EIIP Virtual Forum Presentation — April 12, 2006

The Importance of Evidence-Based Disaster Planning
Issues in Emergency Medical Response

Erik Auf der Heide, MD, MPH, FACEP
Medical Officer
Agency for Toxic Substances and Disease Registry (ATSDR)

Avagene Moore
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]

Avagene Moore: Welcome to the EIIP Virtual Forum! We are pleased you could join us today! Today's topic is "The Importance of Evidence-Based Disaster Planning - Issues in Emergency Medical Response."

It is my pleasure to introduce our guest speaker, Erik Auf der Heide, MD, MPH, FACEP, author of the article under consideration today, and Medical Officer for the Agency for Toxic Substances and Disease Registry (ATSDR) U.S. Department of Health and Human Services, Atlanta, Georgia, since 1998. Prior to becoming involved in public health, Dr. Auf der Heide, practiced clinical emergency medicine for 18 years. He has published several previous articles on disaster planning.

To learn more about our speaker's expertise and experience and to check out the related Web site references see background page at http://www.emforum.org/vforum/060510.htm.

Welcome to the EIIP Virtual Forum, Erik. I now turn the floor to you for your formal remarks.


Erik Auf der Heide: Hi; it’s good to be here with you today. I have spent about 25 years writing, lecturing, and teaching about disaster preparedness, and my focus has been on what we can learn from the results of field research on domestic, peacetime disasters.

During this session of the Virtual Forum, I would like to share with you some of the information I have learned from reviewing field research studies on the emergency medical responses to disasters, and how it can help you to develop realistic, evidence-based preparedness programs and plans.

Some have suggested that disasters are just like daily emergencies, just larger, and the best way to deal with them is by expanding your normal emergency response. One of the most important things I have learned is that disasters are different than daily, routine emergencies. They are different not only quantitatively, but also qualitatively.

Disasters present a number of problems that have no counterpart in routine, daily emergency responses. This is may help to explain why routine emergency procedures often fail and why planning specifically for disasters is necessary. By looking at the evidence from field disaster research studies, we can learn how they are different. This knowledge may be helpful to planners and practitioners who want to avoid repeating the errors that have occurred in the past.

What I am going to do today is illustrate the importance of evidence-based (or research-based) planning by looking at several common assumptions, contrasting them with field research findings, and discussing the implications for planning.

ASSUMPTION 1: Dispatchers will hear of the disaster and control which emergency response units are sent to the scene.

Research Finding: Emergency response units, both local and distant, often self-dispatch.

Planners therefore need to:

(1) plan for both the community AND intercommunity levels,

(2) expect unsolicited responders, and

(3) plan for coordinating them.

ASSUMPTION 2: Trained emergency personnel will carry out field search and rescue.

Research Finding: Most initial search and rescue is ad hoc, uncoordinated, and carried out by the survivors themselves, rather than by trained first responders. Survivors often know the location of missing persons. Law enforcement agencies may not anticipate that search and rescue are their official duties, but often become involved anyway.

Planners therefore need to:

(1) train first responders, including law enforcement officers, to work with survivors to coordinate search and rescue, and

(2) designate personnel to obtain information from survivors about missing persons.

ASSUMPTION 3: Trained EMS personnel will triage victims, provide care, and decontaminate exposed casualties before transport.

Research Finding: Casualties will likely bypass field triage and decontamination sites and go straight to the hospital. Thus, hospital staff needs to assume arrival of untriaged, undecontaminated, and unstabilized casualties.

Planners therefore need to:

(1) develop instructions for survivors on how they can protect themselves, provide first aid, and manage contamination;

(2) provide citizenry with first-aid, search and rescue, and disaster-care training; and

(3) send first responders to hospitals to help out, e.g., extrication of casualties from cars.

ASSUMPTION 4: Casualties will be transported to hospitals by ambulance.

Research Finding: This doesn’t happen most of the time. Most casualties reach the hospital by private cars, police vehicles, buses, taxis, and on foot. Thus, EMS authorities should not assume that they have control over their EMS systems either in terms of patient destinations or timing of transport. Survivors will be difficult to track.

Planners therefore need to:

(1) educate the public about proper transport techniques, and

(2) establish procedures for obtaining information from hospitals about casualties they have received.

ASSUMPTION 5: Casualties will be distributed proportionately to hospitals.

Research Finding: Most casualties go to the nearest or most familiar hospitals, thereby overloading some hospitals with a disproportionate number of patients and with patients for which the hospital may lack needed specialty services such as burn care expertise. All hospitals need to expect contaminated casualties and prepare to decontaminate them.

Planners therefore need to:

(1) consider bypassing ambulances around closest hospitals;

(2) strengthen EMS system mutual aid and communications systems to facilitate efficient casualty distribution; and

(3) have a protocol for distributing ambulance patients pending information on hospital capacities and patient loads.

