The preceding descriptions of the telemedicine systems in Southern Arizona, Maine, and Virginia demonstrate the benefits of employing telemedicine in response to rural MCIs; however, the widespread implementation of the technology remains in a nascent stage, remarked a participant. Many issues still remain to be determined by individual communities: streamlined funding sources; documentation requirements; provider comfort with the technology and the need for training; cost and provision of technology maintenance; integration with existing technology; and ethical implications of use. Telemedicine should not distract from the need for an increase in well-trained, emergency medicine physicians in rural communities, noted one participant. In response, several suggested demonstration projects as appropriate venues for EMS, regional, and state officials to explore these issues in the future.

THEMES IDENTIFIED BY WORKSHOP PARTICIPANTS

In addition to the challenges previously cited (geographic barriers, long distances, weather, communications, infrastructure, education, training, funding), rural healthcare systems are facing a general fear of regionalization among departments and concerns about what they will potentially lose or have to give up in the process. Several participants noted that regionalization is not centralization. Regionalization involves the building of relationships in advance of a disaster, and cooperative, coordinated planning and education. A participant reiterated the point that the best approach to ensuring a competent mass casualty response is to have a stable, capable day-to-day response.

A recurrent theme in the discussions of coordination and integration across platforms was the importance of leadership, and specifically, training for and implementing the ICS. A unified incident command is the key to coordinating across geographic boundaries, disciplines, and sectors (and could be the link to regionalization).

Another topic of discussion was what the trauma system of the future needs to look like and how trauma surgeons could be better integrated into the current system. A participant noted that not everyone needs to be sent to the top-level trauma center.

Establishing connections and building personal relationships prior to a disaster fosters collaboration during an MCI. People whose primary jobs are nonessential in a disaster can be deployed to fill nontraditional roles. There are also likely to be people within the community who have relevant skills and certifications beyond the scope of their primary job. Essential identification of the available community resources (e.g., people, equipment, vehicles, communications systems) and coordination of regional drills



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