1
Introduction1

On January 6, 2008, about 3:15 p.m. Mountain Standard Time, a 2007 Motor Coach Industries 56-passenger motor coach with a driver and 52 passengers on board departed Telluride, Colorado, en route to Phoenix, Arizona, as part of a 17-motor coach charter. The motor coach passengers were returning from a 3-day ski trip…. About 8:02 p.m. … the motor coach departed the right side of the roadway … overturned … and came to rest on its wheels…. As a result of this accident, 9 passengers were fatally injured, and 43 passengers and the driver received injuries ranging from minor to serious…. Major safety issues identified by this accident investigation include [among other things] emergency medical notification and response with regard to large motor coaches traveling on rural roads.

Excerpted from the 2009 NTSB accident report on the “Mexican Hat incident”2


The 2008 bus crash in Utah known as the “Mexican Hat incident” brought to a head the need for an integrated infrastructure capable of responding to mass casualty incidents that occur in rural settings. Following

1

This workshop was organized by an independent planning committee whose role was limited to the identification of topics and speakers. This workshop summary was prepared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the Forum or the National Academies, and should not be construed as reflecting any group consensus.

2

See Executive Summary of NTSB report posted at www.ntsb.gov/publictn/2009/HAR0901.htm.



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1 Introduction1 On January 6, 2008, about 3:15 p.m. Mountain Standard Time, a 2007 Motor Coach Industries 56-passenger motor coach with a driver and 52 passengers on board departed Telluride, Colorado, en route to Phoenix, Arizona, as part of a 17-motor coach charter. The motor coach passengers were returning from a 3-day ski trip. . . . About 8:02 p.m. . . . the motor coach departed the right side of the roadway . . . overturned . . . and came to rest on its wheels. . . . As a result of this accident, 9 passengers were fatally injured, and 43 passengers and the driver received injuries ranging from minor to serious. . . . Major safety issues identified by this accident investigation include [among other things] emergency medical notification and response with regard to large motor coaches traveling on rural roads. —Excerpted from the 2009 NTSB accident report on the “Mexican Hat incident”2 The 2008 bus crash in Utah known as the “Mexican Hat incident” brought to a head the need for an integrated infrastructure capable of re- sponding to mass casualty incidents that occur in rural settings. Following 1 This workshop was organized by an independent planning committee whose role was limited to the identification of topics and speakers. This workshop summary was prepared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the Forum or the National Academies, and should not be construed as reflecting any group consensus. 2 See Executive Summary of NTSB report posted at www.ntsb.gov/publictn/2009/HAR0901. htm. 1

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2 RURAL MASS CASUALTY INCIDENT its investigation of the crash, the National Transportation Safety Board (NTSB) recommended that the Federal Interagency Committee on Emer- gency Medical Services (FICEMS), “evaluate the system of emergency care response to large-scale-transportation-related rural accidents and, once that evaluation is completed, develop guidelines for emergency medical service response and provide those guidelines to the states” (NTSB, 2009). In response to a request from FICEMS, and with funding support from the National Highway Traffic Safety Administration (NHTSA), the Institute of Medicine (IOM) Forum on Medical and Public Health Preparedness for Catastrophic Events convened a workshop on August 3 and 4, 2010, to examine the current capabilities and future opportunities to improve inte- grated mass casualty response in rural settings. Specifically the objectives of the workshop were to • Review the findings from the NTSB report of the 2008 Mexican Hat incident and discuss near- and long-term opportunities to im- prove response capabilities in rural settings. • Explore existing standards, guidance, and innovative models and approaches in place for state and local jurisdictions. • Examine integrated systems approaches to improve the capabil- ity of the emergency medical services (EMS) system to respond to large-scale rural incidents. • Discuss opportunities to improve integration and coordination with public health systems to address challenges to national public health security, particularly in rural settings. BACKGROUND The vast majority of the land mass in the United States is rural, and much of that is classified as “frontier,” which is defined as counties having less than six people per square mile.3 Mass casualty incidents (MCIs) in rural areas are not uncommon, said workshop chair Robert Bass, executive director of the Maryland Institute for Emergency Medical Services Systems. A nationwide survey of rural hospital emergency departments conducted in 2006 found that more than one-third of those responding had been over- whelmed by what they classified as an MCI, at least once within the prior 2 years, and more than half reported activating their disaster plans within the prior 2 years (Manley et al., 2006). The hospitals cited a broad spectrum of incidents that led to activation of their disaster plans (see Box 1-1). While individual hospital systems are differentially affected by these events, the 3 Throughout this workshop summary, rural will be used to capture both rural and frontier settings.

