• Communications,

  • Funding,

  • Leadership (someone who can work their way through the political process to secure the necessary support and resources),

  • Physician participation or lack thereof (e.g., in medical direction at the scene or hospital),

  • Sustaining commitment to disaster preparedness and planning (which is most intense following a disaster, and wanes over time),

  • Political and cultural landscapes (where disaster preparedness fits as a priority),

  • Existing statutes, and

  • Contingency planning.

Dinerman also described the “rural-urban paradox” of prehospital care: the most highly trained responders are in urban America where the transport times to hospitals are short and the need for in-depth prehospital

BOX 4-1

Challenges Facing the Prehospital System

  • Absence of dedicated federal funding mechanisms

  • Communications capabilities

  • Weather impact on mobilization and deployment of resources

  • Acquisition and mobilization of supplies and assets

  • EMS human resources

    • Integration into healthcare delivery system

    • Recruitment and retention of personnel

    • Transitioning to paid staff to offset decreasing incentive to volunteer

    • Training and education (time, expense, availability of personnel)

    • Leadership

    • Physician participation (e.g., medical direction at the scene and hospital)

  • Trauma transport

    • Hospital availability and access (reaching care within the “golden hour”)

    • Personnel and equipment out of service for other calls during extended travel time

  • Risk assessment

    • Assessing likelihood and consequences of incidents

    • Defining the metrics or markers of success of preparedness

  • Political and cultural landscapes—Where does disaster preparedness fit?

  • Rural-urban paradox of prehospital care

  • Technologic idolatry (i.e., the belief that a technology-based approach is inherently better than one that is low- or no-tech)

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