Editor’s note: This post expands on the theme of the December issue of Health Affairs, The Future of Emergency Medicine: Challenges And Opportunities.
A unique body of knowledge. A distinctive body of knowledge is rapidly emerging with the publication of authoritative textbooks, development of standardized training (including post-graduate fellowships), and the creation of standardized nomenclature enabling reliable and consistent measuring of outcomes.
The term “lessons learned” has no place in the lexicon of disasters. Rather, the scientific field is defined by measurable and impartial observations that can be replicated by other experimental and theoretical scientists. While interdisciplinary sciences exist and transdisciplinary sciences are the new craze, there is no field so global and transdisciplinary as Disaster Medical Sciences. It should take its place among the sciences by generating and testing theoretical propositions, rather than merely consisting of a random collection of experiential “lessons.”
Metrics and Measurements
A common question surrounding disaster preparedness is: “Are we ready?” The tempting retort is: “Ready for what?” What is “readiness” and how do we measure “it?”
On a conceptual level, a “disaster event” can be defined as a condition or situation (with or without casualties) for which the available resources are inadequate. This idea can be concisely described as a PICE or “potential injury/illness creating event.” The local resources of the unit of reference (whether it is a hospital, emergency medical services, public health, or law enforcement entity) are exceeded at a given point in time. The PICE can evolve over time as conditions change (with more or fewer casualties) or resources alter (more or fewer are available). When medical and health needs exceed resources at a given point in time, emergency management systems must be activated. The need for disaster plan activation is not dependent strictly on the absolute number of patients; the key point is whether system resources are adequate to manage the emergency situation.
To develop metrics for disaster management, it is useful to identify the essential elements necessary to continue to provide service (e.g., taking care of patients) and use these for continuity of business operations planning. If one or more of these essential elements are missing or dysfunctional, how will they be reconstituted? How resilient is the community?
The descriptors “natural” and “manmade” should be removed from the disaster lexicon. If a wildfire is fueled by human-caused deforestation or instigated by an arsonist, is it really a “natural” disaster? Would the biological attack in Dallas, Oregon when terrorists sprayed salmonella onto restaurant salad bars in an attempt to sway a political election have been managed any differently (from the medical and health perspective) if it had been known to be a “manmade” event at the time (rather than being determined years later)? We should focus on the functional impact to the medical and health system, not the etiology of the event.
While many attempts to develop preparedness benchmarks have been made, defining readiness presents a difficult challenge and further work remains to refine these existing efforts. Nevertheless, we cannot simply stand still and wait until the classification system is fully developed; disasters are pervasive every day, around the globe.
Conceptual Framework/Major Principles
Despite a lack of international consensus on terminology and metrics, there are several well-accepted principles which can guide our preparedness efforts. These include:
- All-hazard preparedness – performing a hazard vulnerability analysis and creating an emergency management system that is positioned to manage any event, anticipated or novel
- Incident Command/Management System – using a flexible system that is functionally based with clear definitions of roles and responsibilities
- Comprehensive Emergency Management – understanding the four phases of mitigation, preparedness, response and recovery (rather than focusing only on the highly-visible “response” phase)
- Community Resilience – the process of successfully adapting to, and recovering from, adversity
The 3S Concept of Surge Capacity consists of staff (personnel), stuff (supplies and medications), and structure (2 components: physical location for patient care; and management structure). The economic shift to a philosophy of “just-in-time” pharmaceuticals and supplies is a useful strategy for day-to-day operations, but is at cross-purposes with the surge capacity need inherent in a disaster.
Crisis Standard of Care & Allocation of Scarce Resources
While controversy exists regarding the implications of a scarce resource environment for triage and ethical considerations, we are guided by general principles. In a crisis situation, where patient care needs exceed available medical and public health resources, there is a philosophical shift. Rather than focusing on caring for individuals, we strive to “do the most good for the most people.” In other words, there is a shift from optimizing individual outcomes to maximizing population outcomes.
For an event that evolves over time, such as a pandemic, we need triggers to shift to a Crisis Care environment and triggers to return back to baseline operations. This shift could occur multiple times during the same event, and must be implemented on a regional basis. In other words, a patient with the same condition should have an equal opportunity to be treated (e.g., with a ventilator) in one hospital as in the next hospital down the road.
We can have the best fully evidence-based physical science in the world, but if we do not consider non-medical influences we will set ourselves up for failure. Many of these concepts are described in the social science literature, which is not typically readily available to medical researchers.
Sociological publications dating back to the 1940’s describes human behavior in disasters but such references are difficult to find when searching the medical literature. Mental and behavioral factors are critical considerations. Consider how disruptive the anthrax attacks in the fall of 2001 were despite the fact that there were only 22 direct casualties from the event. We must plan for what people will do (rushing to the seaside to marvel at an incoming tsunami), as well as for what protocol calls for them to do, i.e., evacuate to higher ground.
Other Non-Medical Influences
Realistically, assigned health care workers may be unable or unwilling to report to work in a disaster. Similarly, convergent volunteerism may lead to non-affiliated, well-meaning health care workers presenting to a disaster site, which in turn can lead to the unintended consequence of worsening the ability to manage the disaster by diversion of resources to assessment for appropriate credentials, training, and the ability of these workers to protect themselves from harm.
