Why you can’t rely on rescue

Mark Keim WHY YOU CAN’T RELY ON RESCUE

When it comes to disasters, rescue is nearly always “too little and too late”.

Though many people are surprised to hear this, it remains a proven fact, time
after time. This occurs due to a variety of factors, including the very nature of
some disasters. It’s also caused by a set of very human factors as well. In this
blog, I’ll share with you, the very real reason why disaster response doesn’t
work, even in the most affluent societies on earth. There are three main
sources of medical care available to the victims injured by disasters: local,
national and international. Each of these sources has serious limitations in the effectiveness of patient care that it is capable of providing. According to one report by the prestigious Center for Biosecurity of the University of Pittsburgh Medical Center, several major problems become apparent when this system is applied to a mass casualty disaster involving thousands of
casualties.

10 REASONS WHY DISASTER RESCUE IS OFTEN TOO LITTLE AND TOO LATE

1) Local medical systems become casualties too
2) Most hospitals are private
3) There are few incentives for local healthcare systems to fully engage in disaster preparedness
4) Hospitals are not interconnected
5) Even the best equipped national-level response teams have relatively limited capacity.
6) Only a limited number of patients can be transported by Federal teams
7) Most disaster deaths occur during the disaster impact when even local rescue is impossible to deploy
8) Most national and international medical teams arrive too late to save the majority of lives lost
9) The majorities of actions taken by the national public health system occur after a disaster and focus on detecting deaths and illness, rather than preventing them
10) Government funding for hospital and disaster preparedness is difficult to sustain over time

 

REASON #1 – Local medical systems also become casualties of the disaster

Despite admirable degree of heroism often associated with local emergency response, local
systems are often, themselves, casualties of the disaster event. Hospitals and emergency rooms often have significant challenges in maintaining business continuity due to damage by the disaster itself (such was the case in New Orleans during hurricane Katrina and the tornado disaster in Joplin, Missouri). They may lose their ability to function due to losses of power, water, sewer or
personnel that are unable to report to work. Disaster victims as well as emergency medical services often have difficulty in accessing these life-saving facilities due to impassability of roads that are blocked by standing water, fire, and debris or otherwise made non-maneuverable by the destructive forces of earthquakes, landslides or tsunamis. Finally, those local healthcare facilities
that do remain functional can easily become overwhelmed with patients.

REASON #2 – Most hospitals are private.

Most of the 5,000 hospitals in the U.S. are private institutions over which the federal government has little authority during a disaster. And while disasters are not an infrequent occurrence when considered on a national level, at the local level these represent low probability, high-impact events. Local private healthcare institutions must then weigh the cost effectiveness of maintaining a high degree of unused surge capacity every day, for a disaster event which may or may not occur someday. As private institutions these healthcare facilities are also actively participating in a healthy, competitive market that drives cost-saving  measures such as just-in-time inventory and judicious utilization of resources. Most modern hospitals and clinics operate within a narrow margin, using just in time deliveries of supplies as opposed to surplus inventories that can be used as surge capacity for times of disaster. In addition, the current healthcare environment necessitates an optimum utilization of resources within the hospitals. As a result there are few empty beds, and even fewer excess personnel available at any given time to treat what may be a large onslaught of patients. Few private hospitals are capable of keeping a large number of emergency medical and intensive care unit beds open and staffed by medical professionals merely for the sake of disaster preparedness at any given time. Unfortunately, those types of disasters usually associated with the highest degree of severe trauma and life-threatening injuries (e.g. earthquakes, landslides, terrorism, industrial accidents, etc.) are also known as “no-notice” events, which occur without warning. Thus, hospital services are frequently caught off guard without any opportunity to make last-minute preparations before these events.