ASSUMPTION 6: Authorities in the field will notify hospital staff promptly about the disaster and the patients they are likely to receive.

Research Finding: Hospital staff will likely hear first about the disaster from first-arriving casualties or the media, and the quality and timeliness of updated information about incoming casualties will be poor. This means that hospital response capability will rest on resources already in house, and protecting the hospital and staff against contamination (e.g., donning chemical-resistant suits, taping plastic on walls and floors, and erecting stand alone decontamination facilities for chemical casualties) may be impractical.

Planners therefore need to:

(1) base initial hospital response plans on in-house rather than on-call resources;

(2) provide in-house staff with authority to activate and modify the plan; and

(3) develop plans for the expedient decontamination of unannounced casualties, such as use of fire hoses supplied with warm water pending availability of more sophisticated decontamination equipment.

ASSUMPTION 7: The most serious casualties will first be transported to hospitals.

Research Finding: Often it is the least serious casualties that arrive first. Frequently, this is because the more serious cases are trapped in the rubble, cannot be extricated by themselves or other survivors, or may be unconscious and unable to call to rescuers for help. Because of inadequate communications with the field, hospitals may not be aware that more serious casualties are yet to come. As a result, when they do arrive, they may find all patient beds already occupied.

Planners therefore need to:

(1) assign field responders to communicate casualty information to the hospitals, and

(2) reserve beds at hospitals for possible later-arriving more serious casualties.

In summary: It is important for communities to plan and train for disasters. However, planning and training are not enough: one must plan for the right things. Valuable lessons can be learned from formal disaster research studies. Often disaster plans fail to anticipate common response problems that have been identified during systematic field research studies.

That concludes my overview of the paper. I am going to turn you over to the moderator now who will be happy to take questions.

Avagene Moore: Thank you, Erik. We will now turn to questions from our audience.

[Audience Questions & Answers]

Amy Sebring: It would seem that all of these situations have implications for disaster public information. Do you have any thoughts on enhancing rapid public information?

Erik Auf der Heide: In order to provide effective public information, you need to know what the public needs to know. Some of the research can suggest what is needed. For example, since the public transports most disaster casualties they need to know which hospitals they should take them to. If they are told that waiting times may be much less if they go two blocks farther, they may be able to actually get help quicker, while not overloading the closest hospitals.

Sophi Beym: Thank you, what is your opinion about CERT teams?

Erik Auf der Heide: I don't have enough data to evaluate how well they are working; however, I think the research supports their value. This is because we know that bystanders and survivors provide most of the early help in disasters. However, many, many citizens will become involved in helping besides Citizen Corps. For example, after the Mexico City Quake, over 1,000,000 residents became directly involved in search and rescue. First responders in the field also need to be trained how to help coordinate the search and rescue efforts of citizens who spontaneously offer help.

Ray Pena: What are "proper casualty transport techniques" that citizen first responders (non-CERT) can be taught, and who can teach them? Can the techniques be posted in, say, the phone book like other emergency instructions?

Erik Auf der Heide: The phone book concept has been used in California for years, although I am not aware of anyone who has studied its effectiveness. One important point to teach the public is what types of patients not to move. Red Cross also teaches things like blanket drags and use of backboards. (Doors have been used as a substitute in disasters.)

Ryan Pillman: You had indicated earlier that the bulk of people brought to a hospital first are those who are not critically injured. Further, you indicated that there is not an adequate flow of reliable information about the situation at the scene provided by officials. My question is how are hospitals to allocate beds for those who will need them most when there is no information to base a decision on?

Erik Auf der Heide: Two answers to that:

First, every hospital should anticipate more serious casualties and keep some beds in reserve. Having hospital-to-field medical mutual aid radio systems will provide a means of getting the information to hospitals. But, many communities still have not developed such systems.

Second, you need to make sure it is clear who, in the field, is responsible for collecting casualty info and getting it to hospitals. The lack of clearly defined communication responsibilities is one of the problems.

Juan Fraga: I think you have more or less answered this question. From what you say, it seems that using resources in training highly specialized professionals is less beneficial than using the resources in providing the wider citizenship with information about response needs, and 'desired or recommended behaviours'. Professionals would then become 'facilitators' of the response where the citizens would actually become part of the response team. How would you suggest it would be an appropriate way or ways to approach the wider community with this information?

Erik Auf der Heide: It needs to be addressed on two fronts: one is you need to include training of first responders in what to expect and how to coordinate and facilitate bystander or survivor rescue. This needs to be a part of community plans and training. Secondly, you need to train the public. Citizen Corps is one avenue. I still like the idea of making such training a part of high school education.

Audrey Sweazey: This is more of a response to Juan’s question than a question. There are several organizations that deal with citizen response in a disaster like MRC's, VOAD and CERT. The key is to know which ones are in your area and include them in your planning

Erik Auf der Heide: Agreed.

