Storm Surge? Photo by Mike Licht, NotionsCapital.com

Storm Surge? Photo by Mike Licht, NotionsCapital.com

Hurricane Sandy introduced the word “surge” into common use to explain the flooding of Manhattan and New Jersey. Storm surge is an offshore rise in water level caused by high winds pushing on the ocean surface. When added on top of tides, devastatingly high sea levels may result.

Medical Surge Definition

The real definition of surge is broader – “a sudden powerful forward or upward movement, especially by a crowd or by a natural force”. Today’s topic is medical surge, which often involves both crowds and natural forces. Officially, we define medical surge as “providing adequate medical care during events that exceed the limits of the normal medical infrastructure”. In plain English, medical surge means more patients than you know what to do with. Amusingly, Dictionary.com includes a usage example of “the onward surge of an angry mob” – perhaps a real concern if medical surge is not handled fairly and efficiently. Do you remember the high public anxiety during the 2009 pandemic flu? And that was a relatively small surge!

Angry crowds in New Orleans after Hurricane Katrina. Photo by Greg Hounslow

Angry crowds in New Orleans after Hurricane Katrina. Photo by Greg Hounslow

You’ll notice the definition doesn’t mention the cause of the surge or the types of injury and illness. That’s because the basic problem is always the same – how to provide adequate care when patient demand exceeds available staff, facilities, and equipment. Natural disasters, accidents, terrorism, illness – all can cause medical surge. What differs is our response. Surge impact depends on many factors (not in any particular order):

Number of patients in the surge. Duh! A multiple injury accident like a car crash might count as surge for a small hospital. Increase this to a mass casualty incident, like a plane crash or chemical spill, and any hospital needs surge plans, hopefully including coordination with other hospitals for overflow. Step it up further to catastrophic events like a nationwide pandemic or a 9.0 earthquake – I guarantee every aspect of healthcare will feel the pain.

Speed of the surge. Some public health emergencies occur rapidly (mass casualty incidents, chemical accidents, earthquakes, tornadoes), allowing minimal time to prepare or institute plans. Others develop over hours to a few days (floods, hurricanes, bioterrorism), and some advance “leisurely”over days or weeks (pandemic illness). Theoretically, this would allow time to adjust and carry out plans, gather resources, and pull in outside help, but only if resources and assistance exist elsewhere.

Advance warning of the surge.  Even a few minutes warning might allow partial activation of emergency plans – if nothing else, seeking shelter, drop/cover/hold, or saving data (essential in the era of electronic medical records). Hours to a few days’ notice might allow full surge plan implementation, providing plans exist, including requesting deployable resources in advance.

Chemical Spill. Photo by Washington State Dept of Transportation

Chemical Spill. Photo by Washington State Dept of Transportation

Area affected by the surge. When medical surge affects only a single hospital, city, or county, near-by communities often loan assistance and resources, or take in patients. As the area expands, state and federal assets may kick in. However, if large regions experience a disaster (like the potential simultaneous earthquake predicted for Oregon, Washington, British Columbia, and California), or the entire country becomes involved (like a pandemic or war), even federal resources may be inadequate, and communities must prepare to stand on their own.

Hospital versus outpatient care.  Although hospital resources are limited, at least most hospitals are prepared. But what if the disaster or illness creates medical surge primarily in the “walking wounded” (or “walking ill”) category. These patients don’t require hospitalization. Unfortunately, many outpatient clinics have minimal or no emergency or surge plans. Although ambulatory care may be less urgent, we are also less prepared to provide it. Community physicians not only lack education on public health threats, but many have even lost first aid skills – normal physician practice includes sending wounded patients to the emergency room or using specialized staff for these “basics”.

Specialized patient needs. Medical surge requiring intensive care, surgical care, or burn care means specialized equipment (ventilators, monitors, operating rooms) and highly trained staff (nurses, surgeons, anesthesiologists) – resources that are often limited or unavailable in some communities. On the other hand, surge plans might include caring for medical ward and post-op patients in alternative care settings, thus opening up hospital resources for more intense needs. The strategic national stockpile includes medications, antidotes, and vaccines, but obviously not for every disease or disaster, and not enough for everyone in the country. Even in normal times, medication shortages have become common place. Who knows what might be in short supply in a large surge?

Intensive Care. Photo by Emilio Labrador.

Intensive Care. Photo by Emilio Labrador.