REASON #3 – There are few incentives for local healthcare systems to fully engage in disaster preparedness

Many hospital administrators are not convinced that a disaster affecting their own hospital is likely and view spending on disaster preparedness as a luxury they cannot easily afford. If patients treated by Federal response teams are to participating hospitals during a crisis, there is reimbursement for care, but there is no funding provided to hospitals for enrollment in the National
disaster Medical System (NDMS) and ongoing training. It’s also surprising that many of the procedures that hospitals are being asked to perform in the event of a disaster (like decontamination – cleaning a dangerous chemical from the patient – a risky complicated procedure) are not even billable diagnoses. This means that hospitals are expected to do this complicated, costly and potentially dangerous procedure for free, without any chance of
reimbursement from either the government or from insurance companies. It certainly wouldn’t be reasonable for any business to be expected to embark upon a risky enterprise that is sure to lose money. And yet, this remains the case for what is being expected of private hospitals.

REASON #4 – Hospitals are not interconnected

When large-scale disasters occur, no single emergency medical system or hospital has the capability to provide for all of the health care needs of what may be hundreds to thousands of disaster victims. It’s therefore necessary for multiple hospitals, clinics, ambulance providers and
health care professionals to work together in a concerted effort. However, most hospitals are not interconnected in such a way as to be able to respond collaboratively. There are organized efforts at regional cooperation between hospitals in key regions of the country, but regions are pursuing collaboration with different levels of resources and different purposes. Hospitals in many
communities and regions have not yet begun to plan together or in conjunction with public health or emergency management agencies. Few regions have developed the communication or administrative capabilities required for a joint response.

REASON #5 – Even the best equipped national-level response teams have relatively limited capacity.

In 1984, the United States government established the National Disaster Medical System (NDMS).
The NDMS is currently comprised of 55 Disaster Medical Assistance Teams (DMATs) spread out across the country and are formed by local groups of health care providers and support personnel. DMAT members are termed “intermittent” federal employees and once activated by federal order, their status changes to that of an active federal employee. However, significant systemic challenges remain. Once set up, DMATs are limited in the amount and type of care they can provide. If providing only minor treatment and release of patients, all the DMAT teams in the country working together could handle about 5,000 patients per day. (However, during the history of NDMS, all of the teams have never been deployed at once.) If, however, the teams are providing inpatient (hospital-level) care, their capacity would be only 1,400 patients per day for the entire population of the US. One 2009 report by the University of Illinois and Virginia Tech estimated a major earthquake in the New Madrid Seismic Zone of central US could result in 86,000 serious
casualties. Clearly, in these type of catastrophic disaster events (that are currently being considered by the government as National Planning Scenarios), it could be weeks or months before all patients are provided a level of care consistent with our routine daily health services now available.

REASON #6 – Only a limited number of patients can be effectively transported by Federal teams

In 2006, the medical evacuation of hospital and other acute care patients in the aftermath of Hurricane Katrina, was the first time a full-scale operation using the NDMS patient movement capability had ever been initiated. A 2007 Senate report following the federal response to Hurricane
Katrina noted that, while the operation succeeded in moving thousands of patients, medical teams were overwhelmed, overall command structure was absent, a tracking system was not accessible for all patients, and as a result there was no systematic way of knowing where their own patients had been transported. In a major mass casualty, the military medical transportation system could transport only limited numbers of patients. Long-haul transportation of patients is a federal responsibility but is constrained by the limited aeromedical evacuation capacity of the U.S. military. Trained aeromedical personnel needed to transport disaster patients are limited in number.

REASON #7 – Most disaster deaths occur during the disaster impact when even local rescue is impossible to deploy.