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3 INTRODUCTION BOX 1-1 Most Common MCIs Experienced by Rural Hospitals From most to least frequent: · Vehicular crash · Severe weather · Bus crash · Hazardous materials (Hazmat) · Power failure · Tornado or hurricane · Multiple gunshot wounds · Fire · Heat · Flood · Explosions · Airplane crash · Other natural cause · Lightning · Train crash SOURCE: Manley et al. (2006). list demonstrates for state and federal policymakers the type of commonly occurring events that can overload a rural EMS system. Many rural health systems exceed their surge capacity and trigger an MCI event with an influx of only a handful, less than 10, patients. Contrast this, Bass said, to a major city such as Washington, DC, where having 10 patients at a single time is a daily event, and the capacity to surge and respond is much more robust. Drew Dawson, director of the Office of Emergency Medical Services of NHTSA said that, although the impetus for the NTSB recommendation to FICEMS was the Mexican Hat incident, the workshop discussion of solu- tions and approaches should be from an all-hazards perspective. Dawson charged speakers and participants to identify practical, cre- ative, and actionable solutions to incrementally improve rural EMS mass casualty response, both in the short and long term. This includes identify- ing barriers and developing practical strategies, with as much specificity as possible, to work around those barriers. Common Challenges Rural and frontier areas face significant and unique challenges in responding to an MCI, which will be discussed in much greater detail

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4 RURAL MASS CASUALTY INCIDENT throughout this summary. In addition to the fact that only a handful of patients may overwhelm response capacity, transporting responders to the scene is a primary concern. Some areas still lack 9-1-1 service, and available service may be inaccessible owing to relatively limited access to landline phones and areas with limited or no cell phone service. Vast distances also delay response to the scene and transport of patients to care facilities. Once on the scene, rural EMS providers may have radios for communication, but there are numerous “dead areas,” particularly in mountainous regions and expansive land areas with limited communication towers. In addition, when multiple EMS teams respond, their radio systems are not necessarily compatible. Another ongoing challenge, Bass said, is the lack of broadband access in rural and frontier areas of the United States. Coordination of response can also be a challenge. Vast distances and lack of coordinated federal funding impact effective planning, training, and exercises. Equally challenging, many participants repeatedly highlighted the absence of directed federal EMS grant mechanisms as a significant barrier. The resulting limited resources (personnel, supplies, funding, and technol- ogy) further limit the localities from being able to adequately plan for and respond to MCIs in rural and frontier areas of the United States. Many rural areas are medically underserved areas with regard to both prehospi- tal and hospital services, facing day-to-day resource challenges including limited equipment, supplies, and healthcare personnel. Richard Serino, deputy administrator of the Federal Emergency Man- agement Administration (FEMA), addressed workshop participants briefly, emphasizing that disasters and mass casualty incidents happen every- where and that the workshop discussions, while stemming from rural, transportation-related incidents, will not only be helpful to rural EMS, but to EMS in general. Common Themes and Opportunities Throughout the workshop, several participants identified a number of common themes and opportunities. Each of these will be discussed in greater detail throughout this report. As already mentioned MCIs in rural and frontier areas of the United States are common and will likely get more frequent in the coming decades as more people use mass transit (trains, buses, and planes) to traverse the vast expanse of rural and frontier areas of the country. The magnitude of these threats as well as the capability and capacity to respond is largely unmeasured. Due to the absence of metrics that can be used to assess risk and capabilities, governments, the public, and responders are frequently unaware of the potential gaps in their response systems until an MCI occurs. Broadly inclusive planning and exercises, stra- tegic partnerships (including NGOs), state/federal coordination and sup-

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5 INTRODUCTION port, the use of Incident Command, teamwork, innovation, and access to communications are factors that appear to improve the response to MCIs. Communications technologies and the lack of interoperability within those systems were a central theme throughout this workshop. Technology plays several roles in rural emergency and disaster response and conse- quently serves as both an opportunity and a challenge. Better communica- tions and patient tracking can be a tremendous asset to everyone involved in a disaster response. Interoperability with all responders, including across state lines, would be the ultimate resolution. Standardization for patient tracking systems would be another desirable outcome. Leveraging existing federal programs (e.g., NG-911, HHS, and DHS preparedness grants, Na- tional Broadband Plan) will also provide an opportunity to improve access to broadband technologies (public safety communications, telemedicine, and patient tracking) in rural and frontier areas of the United States. Moving forward, many participants emphasized that grant guidance will need to be updated to facilitate the development of regionalization and the necessary partnerships—within government, local military bases, and the private sector—and establish the metrics necessary to assess capabilities. While some participants expressed concern about regionalization decreas- ing “local” control, as will be highlighted later in this report, regionaliza- tion facilitates partnerships and sharing of increased resources that result in greater flexibility to plan and respond at the local level. Workshop chair Robert Bass suggested that mechanisms to identify and share best practices in planning for and responding to MCIs will help federal, state, and local governments. ORGANIZATION OF THE REPORT The report that follows summarizes the presentations by the expert panelists and the open panel discussions that took place during the work- shop. An overview of two rural MCIs, the 2008 Mexican Hat incident and the 2010 Albert Pike flood, are provided in Chapter 2. Chapters 3 through 5 examine some of the specific challenges of re- sponding to mass casualty incidents that occur in rural areas, as well as strategies and innovative approaches to improving response. Chapter 3 discusses the impact of limited 9-1-1 access and other communications challenges; Chapter 4 examines the unique challenges of rural prehospital response; and Chapter 5 considers the lack of resources and other issues facing rural healthcare systems. It also discusses strategies to address the challenges posed by coordination and integration across response platforms. Metrics for assessing capabilities and guiding resource allocation are discussed in Chapter 6. Chapter 7 discusses opportunities for improving rural mass casualty response, including the roles of federal, state, and lo-

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6 RURAL MASS CASUALTY INCIDENT cal governments and the private sector. Concluding remarks by the panel chairs of each session are summarized in Chapter 8. The workshop agenda and biographical sketches of the panelists are available in the appendixes.