Pediatric patients. Many communities currently delegate most pediatric specialty care to outside hospitals and specialists, and lack local expertise in surgical or even basic hospital level pediatric care. If pediatric specialty centers become overwhelmed in medical surge, expect mass pediatric care to be particularly problematic.

Workforce issues. Employees often stay home in medical surge situations because of personal illness, family illness, or childcare needs.  They can be afraid of contagion, feel too stressed to help others, or be unwilling to separate from family in anxious times. Even disaster pet care prevents employees from working, particularly if shifts are long, or they cannot easily return home. Caring for an increased number of patients is problematic with full staffing. With staff shortages, the issue becomes critical. And it’s not just healthcare employees! Vendors, transportation, you name it – everyone needs employees to continue functioning. Our intricately interwoven healthcare system means that failure in any part will affect all others. In fact, medical surge effects extend beyond healthcare when employees stay home from other critical services, like sanitation, public works, gas stations, and grocery stores.

Infrastructure. Medical surge with intact infrastructure (pandemic, chemical, bioterrorism) is completely different from mass care without electricity, phones, water, and the internet (natural disasters). Intact roads, bridges, and public transportation are necessary for staff travel and delivery of supplies. With infrastructure failure, communication drops down to radios, satellite phones, and good old-fashioned person to person messages. Lights and equipment depend on generators. Hospitals beat clinics hands down in preparations for infrastructure problems, yet look at Bellevue and NYU in New York. Mass patient evacuations because of infrastructure failure!

H1N1 Vaccine Line 2009. Photo by ellenm1

H1N1 Vaccine Line 2009. Photo by ellenm1

Public fear and anxiety. An anxious public means lots of calls and visits to clinics and emergency rooms, even without illness – the “worried well”. Media, school, and workplace interventions to reassure and educate the public can help medical surge immensely, if they keep the worried well from unnecessary healthcare visits. On the other hand, inadequate or incorrect public information worsens the problem (and has even caused civil unrest in some countries). Public Information Officers are guaranteed employment in medical surge.

Advance planning. Hopefully it is glaringly obvious to every reader that medical surge plans are essential. If a major disaster or pandemic outpaces federal support, surge plans might be the only thing standing between health and massive deaths and injuries.  Hospitals are making progress – I wish I could say it was altruism, but in reality, the major incentives are probably hospital regulatory and certification requirements, supported by state and federal guidance and money.  On the other hand, clinics and healthcare providers are private entities with minimal regulations and no financial support for preparedness. Since surge planning takes time and money, don’t expect clinics to make it a high priority. Finally,  the federal government has given public health departments the task of preparedness, while simultaneously cutting staff and funding (and no, I don’t work for public health) – how much can we really expect them to do?

What happens when medical surge hits without planning?

When significant medical surge is limited to your city or state, treatment could be delayed and you and your loved ones might receive care from a volunteer clinic or field hospital.  You might have to put up with non-life-threatening or disabling illness or injury. Expect difficulty in refilling prescriptions or obtaining routine care. Despite this, you’ll probably be OK if you are healthy. Vulnerable populations, such as children, senior citizens, and the medically frail, will be the real victims, particularly when someone doesn’t actively advocate and hunt down care for them.

For a widespread severe medical surge, it’s anyone’s bet how bad the consequences could be. Current plans are definitely inadequate, so I guess we’ll just have to wait and see.

You can help with medical surge planning!

Make individual and family plans. Identify reliable community information sources, including public health, 2-1-1, and dependable media. Don’t count on using your doctor for information during medical surge – save them for when you or family members are really ill. Keep a stash of over the counter meds, prescription meds, and first aid supplies at home. Stay on top of your health issues during normal times – don’t postpone routine appointments or tests. Keep a printed copy of your medical records with your emergency supplies.

Make plans for child, family, and pet care, so you can continue working. Not only will you earn money, but you will help your community continue to function. If your employer provides an essential service, lobby for emergency workplace family/pet care and employer-provided vaccinations. Oh – and make sure your employer has a real emergency and business continuity plan, or you’ll be out of a job even if you want to work.

Theoretically, we live in a democracy. Make public officials aware of preparedness concerns, and encourage adequate attention and funding. Ask questions of your doctors, clinics, and other healthcare providers about preparedness. Don’t accept vague answers about mysterious plans somewhere. If employees don’t know the clinic emergency plan, it can’t be much good.