Disasters occur in three main phases according to timing of impact: pre-impact, impact and post-impact. The pre-impact phase occurs before damages or injuries occur. For example this may be before the tornado, the flood or the tsunami reach the affected community. This is typically the time when all disaster risk reduction occurs.
The impact phase is defined as when the actual damage occurs. For example, the impact phase occurs when high winds from the hurricane are striking the community, when flames from the forest fire are reaching the homes or when the earthquake shaking is actually occurring. Finally the post-impact period is defined as that timeframe following the occurrence of damage and injuries.
This is typically the time when emergency rescue and response as well as later disaster recovery are known to occur. Rescue is often too late because it comes during the post-impact period – after most disaster related injuries and subsequent deaths have already occurred. For example, in the case of tropical cyclones (otherwise known as hurricanes or typhoons) 90% of disaster related
deaths occur as a result of flooding during the storm surge. The storm surge is a rising of ocean waters that occurs in front of the tropical as it makes landfall. This 20 to 30 feet high set of waves commonly break ground in coastal communities during the impact phase of the tropical cyclone. This is the time when the community is also experiencing peak wind speeds. It is therefore impossible to send out ambulances or rescue teams to assist the disaster victims. Thus, any rescue mounted during the post-impact phase immediately following the storm surge flooding, is most likely to find that 90% of all disaster related deaths have already occurred. So one may only
conclude that in order to effectively reduce the majority (90%) of mortality related to tropical cyclones, activities must be focused on preventing drowning deaths that occur during cyclone impact. This concept of the effectiveness of pre-impact risk reduction measures is not merely limited to that of tropical cyclones. Most disaster-related deaths occur during the impact phase. This is true for tornadoes, earthquakes, tsunamis, landslides, explosions, flash floods, chemical releases, and the list goes on. Simply put, most disaster deaths occur during impact. And therefore by the very nature of the disaster event, most disaster rescue arrives too late. One recent study of
13 separate flood events in Europe and in the United States documented that the majority of flood related deaths occurred during the impact phase (87.4% in Europe and 68.4% in the US).

REASON #8 – Most national and international medical teams arrive too late to save the majority of lives lost

The 2007 Senate report on Hurricane Katrina also noted that DMATs are a fundamental component of the NDMS response, particularly in the early stages of a disaster when their work in the field in triage and stabilization of patients at the site of the event is crucial. However, although some teams can be activated within hours of the recognition of an incident, experience indicates that it will likely be a day or more before most teams reach the disaster site, meet up with their equipment, and are ready to work. The current plan relies on commercial air travel for NDMS teams, which in a mass
casualty event may be difficult to arrange. In addition, the teams’ equipment may have to travel by truck. The equipment belonging to the Oregon-2 DMAT, deployed to New Orleans after Hurricane Katrina, arrived at the New Orleans airport 5 days after the team arrived. This is especially important to consider that local hospitals and clinics affected by the disaster are also often victims
themselves. For these reasons, the DMATs are considered a critical asset for disaster response. Unfortunately, this asset is readily available during the early hours of a disaster when it is most commonly needed. I According to the Center for Biosecurity of the University of Pittsburgh Medical Center, if you are seriously injured during the rapid onset of a highly violent disaster, you may
expect a very limited capacity for local or federal rescuers to assist you.

REASON #9 – The majorities of actions taken by the national public health system occur after a disaster and focus on detecting deaths and illness, rather than preventing them

The risk of disasters is commonly conceived as a combination of exposure to dangerous hazards that exist in our environment as well as a vulnerability to this hazard that exist inside of us. For example, let’s consider the risk of sunburn. People get sunburns when they are exposed to high levels of sunlight. However, given the exact same degree of exposure, some people (particularly those with a fair complexion) are more vulnerable to getting sunburned. Therefore the risk of sunburn is based upon both exposure and vulnerability. So in order to prevent sunburn, everyone must limit their exposure to direct sunlight. However some people are more vulnerable than
others and therefore must take additional precautions in order to avoid injury. On a larger scale, the risk of disasters is also a function of both exposure and vulnerability. In order to prevent injury from disasters, we must also consider how to prevent exposures and to recognize and lessen vulnerabilities. This is the fundamental key for prevention of disaster related deaths, injuries and
illness. Prevention is a key element of public health. However, the application of prevention by public health practitioners involved with natural disasters (such as storms floods and earthquakes) has lagged far behind. For centuries, prevention has been played a significant role in the public health approach for epidemics and pandemics. For hundreds of years public health practices
have been applied within societies all over the world to prevent exposures to biological hazards. However, to this day, relatively few public health agencies work to prevent illnesses and injuries due to natural disasters. The overwhelming majority of activities performed by federal state and local public health agencies related to natural disasters is limited to preparing for what is erroneously viewed as the inevitable disaster. Very little effort is given to the preventive approach – reducing the risk of disaster related injuries and deaths by the age-old proven methodology of reducing exposure and vulnerability. Instead, many societies continue to face a never-ending cycle of response, response, response – always focusing on an expensive, inefficient and largely
ineffective curative approach rather than seeking to prevent future disaster related injuries from ever occurring.

