Catastrophic Event Patient Care: An EMS and Disaster Healthcare Paradigm Shift

Battlefield casualty management experience has resulted in advanced and effective rescue, resuscitation, stabilization, definitive treatment and rehabilitation of soldiers ever since World War II. The use of the helicopter as an air ambulance greatly improved the survival rates of soldiers wounded in combat in Korea and Vietnam and in all conflicts since. Many trauma procedures develop in combat medicine have been applied with great success to our civilian trauma systems. With the ever-present threat of terrorist attacks using biological, chemical, radiological/nuclear and explosive agents or devices, the time may be right for jurisdictions and their civilian healthcare systems to implement a combat proven system for mass casualties called the 4-Echelon Mass Casualty Management System.

For more than 10 years, Public Health agencies at all levels of government have been ramping up capabilities for early detection and responses to biological warfare agents and disease outbreaks. HHS through the Hospital Preparedness (HPP) grant program has advocated a 6-Tiered approach to managing expanding disasters from local communities (Tier 1) all the way outward to a National (Tier 6) fully integrated response to catastrophic events. The overarching idea is to build a scaled response to disasters by forging strong relationships between the Emergency Management community, public health agencies and Private Sector healthcare organizations in order to effectively manage casualties resulting from any disaster event. The system should maximize the number of casualties stabilized during the “Golden Hour” and then rapidly transport stabilized patients to hospitals and medical centers away from the affected community for definitive care and long term rehabilitation.

What is the 4-Echelon Disaster Patient Management System? The 4-Echelon Disaster Patient Management System is a highly effective and efficient system of managing very large numbers of casualties throughout a disaster and until local healthcare organizations recover and can resume normal operations.

The 1st Echelon of care is provided by first responders and consists of immediate lifesaving procedures and the rapid transport of the living to a 2nd Echelon facility. All living casualties are transported to 2nd Echelon facilities with the dead left for the mortuary affairs team.

A 2nd Echelon facility may be a trauma center or an emergency department. The 2nd Echelon is essential in making the most of the patient’s “Golden Hour.” By providing immediate care and by dramatically increasing the casualty throughput to 3rd and 4th Echelons, the 2nd Echelon care providers prevent or reduce the patient gridlock associated with a disaster and thus, optimize the saving of lives. 2nd Echelon care is designed only to save lives and stabilize patients and not to provide definitive care. Typically at the 2nd Echelon, providers ventilate patients if necessary, control bleeding, infuse blood products and expanders and amputate limbs as required. Once stabilized, patients are quickly transported to the 3rd Echelon of care for definitive treatment.

The 3rd Echelon disaster healthcare facility is typically a hospital or medical center away from the immediate disaster location. In the early stages of a disaster, a hospital or medical center may provide both 2-E and 3-E care. It is likely that a hospital’s 3-E capacity will almost immediately be reached and the facility will revert to 2-E care only. 3rd Echelon facilities may be within a jurisdiction or may include hospitals in several jurisdictions or even national regions, depending on the number of casualties and the care requirements. Definitive care is provided at all 3rd Echelon facilities, but specialized care such as burn centers may also be provided in a 3rd Echelon facility. This includes a full complement of surgery specialties, diagnostics and follow-on care for about 7 days. Patients who cannot be discharged within a week are normally candidates for 4th Echelon care.

The 4th Echelon may include specialty centers or rehabilitation hospitals capable of providing long term ventilation care, psychiatric care, burn or wound care and rehabilitation or specialization in physical therapy or orthopedic care including providing prosthetic devices and associated therapies.

Depending on the location and scope of the disaster, a particular hospital may function as a 2nd, 3rd or a 4th Echelon facility. When close to the disaster location, a hospital may have to function only as a 2nd Echelon facility, transporting all stabilized patients to 3rd and 4th Echelon facilities further away from the disaster location. By so doing, the hospital serving as a 2nd Echelon hospital may be able to treat more patients in need of stabilization than it could as a multiple-Echelon facility. In another disaster scenario further away, this same hospital could be functioning as a 3rd or 4th Echelon facility, providing definitive and/or specialty care to stabilized patients.

