EIIP Virtual Forum Presentation — May 14, 2008

EMS and Disaster Preparedness
Practice Resources from the American College of Emergency Physicians (ACEP)

Marshall Gardner, EMT-P
EMS and Disaster Preparedness Manager
American College of Emergency Physicians

Amy Sebring
EIIP Moderator

The following version of the transcript has been edited for easier reading and comprehension. A raw, unedited transcript is available from our archives. See our home page at http://www.emforum.org

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon/evening everyone. On behalf of Avagene and myself, welcome to the Virtual Forum! We are glad you could join us today.

In honor of the upcoming 35th Annual National EMS Week, May 18-24, today's topic is "EMS and Disaster Preparedness: Practice Resources from the American College of Emergency Physicians (ACEP).

Now it is my pleasure to introduce today's guest. Marshall Gardner, EMT-P, is Manager of the ACEP EMS Disaster Preparedness program and coordinator for the EMS Week Planning Kit. Mr. Gardner began his EMS career in September of 1986 as an Emergency Medical Technician, and finished paramedic training in 1990. He graduated from the University of North Texas in 2004 with a degree in Emergency Administration and Disaster Planning.

Previously, Mr. Gardner worked in Fort Worth, TX for MedStar Emergency Services as a paramedic preceptor, Field Training Officer, System Status Controller and Mass Casualty Incident team member. He also served as a part-time faculty member for the Weatherford College Paramedic Program. From 1996 to 2003, he was a flight paramedic and clinical base manager for CareFlite Air Ambulance. After leaving private EMS, he worked in local municipal government as an emergency manager. During this time, he worked on three presidentially declared disasters, including Hurricanes Katrina and Rita.

Welcome to the Forum Marshall, and thank you for being with us today. I now turn the floor over to you to start us off please.


Marshall Gardner: I would like to start by saying thank you to Avagene and Amy for inviting me to give today’s presentation. We appreciate the opportunity to share some of the resources that we have available to the EMS and disaster preparedness community. I have listed some web addresses in this presentation. Those URL's will be available in the transcript that will be published.

The American College of Emergency Physicians (ACEP) exists to support quality emergency medical care, and to promote the interests of emergency physicians. This idea guides its Board of Directors, Council and Committees.

Founded in 1968 by a small group of physicians who shared a commitment to improving the quality of emergency care, ACEP set out to educate and train physicians in emergency medicine to provide quality emergency care in the nation’s hospitals. This has expanded over the years to include medical directors for emergency medical service (EMS) agencies.

Today, ACEP represents more than 25,000 emergency physicians, emergency medicine residents and medical students. ACEP promotes the highest quality of emergency care and is the leading advocate for emergency physicians and their patients, and the public.

The EMS and Disaster Preparedness Department is an integral component of the College’s Policy Division and serves as a resource for emergency physicians, EMS physician medical directors as well as the emergency medical services community. ACEP has made a strong commitment to supporting EMS through its physician members and staff. Some of the services the College provides the EMS community include:

• As a recognized authority on emergency medicine, support issues of common cause in EMS.
• Support federal and state programs and legislation to further injury prevention.
• Work to ensure that continued high quality prehospital emergency care is available.
• Promote evidence-based research on clinical practice and prehospital emergency care.
• Serve as a clearinghouse on emergency medicine and related issues.

The EMS Department maintains active liaisons with a number of federal and state agencies as well as approximately 30 other EMS related organizations. We work with these groups to promote EMS and disaster preparedness related policies and education.

Some of the projects our department has worked on are:

• Institute of Medicine (IOM) Future of Emergency Care: EMS At The Crossroads
• National Highway Traffic Safety Administration (NHTSA) Programs: EMS Agenda For The Future, EMS Education Agenda For The Future
• National EMS Core Content
• National EMS Scope of Practice
• National EMS Education Standards
• EMS National Research Agenda For The Future
• Trauma Systems Agenda For The Future
• National EMS Workforce Study

Parts of these projects have been published as official policy statements from the College. These statements are official endorsements by the College for various topics. As it relates to EMS, our Department maintains a compendium of College EMS related polices and Policy Resource and Education Papers (PREP’s). The EMS and Disaster Committee develops policy statements and guidelines for current topics in EMS and presently has more than 45 policies that relate directly to EMS or disaster preparedness.

