they can allow street-level providers to prepare for larger events and to practice the protocols instituted by the medical director. This model trains providers on resource and partnership utilization, communication, ICS, and systems-wide decision making without placing stress on the system itself. Evidence-based improvement of MCI protocols requires periodic and formal evaluation of protocols and personnel responsible for their implementation. Various models for evaluation include computer simulation, tabletop exercises, and large-scale drilling. Studies show a trend toward increased robustness through large-scale drilling [4]. An example of comprehensive drilling can be observed in airport-based EMS triennial response drills formally mandated by FAA part 139. Objectives learned from this type of drilling can be applied even at the small service level: preinspection review of policies and protocols, set calendar drill dates, outside review of policies and protocols, geographic response area movement inspection, equipment inspection, live drilling with timing and patient movement tracking, and postinspection, which highlights areas for improvement. Communication and information sharing during an MCI rely on technology as well as on human beings interacting during a high-pressured crisis environment. Review of historic disaster events demonstrates the importance of communication as well as the likelihood of communication technology failure [5–7]. For example, high-volume public inquiry can quickly overwhelm cellular systems during a highly publicized event. An MCI plan should account for the failure of cellular systems, wireless electronic medical record systems, and patient tracking systems and should prepare for 800 mHz and VHF radios and even paper and pencil back-ups as necessary. Similarly, human communication can be a weak point during an MCI, as response will typically involve multiple agencies that during routine operations will have little interoperability, occasionally competing interests, and often incompatible infrastructure. Actionable information and clear, rapid communication beginning with dispatch and ending with the after-action review are vital to the success of an MCI response and recovery.
Mass casualty management
Introduction
Investment
Command
Role
Mitigation and preparedness
Key personnel and resources
Policy, protocol, and training development
Intelligence and communication infrastructure
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