VOLUNTEERS NEEDED

CERT Volunteers, HawaiiPhoto by Ryan Ozawa

CERT Volunteers, Hawaii
Photo by Ryan Ozawa

Get involved now. The CDC Clinician Outreach and Communication Activity page is an excellent healthcare education resource, as is their Emergency Preparedness and Response page for the general public. For healthcare providers of any type, visit the Emergency System for Advance Registration of Volunteer Health Professionals page to learn about registering in  advance with your state healthcare volunteer registry (credentialing before the need arises).  Read my blog posts on CERT training and the Medical Reserve Corps for other opportunities to volunteer. Extra staff needed for medical surge must come from somewhere – volunteers are our only hope.

If you are really inspired, consider helping your clinic or public health department with surge planning. I’ve agreed to spearhead local public health efforts to develop a community wide pandemic surge plan. I’ve spent the past few years discovering healthcare preparedness gaps in our community (almost everything outside the hospital!), so now it’s time to try and bring all the players to the table and see if we can fix some things.  I may have bitten off more than I can chew, but anything is better than nothing. Wish me luck.

Stay safe,

Sheila Sund, M.D.

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Comments
  1. Nice article. Hope you can fill in the gaps. Science needs to clone you! 8^)

  2. As a GWOT vet, I tend to look at surges from the other direction. When a pandemic, mass-cal, or other potentially catastrophic incident exceeds local capacity, the surge to me is the descent of 11 DMATs on the affected area. Nonetheless, you do bring some important points to the forefront about exactly what we need to be preparing for.

    • disasterdoc says:

      I hope sincerely there will always be plenty of DMAT teams available for my area (and federal medical stations, national guard field hospitals, etc). It’s the events that are too small or too big for these resources that bother me!

  3. Well it looks like it is time to work with the State and County Public Health planners to engage the free-standing clinics. Both those that are not affiliated with a hospital (the doc-in-a-box) and the outpatient clinics of local hospitals. Seems the hospitals have some planning to do. They also need to communicate their plans with local fire departments and other emergency responders.

    • disasterdoc says:

      Without a doubt, medical clinics are our weakest link – both urgent clinics but also standard doctor’s offices. If primary care disappears after a disaster, it becomes difficult for a community to recover. We’re inviting our major clinics to the table in planning pandemic surge. I figure it will be easier to engage them in this topic, which they know they will need to deal with, then in natural disaster planning, where they can pretend it’s not their problem.

  4. Mark Urban says:

    One element that (from experience) becomes a real challenge is managing workforce surge. After the initial disaster, you often find an influx of volunteers, DMATs, MRC, National Guard, local hospital and EMS, and other staffing resources. problem is, you don’t have a mechanism to quickly assess their skillsets and use them to best effect. titles and skillsets are often mismatched – for example, a “Nurse” can be an LPN from a local home care, or a Critical Care R, or an Army Medic or Navy Corpsman can have wide variations in skillsets from basic first aid to Chest tube insertion and PA-level clinical skills. When I arrived on site at Katrina, I saw trained responders carrying stretchers and filling out forms, because the onsite civilian staff didn’t know what to do with them or whether local laws allowed them to practice.

    • disasterdoc says:

      I agree. Everyone knows a doctor isn’t a doctor isn’t a doctor, but we seem to forget that in volunteer deployment. I am building my MRC on a DMAT model. I want to develop plans to fit JIT healthcare volunteers into our structure under my command. I’ll depend on ESAR-VP or hospitals for proving licensure, but I am designing a “skills” form for both MRC members and JIT volunteers, so that I can quickly assess qualifications and experience when deciding where to use them. The legality issue is a different thing, since it varies from state to state, but at least I’ll know our local laws.

  5. Steve Chambers says:

    Your comments are right on. I have worked in Public Health Preparedness for 23 years and only since the Anthrax attacks in the Fall of 2001 and the H1N1 outbreak 2009-10 has the primary medical care community been even slightly concerned about medical surge. Your readers may want to read the 2012 NIH Report on Crisis Standards of Care, A Systems Framework for Catastrophic Disaster Response. It lays out the scenario for medical surge across a large region (or even nationally or worldwide pandemic) where there are no additonal medical mutual aid resources. Every community will have to use the existing cadre of resources available, perhaps for several months. Having a well organized and trained Medical Reserve Corps (MRC) may be the only surge support for many communities. Hospitals should actively support the development of the MRC in its area by providing a location for the MRC to recruit and train its members.