These policies are an excellent reference or supporting documents for legislation or policy and procedure development. They are also a good resource for a new EMS Medical Director, and can provide the foundation for the development of new medical protocols. Many of these policies are joint projects with other EMS organizations including NAEMT, NAEMSP, NASEMSD, and ACS.

Some of the EMS policies can be accessed online by visiting http://www.acep.org/practres.aspx?id=32672&LinkIdentifier=id&ekmensel=c580fa7b_90_200_32672_4&fid=2412&Mo=No&acepTitle=EMS


Another task of our Department is to provide staff support for the ACEP EMS and Disaster Preparedness Committees. These committees provide the ACEP Board of Directors with advice on EMS, disaster and terrorism topics and develop policy statements as directed by the Board. These committees also work closely with other national EMS organizations representing fire-based, private and volunteer EMS systems.

The EMS and Disaster Preparedness Department also coordinates College liaison activity and joint projects with the American College of Surgeons - Committee On Trauma. This has included a number of joint meetings between the two groups and several joint projects. Recent projects have included a joint document on essential equipment for ambulances and College input into revisions to the Advanced Trauma Life Support (ATLS) course, the Resources For Optimal Care Of The Injured Patient document, and the ACEP/ACS Equipment for Ambulances document.


The EMS Department also provides liaison support to the following four ACEP membership sections. Sections are member-networking groups organized around a central topic.

• EMS Section - Physicians who serve as EMS Medical Directors for EMS providers and EMS educational programs across the country.

• Disaster Medicine Section - Physicians who are involved in disaster planning and response from the local hospital to the state or federal level. Many are also active in DMAT or USAR teams.

• Air Medical Transport Section - Physicians who serve as EMS Medical Directors or flight physicians with air medical transport services.

• Tactical Emergency Medicine Section - Physicians who serve as Medical Directors to SWAT and tactical teams at the local, state and federal level. Many are also sworn peace officers. Federal agencies represented include the FBI, Secret Service, ATF, and the military.

These sections of membership are joined based on member interest, and serve to provide a community for these physicians to share information.


Another function of the department is to coordinates the College’s terrorism and disaster planning and response activities. This includes seeking and managing federal grants and contracts. A current grants includes Department of Homeland Security (DHS) Grant

With this grant, ACEP conducts an all hazards assessment of community’s hospital emergency preparedness plans and capabilities. The assessment will include both a written self-assessment and an on-site survey by a team of disaster medicine experts. The surveyors used for the assessment include an emergency physician, emergency nurse, and a hospital emergency planner.

More specifically, the objectives of the grant are to:

• Assess the medical response preparedness of a community health care system
• Provide strategies to correct deficiencies identified during the assessment of the community’s health care system to respond to a mass casualty incident.
• Address identified deficiencies through customized training for each community.
• Provide hospitals with a framework to develop a strategic plan to improve emergency preparedness through comprehensive recommendations and planning assistance
• Assist each community in conducting drills to test the effectiveness of improvements made to their emergency response plan.
• Conduct a Lessons Learned Conference for all of the target cities.

Our other grant is from the Centers for Disease Control and Prevention (CDC) Traumatic Injury from Terrorism. This is a three year grant to develop core competencies and a training module for physicians, nurses and EMS to respond to blast related injuries from a terrorist event.

The Bombings: Injury Patterns and Care curriculum is designed to be the minimum content that should be included in any all-hazards disaster response training program. This content is designed to update the student with the latest clinical information regarding blast related injuries from terrorism.

A writing group developed teaching objectives and course content based on the core competencies. The following topics were assigned:

• System Issues
• Scene Safety
• Triage
• Blast Injuries
• Crush Injuries and Compartment Syndrome
• Military Experience
• Special Considerations
• Psychological Issues

These topics have been developed into a one and three hour blast course curriculum guides and PowerPoint presentations. The one-hour module can be inserted into existing disaster preparedness courses that need information on blast injuries. The 3 hour seminar can be taught as a stand alone course for those first responders who only want blast injury training.

