Several bombs went off in London not quite four years ago – more specifically, on 7 July 2005, when Muslim terrorists brought the city’s Underground (subway) system to a virtual halt by detonating explosives that killed 52 innocent people and sent an estimated 700 or more other victims to hospitals throughout the city. The London hospital system differs from most systems in the United States in that it does not have a number of specialized hospitals serving as trauma centers. On the day of the bombings, therefore, numerous victims of the bombing were triaged very quickly and then taken to various hospitals throughout the city, rather than to centers specializing in the treatment of trauma or burns.
In a follow-up review of the incident, British officials said that the lack of a coordinated trauma system may possibly have been better for the patients. Had there been a trauma system in place, it was suggested, patient care might actually have suffered because of pre-designated trauma or burn centers being overloaded with so many severely injured patients arriving at or close to the same time. Instead, the injured were distributed to non-specialty hospitals throughout the city and received better and more immediate care.
In the United States there is, in contrast to the British system, a well planned trauma system with centers in each state providing different levels of care. Pre-hospital trauma protocols direct that patients suffering from trauma or burns be taken (directly, if possible) to a trauma or burn center – but if the distance is too far away patients may first be stabilized at a lower-level community emergency department and transferred later to a specialized center.
U.S. Approach: Focus on Even Greater Disasters
There is considerable evidence, however, to support the belief that the U.S. system of taking triaged trauma or burn patients directly to specialty centers gives patients their best chance of survival. Since the 1980s, studies that have been carried out – at such institutions as the R. Adam’s Crowley Shock Trauma Center in Baltimore, Md. – show that stockpiling the expertise needed at a specialty hospital is much better for patient outcomes.
Moreover, a rapid-response system that ensures the availability – 24 hours a day, and at one location – of the specialists needed for trauma care allows patients not only to survive but also, possibly, resume a more normal life. The same theory holds, of course, for the teamwork of caregivers working with a complicated burn victim.
During disasters such as the 2005 London bombings, the 2001 terrorist attacks on the World Trade Center towers in New York City (which took the lives of 3,000 people), or the February 2003 fire at the Rhode Island Station nightclub (which killed 96 people and required the hospitalization of almost 200 more), one specialty hospital obviously could not provide care for the very large number of trauma and/or burn victims needing immediate and highly specialized medical attention. Surge planning at even the very best healthcare facilities can do only so much.
No matter how large or how well prepared for certain disasters a specialty hospital may be, therefore – as the U.S. healthcare system already has seen, and will undoubtedly continue to see – it is still possible that some disasters (earthquakes or major terrorist attacks are probably the best examples) might be of such overwhelming magnitude that even the best and most highly specialized facilities would not be able to provide adequate care for all of the severely injured victims.
Stretching the Limit – Plus Cost Complications
Emergency planners at the state and federal levels have recognized this problem for a long time and have recommended that a different approach be used to deal with truly major mass-casualty events. The theory here is that, by trying to cope with such events at trauma, burn, and pediatric specialty hospitals – when the resources of those hospitals are already stretched beyond their possible limits – the patient load will surge to levels that might well compromise the survival of a large number of the patients taken to the specialty hospitals.
That problem is now compounded, of course, by the fact that, in difficult economic times such as the present, the financial pressures on the specialty centers (and other healthcare facilities) have become so great that many of them either have closed or have significantly reduced their previous surge capacities.
The same planners believe, though, that an alternate “halfway” type of system is perhaps needed to cope with major disasters – a system, for example, in which patients are field-triaged by EMS (emergency medical services) technicians differently for larger disasters (perhaps 100 or more victims) than they would be for “smaller” disasters involving “only 20 or 30 victims” or thereabouts. The new protocols needed for such an alternate system would have patients taken first to non-specialty centers; those centers would be prepared to activate hospital-disaster plans that require them to hold onto certain groups of patients (trauma, burn, pediatric, etc.) whom they would normally, and quickly, transfer out until a specialized trauma center, possibly even in another state, could accept them. In addition, a planned system such as that proposed would be responsible for coordinating the secondary level of patient transport, during the next 72 hours, to the specialty hospitals.
