Tuesday, March 31, 2009
News is a matter of perspective and perhaps it’s only an emergency physician who might connect an erupting volcano in Alaska to a riot at a World Cup soccer match in the Ivory Coast. Opposite ends of the earth and tragedies of different scale tend to stretch emergency medical response systems. Disaster drills are routinely practiced, but only the real world can decide whether practice does make perfect.
In the Ivory Coast, spectators rushed the gates to get into the game and the mass of people caused the walls of the stadium to come tumbling down, killing 19 and injuring more than 130. The ability to care for hundreds of victims would strain the best trauma hospital in the US. Your neighborhood hospital may have 15 emergency department beds and a designated trauma hospital may have 60, but even if there were enough beds, the number of trained staff needed would strain the imagination. Aside from the ER doc, a couple of surgeons and an anesthesiologist, there need to be nurses, EMTs, radiology technologists and lab personnel for each patient.
The key to disaster is planning, cooperation and fatalism. Triage at the scene has to determine who is salvageable and can be sent to a hospital and who needs only to be made comfortable at the scene. Helicopters and ambulances are a limited commodity for the critical patients have to be ready and buses are needed for the walking wounded. Communication planning allows hospitals to tell people at the scene how many and what type of patients they can take. Spreading the workload allows everybody to get care. In many areas evening the US, there may be only one hospital with limited capabilities. In eveloping countries, there may not be enough beds, IV poles or casts, let alone people to care for large numbers of casualties.
Volcanoes cause can reverse the problem. What if you couldn’t get the patient to the hospital? With ash in the air, planes couldn’t land at Anchorage airport, effectively closing access to the major referral hospitals in the state. Alaska is a big place and those who are injured or ill hours away from medical care, lack of access is more dependent upon weather than resources. On the North Slope where oil exploration occurs, injured patients couldn’t be transported for the critical care they might need. Care for individuals in remote places takes as much planning as the disaster drills for mass injuries. People with less training and skill may need to be taught, sometimes in real time, to do things they have never done before, for medical conditions they have never seen, guided by advice from a doctor they have never met. If this is a leap of faith for a paramedic or nurse, imagine the leap for the patient.
For all the concerns about health care access in this country, most people expect that there will be an emergency bed available for them if the need arose. Sometimes though, news and nature can intervene. When the numbers of patients overwhelm the system, triage will decide who gets care when or if at all. And if the hospital is there but the patient can’t get there, care may be delivered in creative ways.
In sports, imagining potential situations and practicing to meet those challenges may lead to a championship. In medicine, the same imagination is needed, but there is no guarantee that practice will be enough.