    • disasterdoc says:

      It’s amazing how short memory is – even now, the hassles and difficulties of H1N1 fade away. A small part of me wants a small pandemic just to wake everyone up again!

      As both a geology and disaster fanatic, I am fixated on the Cascadia earthquake overdue in the Northwest (some of my colleages think we should rename it the “Sheila earthquake”). It may involve from Vancouver Island in British Columbia to Mendocino in California simultaneously, extending from the coast (which will be wiped out by a giant tsunami) to the Cascades. This area includes Vancouver, Seattle, and Portland. To make matters worse, our infrastructure is woefully unprepared. They predict we will lose all our major highways and bridges, our main airports, and even river access to Portland. They anticipate months to restore power.

      It’s glaringly obvious that we’ll be on our own for that one. Even if the federal medical resources can reach us, there are not enough of them to handle that large of population and area. That’s why I am so involved (run our MRC, work with hospitals/public health/Red Cross, education and outreach to docs and clinics – you name it). If the earthquake holds off 10 years, I think I can put together a medical plan that will work, at least for Salem.

  6. Paul DeLuca says:

    Informative and very well written.

  7. Howard Richards says:

    The Army has restructured its Reserve and National Guard Forces. The Reserves are mostly the Support Troops – Transportation, Medical, etc., while the National Guard is mostly Combat Units. Not saying there are no medical units in the National Guard, there are but they are now smaller. The Reserves has what is known as Combat Support Hospitals (actually two units – one the main hospital the other like an old fashion MASH unit) which can expand to a 1,000 bed hospital. Problem is that if a local unit is called up, many of its members may be victims themselves. Further, most of the Reserve Units’ equipment is not stored at the unit’s home base but at another location. Not true for the Guard. Just some of the things to keep in mind.

    • disasterdoc says:

      Thank you Howard. This is very helpful – I have a poor understanding of the military role. My to-do list (which is scarily long) includes talking to our local National Guard to see what medical resources might be available in a large regional disaster like the Cascadia earthquake. People worry about dying from the earthquake. Certainly we will have fatalities, but outside the tsunami zone, the bigger problem will be the massive number of injuries. I wish we could count on outside assistance, but after reading the dismal Oregon Resilience Plan for Cascadia, I think we must prepare for quite a period of self-sufficiency. It would be nice to understand how the Guard or Reserves might figure in (and where their stuff is stored).

  8. Disaster Doc…you are my hero!!! You’re research is DEAD ON! Having spent twenty nine years in the security forces, firefighting and medical fields in the USAF, USAFR, and ANG, I have been through trading evals, mass casualty exercises, disaster preparedness, and CBRNE (among other related areas). You have evaluated well and put it all in the military mindset. We were subject to command directives, JCAHO, and OSHA and FEMA.

    The comment about Navy Corpsman and US Army Medics was very accurate. Add to that USAF Medical Technicians and Explosive Ordinance Disposal Teams. EOD and Disaster Preparedness. We Medical Technicians were also NREMT’s. We had 6 person Rapid Retrieval Teams to pick up casualties, quickly assess and treat them, and transport them to field hospitals. Eventually everyone knew each other’s jobs and “orderlies” acquired some of the skills of doctors. Medical HR staff, hear me. If an ex medic, corpsman, or med tech comes to you for an ER job….you know what to do. How many beginning RN’s can insert a chest tube, or perform a tracheotomy? EOD and DPP trained us for establishing our hospitals in wartime conditions. I never once got deployed, even though I volunteered. Thanks to the assistance of all these people, I was prepared if I ever got deployed.

    My point is, they all did the mass casualty stuff RIGHT. Now, why don’t hospitals use these military people on a regular basis instead of worrying how much money they dumped into nursing school to learn to be a bedpan commando? In a disaster crisis, a trained Medical Triage or Disaster Preparedness military member are your finest resources.

    • disasterdoc says:

      At a statewide MRC meeting today, we talked about how to increase Medical Reserve Corps volunteer participation, training, and leadership. I think military “medic” experience could help in all these areas. So pass the message along. Retired or inactive military medical and preparedness folks – volunteer for your local medical reserve corps units now. Don’t wait for deployment – use your expertise now to help with education and planning.

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