What is the role of Healthcare Organizations as part of a 4-Echelon Disaster Patient Management System? Most medical centers and many hospitals operate as a de-facto full 4-Echelon self-contained system during normal everyday operations. During a disaster, Healthcare organizations will periodically self-declare their capabilities to the Emergency Operations Center (EOC) in terms of the Echelon of care they can provide in a fluid environment. Depending on the size and scope of a Mass Casualty event, a hospital may eliminate the 4th-Echelon immediately and declare itself as 2nd and 3rd Echelon capable to the medical representative in the Emergency Operations Center. At that point, the EMA would reach out to adjacent jurisdictions to activate their EOC (s) and to provide a list of healthcare organizations capable of providing 4th Echelon care. In any case, healthcare organizations must be able to efficiently communicate their capabilities with the jurisdiction’s EOC throughout the disaster.

How can 4-E work in a competitive Healthcare Marketplace?

A traditional model of disaster healthcare seems to dictate that healthcare organizations provide the full continuum of care to all patients presenting for care. Competition would seem to dictate that hospitals or medical centers expand (surge) their services until their individual capacity and capabilities are reached. Why then would hospitals want to self-declare themselves as a 2nd Echelon facility and request rapid transport of stabilized patients to healthcare organizations outside of their service area? The answer lies in continuity of operations. Hospitals in the affected area need to recover and resume normal healthcare services as soon as possible after a disaster. 2nd Echelon healthcare facilities performing thousands of life saving procedures over the course of a disaster, (if properly documented) may generate significantly more revenue than 3rd Echelon facilities away from the disaster location. Also, by serving as a 2nd Echelon facility and rapidly transferring patients to 3rd and 4th Echelon facilities outside the affected area, hospitals and medical centers in the affected area can conserve staffing and specialty care material resources and thus, can more rapidly recover after the disaster event.

This definitely requires a paradigm shift, but experience shows that after a disaster, healthcare providers need decompression time. If the staff is exhausted, who will provide healthcare services immediately following a disaster? Likewise, medical supplies are consumed at an enormous rate during a disaster. Equipment used during a disaster needs to be disinfected and inspected prior to being returned to normal service. If the support services personnel are exhausted, who is going to disinfect hospital areas and the equipment and how long will the hospital be closed after a disaster? Heart attacks and strokes will still occur, babies will be born and the population in general will need care immediately after a disaster.

Finally but importantly, disaster operations can and do strain healthcare financial resources to the breaking point. The last thing that any community needs after a disaster is a number of bankrupt hospitals or medical centers. Civilian healthcare organizations cannot issue continuing resolutions in order to make payroll or pay suppliers during and after a disaster. Federal and State payers as well as private insurance companies must develop and publish simplified health care claim procedures for use during declared emergencies. These simplified claim procedures will sustain healthcare organizations and their services during and after a disaster and can help ensure that healthcare services are available after the disaster. Perhaps, simplified financial procedures can be tied to services rendered at each Echelon of care.

Adopting the 4-Echelon Disaster Patient Management System. The first step is the adoption of the 4-Echelon Disaster Patient Management System by a state or territory EMA, EMS organizations and the Healthcare organizations within the jurisdiction. Once proven in a single state, the 4-Echelon System may be adopted throughout a federal region or multiple regions. In time, the 4-Echelon System can be adopted Nationwide. The 4-Echelon System will fit seamlessly into the National Disaster Medical System (NDMS), since had the Cold War turned hot, the NDMS healthcare facilities were the planned 4th Echelon of care for service members returning from either the European or Pacific theaters of operations. The 4-Echelon System is in effect today for returning injured service members. Thus, while jurisdictions and health systems struggle to develop an effective “Medical Surge” system, this may be the right time to integrate this efficient and effective patient management system into our civilian disaster healthcare system. ©2011 JVR Health Readiness Inc.