Resources: Adapting a Battlefield Medicine System to Civilian Mass Casualty Events

As part of the disaster preparedness planning process, many emergency managers, especially in large metropolitan areas, are facing the realities of a possible London or Madrid-style mass casualty scenario.  Even more disturbing, emergency managers in financial and political centers which are likely considered “high-value” targets by terrorists are facing the prospect of thousands or tens of thousands of casualties and evacuees associated with a nuclear attack.  Overwhelming numbers of casualties in a truly catastrophic event can be managed by looking at healthcare models affectively used on the battlefield.

This writer was fortunate enough to be a part of a 1980 US Air Force initiative which adopted many of the lessons learned by the Israeli Defense Forces in battlefield medicine, particularly during the Yom Kippur war in 1973.   This system, called the 4-Echelon Battle Casualty Management System, can now be adopted by emergency planners and managers for managing mass casualty scenarios in civilian settings.

Introduction to the 4-Echelon Mass Casualty Management System.

Battlefield casualty management experience has resulted in advanced and effective rescue, resuscitation, stabilization, definitive treatment and rehabilitation of soldiers ever since World War II.  The use of the helicopter as an air ambulance greatly improved the survival rates of soldiers wounded in combat in Korea and Vietnam and in all conflicts since.  Many trauma procedures develop in combat medicine have been applied with great success to our civilian trauma systems.  With the ever-present threat of terrorist attacks using biological, chemical, radiological/nuclear and explosive agents or devices, the time may be right for jurisdictions and their civilian healthcare systems to implement a combat proven system for mass casualties called the 4-Echelon Mass Casualty Management System.

For more than 10 years, Public Health agencies at all levels of government have been ramping up capabilities for early detection and responses to biological warfare agents and disease outbreaks.  Public Health planners have also developed strategies for providing rapid post exposure medications and vaccinations to millions of people affected by these man-made and naturally occurring events.  The time is right to forge strong relationships between the Emergency Management community, Public Health agencies and Private Sector healthcare organizations in planning for large scale disaster or emergency events.

What is the 4-Echelon Mass Casualty Management System? The 4-Echelon Mass Casualty Management System is a highly effective and efficient system of managing very large numbers of casualties throughout a disaster and until local healthcare organizations recover and can resume normal operations.

The 1st Echelon of care is provided by first responders and consists of immediate lifesaving procedures and the rapid transport of the living to a 2nd Echelon facility.

A 2nd Echelon facility may be a trauma center or an emergency department.  The 2nd Echelon is essential in making the most of the patient’s “Golden Hour.” By providing immediate care and by dramatically increasing the casualty throughput to 3rd and 4th Echelons, the 2nd Echelon care providers prevent or reduce the patient gridlock associated with a disaster and thus, optimize the saving of lives. 2nd Echelon care is designed only to save lives and stabilize patients and not to provide definitive care.  Employing the latest advances in trauma care, 2nd Echelon care includes procedures for saving life and limb and stabilizing patients. Typically at the 2nd Echelon, providers ventilate patients if necessary, control bleeding, infuse blood products and expanders and amputate limbs as required.  Once stabilized, patients are quickly transported to the 3rd Echelon of care for definitive treatment.

The 3rd Echelon of disaster healthcare is typically a hospital or medical center away from the immediate disaster location.  In the early stages of a disaster, a hospital or medical center may provide both 2-E and 3-E care. It is likely that a hospital’s 3-E capacity will almost immediately be reached and the facility will revert to 2-E care only.  3rd Echelon facilities may be within a jurisdiction or may include hospitals in several jurisdictions or even national regions, depending on the number of casualties and the care requirements.  Definitive care is provided at all 3rd Echelon facilities, but specialized care such as burn centers may also be provided in a 3rd Echelon facility.  This includes a full complement of surgery specialties, diagnostics and follow-on care for about 7 days.  Patients who cannot be discharged within a week are normally candidates for 4th Echelon care.

The 4th Echelon may include specialty centers or rehabilitation hospitals capable of providing long term ventilation care, psychiatric care, burn or wound care and rehabilitation or specialization in physical therapy or orthopedic care including providing prosthetic devices and associated therapies.