In addition to the classroom material, an interactive CD-ROM training program is available that can be used in a classroom setting or on individual basis. The participant is presented with four different patients involved in an explosion in a subway station. The participant gets an overview of the scene and can treat and follow the patient from the scene to the emergency department.

The information was also used in the creation of a quick reference pocket guide and wall poster. All of these materials are available free and can be ordered, or downloaded at http://www.acep.org/blastinjury. Additional information including fact sheets and primers on the treatment of blast injuries can be found at http://www.emergency.cdc.gov.


ACEP is proud to have supported and sponsored the National EMS Week program since 1974. ACEP annually develops and distributes 30,000 free EMS Week Planning Guides to EMS services, State EMS agencies and emergency departments across the country.

[Slide 1]

EMS Week is celebrated during the third week of May each year. We partner with fifteen national EMS organizations, four federal partners and corporate sponsors to develop the content and distribute the planning guides.

EMS Week was first created by President Gerald R. Ford to help promote the newly developing field of emergency medical services. The EMS Act had recently been approved and this awareness campaign was meant to educate the public about this emerging field.

Today, EMS Week is meant to not only educate the public about EMS, but also allows an opportunity for EMS personnel to be recognized for outstanding contributions to the field.

The public awareness material in the planning kit has provided agencies the ideas to put on various injury prevention and other health related educational opportunities. These include, blood pressure screening, safe bicycle operation clinics (bike rodeos), child car seat installation clinics.

Also, there are tips on how to promote your EMS agency using these events, as well as other open house opportunities. The EMS Week Planning Guide is available online at http://www.acep.org/emsweek.

This concludes my presentation, I would like to thank both Avagene and Amy for allowing me an opportunity to present today, and I hope the information presented has been helpful. With that, I would like to turn it back over to the moderator.

Amy Sebring: Excellent job. Thanks very much Marshall. Now, to proceed to your questions or comments.

[Audience Questions & Answers]

Kailash Gupta: Greetings from Jaipur, India. Yesterday Tuesday May 13, 2008 in 14 minutes interval from 7:15 PM there were 8 terrorist bomb blasts in the crowded parts of the walled old city in which 65 people died and 200 injured. Did you hear about that? What is your comment?

Marshall Gardner: Yes, we did hear about portions of it. The blast injury information we have is being distributed by the CDC during these types of events. They try to get this information out in the form of blast faxes to interested parties.

Avagene Moore: Marshall, how has the national emphasis on standards impacted EMS organizations and personnel?

Marshall Gardner: Good question. This has created a collaborative effort between all the various groups in EMS; including professional associations, federal agencies, and education. All these groups are working together now to identify the commonalities and are working on the solutions.

Isabel McCurdy: Marshall, curious here as I am Canadian. Does every one get access to emergency services whether they have medical coverage or not in a mass casualty event?

Marshall Gardner: Yes however, the type of service may vary between private services, or municipal services.

Amy Sebring: Marshall, in follow up to Kailash's question, can you tell us why it is important for EMS personnel to be prepared for blast injuries?

Marshall Gardner: Yes. US EMS may not face terrorist bombings every day, but they may face some of the same affects from industrial accidents or other events that can produce the same type of injuries.

Amy Sebring: And they do not typically receive this training elsewhere?

Marshall Gardner: Some of these components are beginning to show up in classes and the blast injury information is being made available to assist with this Also, by providing this information, a consistent approach to treatment can be achieved.

Amy Sebring: Speaking of which, are ACEP and its partner's working to incorporate some of the disaster aspects into regular curricula?

Marshall Gardner: Yes. We are working with various groups to identify current Emergency Medicine resident training and what or how much disaster response training they are receiving.

Craig Harner: What about military medical training? Does this cover some of the aspects?

Marshall Gardner: Yes. Actually, we are learning from them. Many of our members are in the military and have brought back scientific data that promotes some of the treatments. Those members serve as subject matter experts on this material.

Avagene Moore: Marshall, I read there seems to be more and more of a trend to private sector-owned EMS rather than governmental EMS organizations. Are there advantages, in your opinion, to private sector EMS vs. local government EMS departments?