Juan Fraga: If you were able to introduce a curriculum into high school, what would you include there? What topics?

Erik Auf der Heide: I think that is open to exploration. The important thing is to recognize that citizens will respond, and give them the tools. First aid, knowledge about protecting oneself are important topics.

Avagene Moore: Erik, I am struck by the thought that we still have not applied the so-called "lessons learned" from the multitude of past disasters and research such as yours. In your opinion, what can be done to remedy the problems that we encounter over and over again? Can we finally learn the lessons?

Erik Auf der Heide: What is sorely lacking in this country is an institutionalized process for learning, and benefiting from our collective disaster experiences. We need to establish an on-going national disaster research agenda and tie it to planning and training programs.

David Thompson: What about utilizing highway information signs to notify people of available hospitals?

Erik Auf der Heide: That is certainly one approach. Another is Amber Alert Systems. You can also produce local 8 x 11 inch maps showing all the area hospitals, and first responders could hand them out with suggestions about which hospitals are appropriate and which are not yet overcrowded with victims.

Amy Sebring: Would you agree that rapid situation assessment is something that needs to be incorporated into planning? During everyday emergencies, "first responders" expect the public to come to them via 9-1-1, e.g. Perhaps we need training on being more proactive in seeking to assess the situation, particularly where power and phones are out?

Erik Auf der Heide: Excellent point. One of the problems is that outside responders always assume that a lot of outside help is needed. In most U.S. Disasters, personnel and equipment shortages do not actually develop. In such cases, it is wise to proactively have the media notify the public that additional help is not needed and, may actually worsen the problems at the disaster. Blood donors are often a problem, too. Hospitals can get inundated with donors, even when no blood is needed.

Avagene Moore: Erik, when I was the EM for my city/county, I tried my best to have the hospitals tied into the emergency infrastructure's communications so they could be notified per our plans to expect patients as accidents and emergency situations arose. I have been out of the local process here for 15 years. Is this something that hospitals and communities are now doing?

Erik Auf der Heide: I am not aware of any good data on the extent to which this is happening. We did not have such a system in place for the Olympic Park Bombing. NYC also did not have such a system. One of our research shortcomings is the lack of data on what preparedness procedures and systems have been implemented across the country. It is hard to know where we need to go when we don’t know where we are.

Amy Sebring: I would like to comment as someone who is involved with a local Metropolitan Medical Response System (MMRS) that many of your suggestions have been incorporated into the program guidance; however, we are still having difficulty with getting a designated hospital representative to perform liaison in our EOC. There are some competition issues involved. I would appreciate any suggestions for tactfully dealing with this issue.

Erik Auf der Heide: In my text: Disaster Response, I devoted a whole chapter to the Apathy Factor in planning. You might want to read the text. It is on line, full-text, at no charge. The URL [http://orgmail2.coe-dmha.org/dr/index.htm] is in the ‘Further Reading’ section of the paper.

Erik Auf der Heide: I might mention in agreement, that motivation and apathy are the single most important issues in preparedness. Unless you solve those issues, you are dead in the water.

Audrey Sweazey: I am the Assistant Coordinator for the Salt Lake MMRS and each of our 10 area hospitals is represented on our Steering Committee. However the hospitals are still not always recognized as a responding agency. We are doing our best to help them get recognized.

Erik Auf der Heide: First, let me say, I think MMRS is a great concept. Perhaps one approach is to use the examples in the paper to illustrate how the hospital can be at the mercy of what happens in the field and the importance of their involvement.


Avagene Moore: Thank you, Erik, we greatly appreciate your effort and time on our behalf and wish you continued success in your work and your writings.

Erik Auf der Heide: Thank you. I think it is also important to understand that the assumptions that we have discussed are only a few of what exist. I have provided sources in my paper for other sources of information on disaster research findings.

Avagene Moore: Please stand by a moment while we make some quick announcements. If you are not currently on our mailing list, and would like to get program announcements and notices of transcript availability, please see the Subscribe link on our home page.

We have two new EIIP Partners to announce today -- Indiana University of Pennsylvania Research Institute: http://www.iup.edu/researchinstitute/ . The Point of Contact is Patrick Higgins, Sr. Analyst.

The other new Partner is the Westinghouse Chemical Agent Disposal Facility in Anniston, Alabama. Our POC there is the Emergency Response Coordinator, Gary Stanley. Welcome to both new Partners!

If you are interested in becoming an EIIP Partner, please see the "Partnership for You" link on the EIIP Virtual Forum homepage http://www.emforum.org . Again, the transcript of the May 10th session will be posted later today and you will be able to access it from our home page. An announcement will also be sent to our Mail Lists when the transcript is available.

Thanks to everyone for participating today. We especially appreciate everyone in our audience! Thanks to Dr. McGlown's class for being here today as well. Please come back again. Before you go, please help me show our appreciation to Erik for a fine job. The EIIP Virtual Forum is adjourned!