Political forces can also be highly influential. For example, a well-connected person might circumvent the system and make a direct request to a political leader, undermining a coordinated disaster management system. Furthermore, the political process can result in medical decisions uninformed by adequate input from subject matter experts. On the other hand, the ability to cut through bureaucratic barriers by political fiat can be invaluable in some situations. Developing channels of communication with political leaders in advance of the disaster to prospectively implement good policy is essential.
We need to have coordinated international scientific standards. International and national authorities should not issue conflicting recommendations, as was the case regarding the use of N95 respirators versus surgical masks for health care workers caring for patients with the 2009 novel H1N1 virus.
The media can, of course, strongly influence disaster management. The dissemination of conflicting or inaccurate public health messages can negatively affect outcomes. Conversely, partnering with the media ahead of the event can facilitate their assistance in distributing appropriate messages within the principles of crisis and emergency risk communication.
For potential terrorism and other criminal events (e.g., active shooter scenarios), the law enforcement and intelligence communities have an important role in crime scene investigation. The desire to preserve a crime scene for future investigation and national security concerns may not always fully align with pressing medical and health needs.
Future Challenges and Opportunities
It is difficult to conceptualize a truly catastrophic disaster in the United States because we fortunately have experienced very few events with tens of thousands or hundreds of thousands of casualties (as have occurred in other countries). In many smaller-scale disasters, it is a lack of an incident management system, rather than a true lack of resources, that is the cause of ineffective management. Yet, we are certainly at risk for a large-scale disaster, e.g., from the Yellowstone supervolcano, a mega-earthquake (or even a moderate quake in less prepared parts of the country like the central United States), the aerosolized release of a biological agent over an urban population, or the mass psychological effects of the detonation of a dirty bomb.
While there is an ongoing scarcity of resources in the U.S. (as in other countries) on a daily basis, this pales in comparison to the surge capacity that will be needed in a catastrophic disaster scenario. However, momentum to prepare for the “what if” is often undermined by the complexities of managing an incessantly busy here and now. This challenge is magnified by the tendency of government — especially in an era of budget cutting — to be reactionary rather than proactive. Sadly, the best time to attain funding and attention for disaster preparedness isn’t until after a real disaster occurs; an entire new cabinet level Department of Homeland Security (the largest U.S. government transformation since the founding of the Department of Defense) was created after the 9/11 terrorist attacks.
Even when resources are dedicated to disaster preparedness, there is frequently a disconnect between health policy and front-line operations. Just as academics are said to sit in an “ivory tower” and not understand the “real world,” policy makers frequently do not grasp the complex realities of ground zero. It is often difficult for emergency managers and front-line health care workers to operationalize policies (especially within the expected timeframe), particularly when they lack an understanding of the concepts that inform policy decisions. It is rare to find individuals who have a good grasp of both the strategic and tactical dimensions of the situation, especially in the heat of crisis.
Furthermore, current operational threats render many historical approaches obsolete. Much of disaster preparedness was developed with a “bunker mentality” that is not entirely relevant to today’s world. For example, school children were taught to “duck and cover,” whereas in the contemporary environment there is more likely to be a need to “strip and shower” after a chemical terrorism attack.
The present National Disaster Medical System was founded on a predictable catastrophic earthquake and fails to account for settings where patients can not readily be transported to unaffected regions of the country, e.g. because they are contagious or contaminated, or because the transportation and communications infrastructure is too severely disrupted. In addition, cybersecurity threats are more of a concern in contemporary technologically advanced societies.
There may not be a discrete “scene” for a disaster. There could be multiple pockets of victims with traumatic injuries or a completely different scenario of an event evolving over time, such as a pandemic, potentially with a novel virus.
There is an evolving influence of social media on crisis and emergency risk communication. Policy makers should embrace these new technologies rather than remaining stuck in older methods of communications and potentially being undermined or rendered ineffective by online sources of information.
Hospitals have traditionally planned in a vacuum. We need to include disaster planning in our comprehensive systems of care. Community Paramedicine is an emerging example. In addition, hospitals themselves may be victims of the disaster, a scenario commonly neglected, such as occurs with the flooding of emergency generators located below ground, with a major earthquake causing structural or non-structural damage, or some forms of cyberattack. Hospitals need to plan with other entities in their community and on a regional basis. Evacuation is a real possibility in the “hospital as a victim” hypothetical.
While it is easy to count “stuff” and to stockpile things like ventilators and antiviral agents, these items are insufficient by themselves. We must focus on “patient care capacity” and stop counting “beds.” Beds by themselves don’t take care of patients – we need all the elements of a surge system to operative effectively. It’s time to for disaster preparedness to align with other modern health care strategies and become patient-centered.
When considering challenges and opportunities for the future of emergency medicine, Disaster Medical Sciences takes a front and center role. Emergency preparedness faces a multitude of policy and operational challenges. There are many non-medical factors that influence disaster management systems. Patient-centered solutions are necessary.
As an emergency physician who has traveled extensively internationally and worked in both academia and government at all levels (local, state, federal), I have unique perspectives on the challenges we face. The science of Disaster Medicine is in its infancy. Is there a unique body of knowledge? I believe so, but we have not yet fully defined it.
In the meantime, the global and transdisciplinary nature of Disaster Medical Sciences requires us to both develop scientific doctrines and manage disasters concurrently. Fortunately, we have a number of basic principles to guide our actions and the development of robust health policy. The future lies in connecting the science to medical and public health policy. We must advocate for outcomes-based research and scientific inquiry with a focus on patients and disaster preparedness to inform policy decisions.