Abstract
This chapter describes the role of prehospital teams deployed to large scale disaster events. It describes two categories of type I emergency medical teams (EMT), and provides an overview of their capabilities and expectations. It reviews competing models of prehospital care delivery that are prevalent worldwide, including the levels of service that can be expected within such systems. Finally, the chapter describes the role of the medical component of urban search and rescue (USAR) teams, and notes the differences that exist between type I EMTs and USAR teams. Future trends in the development of EMTs are explored, including the importance of national capacity building, the commitment to acute and long term community needs, and the continued promotion of EMT and USAR medical coordination.
Introduction
The delivery of health and medical services occurs across a continuum, which includes prehospital, ambulatory based, facility-based, and rehabilitative care. When a disaster event occurs, disruption to any one of these integrated levels of care can have tremendous impact on the ability to meet fundamental health and medical needs of the affected community. When considering the effects of a “catastrophic disaster,” defined by Quarantelli to have key characteristics including the loss of governance, the loss of mutual aid, and the loss of key municipal services[1], it can be assumed that the prehospital phase of health-care services will barely be functioning, if at all. Furthermore, it is under these conditions that national capacities in the health-care delivery sector are anticipated to be overwhelmed, thus requiring the support of the international medical and humanitarian response community.
The intent of this chapter is to explore the types of prehospital care that can be expected to be provided under catastrophic disaster conditions. The chapter will review the role of the International Red Cross and Red Crescent Movement, particularly as it relates to the delivery of emergency medical services (EMS). It will explore the role of type I emergency medical team (EMT), defined by WHO as those teams capable of providing initial, stabilizing emergency care in the outpatient environment[2,3] in response to the health and medical needs of an acute phase response (Box 3). In addition, the chapter will highlight the complementary role that the urban search and rescue (USAR) response system provides with regards to both the focused delivery of stabilizing emergency care to rescued victims, as well as the fundamentally important public health support role that medical staff is available to provide in the acute phase of a disaster response.
Box 3
Type 1 Fixed EMT
Provide outpatient initial emergency care of injuries and other significant health-care needs. Teams must be capable of treating at least 100 outpatients per day and function during daytime. Key services include triage, first aid, patient stabilization, referral of severe trauma, nontrauma emergencies, and care for minor trauma injuries. These teams can work from suitable existing structures or supply their own fixed or mobile outpatient facilities, such as tents or special equipped vehicles.
Type 1 Mobile EMT
Provide outpatient initial emergency care of injuries and other significant health-care needs. Teams must be capable of treating at least 50 outpatients per day and function during the daytime. Key services include triage, first aid, patient stabilization, referral of severe trauma, nontrauma emergencies, and care for minor trauma injuries. These teams do not work out of a fixed structure and the team, including all equipment, can be easily moved throughout the mission deployment.
Models of Prehospital Health-Care Service Delivery
It is important to understand the existing models of prehospital services that are likely to be encountered in the host country, recognizing that, in many cases, the prevailing system may represent a hybrid or combination of multiple approaches. It is important also to note that the degree of prehospital service capability will likely vary depending on the existing social and economic constructs of the host county. High- and middle-income countries are more likely to have functioning prehospital care systems, whereas in the case of low-income countries, prehospital services may be entirely un-resourced and essentially nonfunctioning.
There are two models of prehospital care that are largely recognized, and often emulated, based on sociopolitical, historical, and geographic precedents. In the case of low-middle and low-income countries, these precedents may be less important given the absence of resources that inhibits the ability to develop such capabilities. The Franco-German model of care emphasizes the utilization of ambulance-based physicians who provide care to patients directly in the field, thus limiting the number of patients transferred for evaluation to the hospital emergency department[4]. This emphasizes a “stay, play, and stabilize” approach, which intends to bring a level of sophisticated hospital services to the patient. The attending emergency physician, who deploys along with paramedical assistance, is authorized to make complex and difficult decisions in the field setting, as well as to conduct an advanced array of physician-level services, which may include intubation, central-line placement, diagnostic evaluation with portable ultrasound, and other advanced techniques. With respect to the disaster response teams that deploy to support field medical operations, this model is similar to the approach taken by the medical component of USAR elements, but may also be used by the type 1 mobile EMTs. In the case of the USAR response, this is mostly due to the longevity and complexity of field-based rescue efforts, which require a component of medical support to the patient over a prolonged course of the rescue effort. It presupposes self-sufficiency and a high degree of clinical competence required to manage complex patients in a field setting prior to being able to get them to the more definitive field hospital for ongoing stabilization, definitive diagnosis, and therapeutic interventions, including surgery, if warranted.
In contrast, the Anglo-American model emphasizes a “scoop-and-run” approach, in which paramedics or emergency medical technicians are responsible for the initial stabilization of patients in the field, and they facilitate rapid patient transport to the emergency department, where definitive patient management can commence[5,6]. With regards to the dispatch of EMTs to support a host nation disaster response, this approach is exemplified by responding type 1 fixed EMTs. They are designated to establish prehospital services chiefly focused on providing initial stabilization and basic treatment, with referral to a type 2 or 3 fixed field hospital made for those patients requiring definitive interventions and ongoing care.