Marshall Gardner: That's a good question. It mainly depends on the community, what their needs are, and what is available. The types of care provided by either service are equal, just delivered in different manners.

Kailash Gupta: The bombs included RDX, and there were ball bearings inside the bombs

Marshall Gardner: That's a good point; the other thing we have learned is to expect other types of injuries associated with blasts. These can include radiological and biological contamination associated with the traumatic injuries that are also seen.

Debbie Kim: Marshall - the data coming back from Iraq that was presented at the recent NDMS meeting is rather specific regarding changing the approach to the patient who has been injured in a blast. The military approach advocates extensive tourniquet use (for extremity trauma), little IV fluids and promotes the use of fresh, whole blood. Your thoughts on how this is going to impact civilian EMS practice?

Marshall Gardner: It already is. There was a recent article published in a journal that looked at the use of tourniquets in the field. This data is obtaining peer review and additional data is advocating some of the military experiences for use here. The article I spoke of is in Prehospital Emergency Care, April/June 08 issue.

Amy Sebring: Marshall, sometimes we see recommendations for "average" adults. Do you have any focus on special needs of children, elderly etc.?

Marshall Gardner: Yes. The blast injury information contains specific information on these types of patients. Also, the Policy Statements I referred to earlier discuss them as well.

Isabel McCurdy: Fresh whole blood as transfusions? Checked for Hepatitis, etc.?

Marshall Gardner: That topic is still under a lot of discussion. The emphasis for field treatment is primarily on the bleeding control through the use of tourniquets and hemostatic agents.

Amy Sebring: In my experience, I find that private EMS services are left out of planning, training, and exercises that may be provided to public EMS services. Do you have a rough breakdown of public vs. private, and are you finding the same lack of participation?

Marshall Gardner: You’re right, they can be. Private services that have 911 contracts usually are more involved but services without municipal contracts can be missed. It's important for both the service and the cities to remember those resources during the planning phase. A lot of times these groups may not be aware of each other’s capabilities and what they have to offer.

Amy Sebring: Regarding breakdown, would you say it is 50-50 between public and private in terms of service provided, or some other ratio?

Marshall Gardner: That's hard to say. The trend we have seen has been more between urban versus rural. The larger cities primarily have large EMS hosted by fire departments while smaller, rural jurisdictions are private services.

Jim Fazackerley: I'm curious about your thoughts on hospital surge capacity for larger bomb related incidents with casualty yields greater than 100 patients. As a system, we've procured some tent-style aid stations but haven't completely worked out whether to transport people to outlying hospitals or to somehow create a surge of beds in our 9 local receiving facilities.

Marshall Gardner: Very good question. We have seen a lot of ways to address surge both in the actual ED by moving more beds in and with on-site patient collection areas. Both have pros and cons, either associated with lack of space in the ED, or lack of equipment outside. A good resource for this would be In a Moment’s Notice: Surge Capacity for Terrorist Bombings, Challenges and Proposed Solutions.

Amy Sebring: Marshall, the publication you referenced above re surge, is that an ACEP publication, or some other source?

Marshall Gardner: I'm glad you asked. It is published by the Centers for Disease Control and is available for free. It lists templates to help with surge capacity in ED's, EMS and other hospital departments. It should be available on the link I provided earlier. [See http://www.bt.cdc.gov/masscasualties/surgecapacity.asp]

Avagene Moore: In your opinion, what is the most pressing challenge facing EMS personnel and organizations in the post-9/11 world?

Marshall Gardner: The meshing of all the different types of EMS agencies; the incorporation of a LOT of different types of technology and agreeing on systematic response mechanisms.


Amy Sebring: Let's wrap it up for today. Thank you very much Marshall for an excellent job and we hope you enjoyed the experience. We also wish you a very successful EMS Week!

Marshall Gardner: Thanks to everyone!

Amy Sebring: Please stand by just a moment while we make a couple of quick announcements. The formatted transcript (with links) will be available later today. If you are not on our mailing list and would like to get notices of future sessions and availability of transcripts, just go to our home page to Subscribe.

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Thanks to everyone for participating today. We stand adjourned but before you go, please help me show our appreciation to Marshall for a fine job.