Depending on the location and scope of the disaster, a particular hospital may function as a 2nd, 3rd and 4th Echelon facility.  When close to the disaster location, a hospital may have to function only as a 2nd Echelon facility, transporting all stabilized patients to 3rd and 4th Echelon facilities further away from the disaster location.  By so doing, the hospital serving as a 2nd Echelon hospital may be able to accept more patients in need of stabilization than it could as a multiple-Echelon facility.  In another disaster scenario further away, this same hospital could be functioning as a 3rd or 4th Echelon facility, providing definitive and/or specialty care to stabilized patients.

What is the role of Healthcare Organizations as part of a 4-Echelon Mass Casualty Management System? Most medical centers and many hospitals operate as full 4-Echelon capabilities during normal everyday operations.  During a disaster, Healthcare organizations will periodically self-declare their capabilities to the Emergency Operations Center (EOC) in terms of the Echelon of care they can provide in a fluid environment. Depending on the size and scope of a Mass Casualty event, a hospital may eliminate the 4th-Echelon immediately and declare itself as 2nd and 3rd Echelon capable to the medical representative in the Emergency Operations Center. At that point, the EMA would reach out to adjacent jurisdictions to activate their EOC (s) and to provide a list of healthcare organizations capable of providing 4th Echelon care.  At some point in disaster operations, an individual healthcare facility may declare itself limited to 2nd Echelon care only, thus requiring outside healthcare support at both 3rd and 4th Echelons.  In fact, in some circumstances, a healthcare organization may reach full capacity and be incapable of accepting any additional patients.  In other cases healthcare organizations may be damaged in the disaster and may need to report to the EOC that all patients must be evacuated and transported to healthcare organizations outside the affected area.  In any case, healthcare organizations must be able to efficiently communicate their capabilities with the jurisdiction’s EOC throughout the disaster.

How can 4-E work in a competitive Healthcare Marketplace?  A traditional model of disaster healthcare seems to dictate that healthcare organizations provide the full continuum of care to all patients presenting for care.  Competition would seem to dictate that hospitals or medical centers expand (surge) their services until their individual capacity and capabilities are reached. Why then would hospitals want to self-declare themselves as a 2nd Echelon facility and request rapid transport of stabilized patients to healthcare organizations outside of their service area? The answer lies in continuity of operations.  Hospitals in the affected area need to recover and resume normal healthcare services as soon as possible after a disaster.  By serving as a 2nd Echelon facility and rapidly transferring patients to 3rd and 4th Echelon facilities outside the affected area, hospitals and medical centers in the affected area can conserve staffing and material resources and thus, can more rapidly recover after the disaster event.

This definitely requires a paradigm shift, but experience shows that after a disaster, healthcare providers need decompression time. If the staff is exhausted, who will provide healthcare services immediately following a disaster? Likewise, medical supplies are consumed at an enormous rate during a disaster.  Equipment used during a disaster needs to be disinfected and inspected prior to being returned to normal service.  If the support services personnel are exhausted, who is going to disinfect hospital areas and the equipment and how long will the hospital be closed after a disaster? Heart attacks and strokes will still occur, babies will be born and the population in general will need care immediately after a disaster.

Finally but importantly, disaster operations can and do strain healthcare financial resources to the breaking point.  The last thing that any community needs after a disaster is a number of bankrupt hospitals or medical centers. Civilian healthcare organizations cannot issue continuing resolutions in order to make payroll or pay suppliers during and after a disaster.  Federal and State payers as well as private insurance companies must develop and publish simplified health care claim procedures for use during declared emergencies.  These simplified claim procedures will sustain healthcare organizations and their services during and after a disaster and can help ensure that healthcare services are available after the disaster.  Perhaps, simplified financial procedures can be tied to services rendered at each Echelon of care.

Adopting the 4-Echelon Mass Casualty Management System. The first step is the adoption of the 4-Echelon Mass Casualty Management System by a state or territory EMA and the Healthcare organizations within the jurisdiction.  Once proven in a single state, the 4-Echelon System may be adopted throughout a federal region or multiple regions. In time, the 4-Echelon System can be adopted Nationwide.  The 4-Echelon System will fit seamlessly into the National Disaster Medical System (NDMS), since NDMS healthcare facilities were the planned 4th Echelon of care for service members returning from either the European or Pacific theaters of operations, had the Cold War turned hot.  Although the 4-Echelon System never needed to be fully implemented on the American battlefield, it may be the right civilian disaster healthcare solution at precisely the right time.

(c) JVR Health Readiness, Inc. 2008

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