REASON #10 – Government funding for hospital and disaster preparedness is difficult to sustain over time

In the preceding discussion, I’ve cited examples from Hurricane Katrina as indicative of the fallacy regarding the effectiveness of rescue. However, we may then ask ourselves, “Have we not learned from that event and improved our approach so that such a tragedy may never be repeated?” Sadly, the answer is “No”. Former New York Mayor Rudolph Giuliani (R) said that FEMA’s response after
Hurricane Sandy was “as bad as Katrina.” After a disaster, there is often an effort to capture “lessons learned” in the way of some degree of after-action study and report. However, as most disaster professionals can tell you, these so-called “lessons” are rarely ever “learned” in the sense of effecting real change. Rather, these same issues tend to arise again and again after every
disaster, leading to the often-quoted phrase, “lessons learned…again…and again.” Unfortunately, it has been proven over time that funding support for public health and medical preparedness is difficult for even the most affluent of societies to sustain. After what were dramatic increases in public funding for emergency preparedness following the 2001 World Trade Center attack (the catastrophe described to change the collective American psyche) within 4 years after the disaster, funding support for these programs began an unabated decline that continues to this day (despite “lessons learned” from Katrina and Sandy and Al Qaeda and ISIS and Ebola, etc., etc.). From fiscal
years 2005 to 2012, there has been more than a 38 percent cut to these federal funds used by the U.S. Centers for Disease Control and Prevention (CDC) in support of state and local public health preparedness (adjusted for inflation). In January 2014, President Obama signed into law a federal
spending bill that included a cut of more than $100 million to the Health and Human Services’ Hospital Preparedness Program (HPP). That one year decrease equals nearly a 30 percent reduction in a program specifically aimed at strengthening health-care preparedness for public health emergencies. These cuts could have severe and dire consequences on the ability of
communities to respond when disaster strikes. According to a recent report by the Trust for America’s Health, “In the past decade, there have been a series of significant health emergencies, including extreme weather events, a flu pandemic and foodborne outbreaks.” “But, for some reason, as a country, we haven’t learned that we need to bolster and maintain a consistent level of
health emergency preparedness. Investments made after September 11th, the anthrax attacks and Hurricane Katrina led to dramatic improvements, but now budget cuts and complacency are the biggest threats we face”.

So, given the fact that we can’t rely on rescue, what should we be doing instead to protect ourselves, our families and our communities? I’ll share my advice with you in my next blog…

 

2 responses on “Why you can’t rely on rescue

  1. James

    Mark,

    This article nails it. I was Director of Strategy and Business Development from 2007-2011 for a community hospital. With the increasing pressure from Medicare/Medicaid towards value based purchasing (think of the equation of higher quality, service, safety divided by cost) – disaster preparedness falls down the priority list.

    AND what we end up with are mandatory online training modules that aren’t tied to true needs and few disaster drills – therefore, the ability to prepare adequate types of resources for the most likely scenarios in a region is limited leaving huge holes in the preparedness systems.

    Great entry.

    1. Mark Keim Post author

      Thank you, James. I agree that it’s important to keep in mind that hospitals are a business like anyone else. I must ask myself, “If we value disaster medical care, then why are these conditions not recognized as billable diagnosis in ICDM-1o?” Do we really intend for hospitals to subsidize societies-at-large by way of maintaining complex and expensive medical capabilities for care of chem-rad-bio terrorism casualties? Have we considered the cost-effectiveness of risk pooling to the extent that is really necessary in order for local and regional alliances to work? My advice would be to start by recognizing disaster-related diagnoses in ICDM-10 imbursements.

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