Disaster preparedness: Where is our place and responsibility?

Michael Guttenberg, DO, Director of Pre-Hospital Care, Department of Emergency Medicine, New York Methodist Hospital

“Everyday we get further away from the last disaster brings us one day closer to the next.”

While this is a fatalistic or pessimistic view, it has become a motto cited by many leaders in emergency management as they learn from the lessons of the past and develop elaborate plans to cope with future disasters- natural, unintentional, man made, and acts of terrorism.

The days following the September 11, 2001 terrorist events showcased the value of the American health care system, our emergency departments, and our emergency medical services system. All members of the medical community perceived a need and wanted to participate. While this was admirable, it also highlighted the vulnerabilities of our current system and lack of understanding of the incident command system. Now, two years later, wars are being fought, articles are being published, drills are being conducted, and billions of dollars are being allocated. While we continue to mourn and remain cognizant of past events, the passage of time has allowed us to move on and refocus our thoughts and efforts. Emergency Department overcrowding, physician reimbursement, and tort reform have once again taken center stage as the major issues facing emergency physicians. While this speaks of the human spirit and ability to move forward, it also places us at risk of complacency and repeating mistakes of the past.

As emergency physicians, we have an obligation to our patients, hospitals, colleagues, and ourselves to continue to promote and participate in hospital and community based emergency medical planning and education. We need to understand the roles and responsibilities of all physicians, not only emergency physicians, during mass casualty incidents and disasters. We are the hospital-based masters of triage and multitasking. As we are firmly entrenched at the front door of our hospitals, it is our responsibility to maintain the leadership role we have taken. We must continue to promote the lessons we have learned. An example of this includes the role of unsolicited, albeit, well-intentioned medical personnel at mass casualty incidents and disaster scenes.

The activities of unsolicited medical personnel, such as physicians, nurses, paramedics, and emergency medical technicians, was a source of much debate and great scrutiny following the World Trade Center attack. While the media was largely complimentary of these activities, interviews with on site leadership and medical incident commanders revealed a different portrayal. The participation of unsolicited medical personnel has been strongly debated and discouraged. Many organizations, including JCAHO, ACEP and National Association of EMS Physicians (NAEMSP), have taken a strong stand to strengthen support for the Incident Command System (ICS)/ Hospital Emergency Incident Command System (HEICS).

A review of the standards put forth by the JCAHO for HEICS makes no mention of an out of hospital role for hospital personnel and physicians. Existing ICS models throughout the country only make reference to EMS based medical directors and physicians. EMS physicians are often emergency medicine trained and have expanded skills and experience in out-of-hospital care. The role of these physicians usually includes medical control and medical oversight. Aside from their role at disasters and mass casualty incidents, these physicians are involved with training, protocol development and the medical oversight of EMT and paramedic field personnel. They have a working knowledge of EMS operations and their out of hospital scope of practice. In addition, EMS physicians have a working fluency with the incident command system as well as a functional familiarity and access to personal protective equipment.

As leaders in the practice of emergency medicine, emergency physicians should understand the limitations of on-site unsolicited medical personnel. The rationale is multi-factorial. The first tenet of pre-hospital care is …… (i.e. don’t become a patient yourself...). Unsolicited medical personnel (UMP) typically follow a visceral response. They will often arrive at a scene unprepared without critical self-protection supplies. They may not have access to the appropriate personal protective equipment (i.e. clothing and shoes) to function in the out of hospital environment, or the appropriate respiratory protection and chemical protection. They are putting themselves at risk and potentially placing further burden on the system.

Unsolicited medical personnel pose a security risk, especially at crime scenes or terrorist activity sights. On-site credentialing is potentially dangerous. The verification process is difficult and subject to abuse. Hospitals have been debating mechanisms to rapidly credential outside physicians at times of crisis. There should be no expectation that it will be done more efficiently at a disaster site. Without appropriate credentialing, physicians may encounter liability risks without insurance coverage as well as place themselves in jeopardy with their own worker’s compensation.

Patient tracking, documentation of injuries, and documentation of treatment is made more difficult when unsolicited medical personnel are present. EMS systems, which have standardized forms and tracking mechanisms already in place, are not always successful completing this task. Failure to account for patients who are treated and released by unsolicited medical personnel is hazardous. Aside from appropriate statistical tracking, patients not appropriately accounted for will lose their ability to seek insurance and legal recourse after an incident. In addition, they may not receive appropriate follow up medical care.

There are also major operational concerns at disasters and mass casualty incidents. The concept of ‘staging’ personnel and equipment is designed to minimize congestion at an incident site and provide an organized flow, not gridlock. Unsolicited medical personnel are usually not familiar with this process nor do they have access to information regarding predetermined staging locations. Their presence, especially in private vehicles, can further complicate an already congested environment. We have already learned this in our own departments. We no longer allow non-essential personnel/physicians to stage at the most active and congested place in the hospital (the ED).

The emergency medical services community in the United States is well equipped and trained to provide care at disasters and mass casualty incidents. They do this with EMS/emergency physician derived protocols and training. The first responsibility of unsolicited medical providers, including physicians, is to their patients at the hospital. This has been clearly established and should be frequently reinforced. They need to make disposition decisions on their admitted in-patients, make beds available, and care for the new patients that arrive. While the potential always exists for a system to become overwhelmed, unsolicited medical personnel will not return order out of chaos. In fact, for all of the above reasons, they may contribute to the problem. On-site Emergency Medical Service physicians have access to back-up through the state and federal Emergency Management Agencies. As emergency physicians, we use components of incident command on every shift. As leaders in the field, we should be educating our colleagues and reinforcing these principles. As quoted in The Book of Household Management in 1861, “A place for everything and everything in its place (Isabella Mary Beeton).”

There is a time and place for us all. Let’s not try to figure it out in the middle of a disaster.