Truly major disasters are very rare occurrences in the U.S. healthcare system. Systems that coordinate day-to-day trauma events or even large multiple-casualty incidents (MCIs) need to be kept operational, though, because the trauma protocols mentioned above have proven their worth in the U.S. healthcare system. The major disaster is the truly special event that must be recognized early, and responded to differently – if those conditions are not met, the nation’s specialty hospitals will be unable to cope fully and effectively with the heavy load of incoming patients, and the level of medical care provided will therefore be much lower.
Better Planning & the Final Piece of the Puzzle
Burn-disaster planning is perhaps the best example, at the state and federal levels, of specialty planning for large disasters. Both New York State and New York City have developed plans, to cite a particularly prominent example, to distribute burn victims to non-burn centers and treat them in those alternate facilities for up to 72 hours. Those two jurisdictions also have recognized the need to train, at non-specialty hospitals, clinical staff members who may have possibly not treated a burn victim in several years. And they: (1) are stockpiling the burn-care equipment that would be needed if a surge of such patients arrive within a very short time; and (2) have adopted a different EMS approach to use alternate protocols for a major burn-disaster incident. The remaining piece of the puzzle is to develop a better system for the secondary transport of patients to burn centers possibly hundreds of miles away during the 72-hour period specified.
Florida and New Jersey are two other examples of states where improved burn-disaster planning has been vindicated by the results. The ABA (American Burn Association), the New Jersey Department of Health, and the state’s burn center – Saint Barnabas Hospital in Livingston, N.J. — have developed a progressive affiliation of burn centers within what is called the Eastern Regional Burn Center Consortium, which is headquartered at Saint Barnabas. The consortium’s mission is to link all of the burn centers from North Carolina to Massachusetts for disaster preparedness, coordination, and communication during a disaster.
The current gaps in burn planning are continuing to be worked through and the larger challenges may be the complicated inter-state issues involved as well as the somewhat different protocols used in dealing with disasters that are not “federally declared.” The larger disaster planning paradigm is therefore not quite complete yet for all aspects of specialty hospitals. It is only just now being reviewed for burn care, in fact, thanks to a required focus attached to federal funds provided by the U.S. Department of Health and Human Services (HHS) in the form of hospital preparedness grants.
From Very Good to a New Level of Excellence
Probably the greatest progress accomplished to date in planning for specialty hospitals has occurred in burn-disaster preparedness. It would be a major step forward if the nation’s healthcare system builds on that progress to move ahead on planning for other equally valuable centers (trauma and pediatric). Better regional planning also is needed – both in the area of specialty hospital surge, and on the delayed inter-facility transportation needs that must inevitably follow. In addition, regional partnership planning must be expanded to include EMS and other emergency first-responder agencies so that the dynamics involved in field triage are adjusted to cope with major disaster events.
Much if not all of that planning can be accomplished by aligning some of the HHS hospital preparedness grant deliverables and emergency preparedness standards that hospitals must demonstrate to meet their Joint Commission requirements. (The Joint Commission, founded in 1910, is an independent non-profit organization responsible for the certification and accreditation of more than 16,000 hospitals and other healthcare facilities throughout the United States.)
In short, the nation’s current healthcare system, although the best in the world in many respects, still has a long way to go to meet the extraordinary day-to-day specialty patient challenge of coping with disasters as large and as complicated as the 2005 London bombings.
Theodore (Ted) Tully, AEMT-P, is President of STAT Healthcare, an Emergency Management consulting group. He previously served as Administrative Director for Emergency Preparedness at the Mount Sinai Medical Center in New York City, as Vice President for Emergency Services at the Westchester Medical Center (WMC), as Westchester County EMS (emergency medical services) Coordinator, and as a police paramedic/detective in Greenburgh, N.Y. He also helped create the WMC Center for Emergency Services, which is responsible for coordinating the emergency plans of 32 hospitals in the lower part of New York State.