In addition to describing the approach to prehospital care, as noted above, it is also useful to place these efforts within the context of the Red Cross and Red Crescent Movement. The movement promotes the delivery of humanitarian assistance and medical care in the setting of armed conflict and large-scale emergencies, and has an important role in coordinating the delivery of health-care services under adherence to humanitarian principles and the rule of law. In that context, they help to promote the integration of emergency responders into an existing emergency response system “adapted to local needs and realities[7].” Thus, many prehospital transport units in the country affected by disaster will be marked by the Red Cross, Red Crescent, or Red Star of David (Magen David Adom) and are tightly linked to the existing national health-care system providing EMS.
Levels of Service in the Prehospital Environment
It is undisputed that, in the initial hours, and perhaps days, of a sudden-onset disaster (SOD) event, the vast majority of lives saved, including rescues made from collapsed structures, are those undertaken by citizen first responders[8,9,10]. Most victims of disaster who can provide assistance to fellow victims do so spontaneously and without specific training or background in medical or rescue experience. Given that prehospital services are likely disrupted in the initial phase of such an event, not to mention overwhelmed by the surge response required, the initial response in the field setting will be largely spontaneous, including the likely coalescence of field triage sites, which arise in areas of common purpose or buildings of opportunity (for example, a school gymnasium or a shopping center parking lot)[11,12]. There are a variety of disaster threat events that can disrupt prehospital services, including conventional, large-scale attack (e.g., sustained military action) and SOD due to natural (e.g., earthquake) or terrorist activity (e.g., including the use of unconventional weapons such as chemical or radiological contaminants). Regardless of the type of event, and despite variation in the social and cultural context in which such events occur, the role of the citizen first responder, often overlooked and underappreciated by the humanitarian response community, will be critical to saving lives and affecting an initial response to a disaster event.
When existing prehospital resources can mobilize in the initial response, they will do so within the context of the prehospital environment that exists in their region. The standard division of EMS is based on the level of training and experience, along with the availability of accompanying resources matched to the level of training of prehospital providers. This ranges from basic (basic life support) to advanced (advanced life support), although in areas with a sophisticated system of health-care service delivery, this may also include the delivery of ground- or rotor-wing-based critical-care services in the out-of-hospital setting. However, in many disaster events, particularly those in low-middle and low-income countries that have not had the opportunity to develop strong prehospital capabilities, the availability of resources may be limited to a van with a stretcher and a vehicle driver. Trained medical personnel, let alone the availability of medications or basic lifesaving medical supplies, may not be present.
Regardless of the model of service delivery in practice, the diligent and consistent application of field triage principles is paramount to the timely and effective utilization of prehospital services. Although beyond the scope of this chapter, suffice it to say that the triage process requires a consistent application of clinical and ethical considerations based both on physiological parameters and ethical decisions made in the context of the situation at hand (see Chapter 32 on medical ethics).
The Role of the Type 1 EMT
The type 1 EMT is a team that is primarily focused on the delivery of outpatient based medical services and interventions, concentrating on the delivery of health-care services needed to address the initial emergent care of injuries, illnesses, and other time-dependent health-care needs[2]. Basic services that are rendered include the delivery of first-aid care, initial patient assessments, and the triage and identification of patients who will require more advanced, definitive medical interventions. This includes the ability to provide stabilizing care to victims of disaster prior to their retriage and transport for additional medical, critical care, or surgical services. Type 1 teams need to be prepared to manage both trauma and nontraumatic medical emergencies, much like those capabilities inherent in traditional prehospital and emergency-department service offerings. Therefore, these teams should be capable of providing definitive care and treatment to minor, less complex injuries or illnesses, with a good referral mechanism provided to patients who might need to seek additional care if circumstances of patient recovery are not straightforward, or injuries or illness develop in a time frame beyond the initial evaluation and management of patient needs. These teams are expected to be able to manage at least 100 patients per day, with services provided during daytime hours, and it is the expectation that they will be staffed and equipped to manage patients of all ages[2].
Type 1 EMTs can work from suitable existing structures, or supply their own fixed or mobile outpatient facilities, such as tents or special equipped vehicles. They should be available to arrive in the fastest possible time, ideally within 24–48 hours, and be considered light and portable. Their staff should be experienced in those elements of initial trauma care that relate to triage on a mass scale, wound and basic fracture management, and basic emergency care of pediatric, obstetric, mental health, and medical presentations[2].
Therefore, type 1 teams can be categorized as being either “fixed” or “mobile,” depending on their configuration and ability to move locations. Some teams may have both capabilities simultaneously. In addition, the basic minimal requirements for these teams are focused on the provision of initial, stabilizing treatment and provision of basic medical and surgical care. The full array of expected minimal standards is described in Table 30.1.
Table 30.1 Minimal requirements for type 1 EMT[2]
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 24 – Intensive Care Unit Buildup Within a Field Hospital Setting
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