Macias, Darryl J. MD, FACEP; Williams, Jason BS, EMT-P
* Successful austere medical deployments in harsh environments share common organizational themes outside a hospital environment.
* The operational framework is the 7 P’s (preparation, planning, personal, partner, public, patient, prognosis) and situational awareness.
* Proper preparation under simulated conditions can enhance the safety and success of a mission.
Recent world catastrophic events and humanitarian crises have demanded more assistance from relief workers than ever before. More physicians and other healthcare workers are answering the call because of a sense of social responsibility, commitment to service, and increased educational offerings in humanitarian health.1 Some participants, however, may not comprehend the difficulties inherent in working in austere environments. Austere medicine is often used in the context of operational medicine, associated with combat, hazardous, or tactical operations.2 Austere medicine also encompasses resource-limited settings, in which advanced hospital technology is not readily available, be it a healthcare clinic in an underdeveloped region, an air ambulance setting, a wilderness expedition or wilderness rescue situation, an in-flight or space mission emergency, or a disaster situation.3–6 In the latter instance, many well-developed, existing disaster response organizations, such as the National Disaster Medical System, assume that critically ill patients will be managed in fixed facilities, whereupon most disaster preparedness focuses on rescue, stabilization, and transport. This assumption becomes challenged when hospitals have poor infrastructure, become overwhelmed with casualties, cannot function because of downed power grids or when epidemics and terrorism occur.6,7 Disasters are not simply defined by the casualty numbers, but rather by the event and the venue.8
Natural events, such as earthquakes, extreme heat, floods, hurricanes, landslides, tornadoes, tsunamis, volcanoes, wildfires, or severe winter weather can cause or worsen existing disasters.9 Knowledge of environmental factors and an appreciation of personal preparedness have long been priorities in search and rescue operations since the formation of the Mountain Rescue Association in 1959,10 and are beginning to be emphasized within disaster medical team training with the online courses offered by the US Department of Health and Human Services.11 The National Disaster Medical System, under the auspices of the Office of the Assistant Secretary for Preparedness and Response, emphasizes an organized response for mass casualties and pandemics along with nuclear, biological, chemical, and radiological catastrophes. Although the Mountain Rescue Association is not typically involved in major disasters, there seems to be a common organizational theme within most wilderness rescues, tactical operations, and disaster responses that occurs during an austere mission.
Common Organizational Themes in Austere Medicine
The initial task of performing medical care in an austere setting can be daunting to a medical professional lacking previous experience or one who may have expertise in one of the above disciplines without having had experience in other aspects. The authors, experienced in all of the above-mentioned disciplines in austere medicine, have empirically observed that many successful austere medical deployments share seven common themes, regardless of the situation, which can give a provider a simple framework regarding proper mission initiation and execution. Many of the initial phases are prehospital oriented, but they apply to almost any resource-limited clinical or hospital environment worldwide. These phases follow a mnemonic called the “7 P’s and 1 S”—preparation, plans (for deployment), personal safety, partner or group safety, public safety, patient rescue (or treatment), prognosis of the patient or mission, and situational awareness at all times, derived initially from the “4 P’s” of rescue priorities of the Wilderness Medical Associates (David Johnson, MD, personal communication, March 10, 2004). The seven phases were presented to an emergency medicine rescue consensus group at the January 2012 First Global Network of Emergency Medicine-Dubai and were believed to be a valid summary of the planning and execution phases of an austere medical mission. Fifty emergency physicians from the United States, France, Italy, the Netherlands, Turkey, Lebanon, the United Arab Emirates, Saudi Arabia and Pakistan who are regularly engaged in disaster medicine, combat and tactical medicine, or wilderness medicine and mountain rescue were involved in the consensus.
First P: Preparation
The preparation phase consists of frequent training in a simulated environment similar to the anticipated stressful environment in which care will be delivered. In periods of stress, elevated glucocorticoid levels act on excitatory amino acids, causing hippocampal atrophy and short-term memory loss; in combat veterans, hippocampal volume reduction correlates with verbal memory deficits.12,13 The mental effects of the stress response appear to stimulate the amygdala, promoting the fear response,13 which may result in operator inaction or error. Helton et al suggested that cognitive disruption and inattention appear after a large earthquake, even when subjects were controlled for earthquake-induced anxiety, depression, gender, and amount of sleep.14 In mass-casualty events, rescue personnel can be overwhelmed by immense destruction and casualty numbers, which is exhibited by dissociative emotional states and posttraumatic stress disorder.15 Combat-related stress inhibits performance, vigilance, planning, situational awareness, judgment, and ideal decision making.16 The degree of this impairment during a military training exercise in highly motivated, elite soldiers undergoing sleep deprivation, continuous physical activity in the heat, and caloric restriction caused a 20% decrement in reaction time in the subjects, exceeding the effects of a 0.10% blood alcohol level.13 Furthermore, task organization and completion appear to be compromised by fatigue, potentially leading to disastrous consequences. These cognitive disruptions could be deleterious to a mission and are linked to later posttraumatic stress disorder.12–16 Educators cite the need to train medical personnel to manage stress and reduce treatment errors,17 and incremental exposure to simulated stress in an educational setting best prepares an individual for stressful situations, which improves coping skills.13,18 This exposure, called stress inoculation, is promoted through role-playing, imagery, and graded stress exposure.18 A meta-analysis demonstrated that desensitization reduces performance anxiety and physiological anxiety and can improve task performance, especially with repeated sessions.19 Simulated laboratory exposures can be equivalent to a field experience, especially with virtual reality training13,16–18,20; nevertheless, most studies fail to quantify these improvements or are limited methodologically. A small study of physician residents in a simulated emergency department trauma room showed significant improvement in team leadership skills and confidence in managing simulated patients.20
Likewise, organizations involved in austere missions train regularly in the anticipated environmental condition,20 using drills, simulated rescues, and patient simulations. This training appears to improve teamwork and skill levels when given within clear, concise, and precise training standards for the particular discipline.21
In addition, maintaining good physical conditioning to be able to carry out the job is stressed in many of these organizations.10,11,22 Proper physiological acclimation to the anticipated climactic condition is emphasized in many programs,23 with some carried out to physical exhaustion.24,25 Logistical training also appears to be of value, including the use of leadership; incident command; communication; triage and resource allocation; procurement of food, water and housing for rescuers; and transport.11 We, therefore, believe that proper physical, mental, and leadership training under graded stress is essential for future mission success.
Second P: Plans (for Deployment)
Thoughtful planning for a deployment is essential, and participant availability should be known in advance. Understanding the geography and existing infrastructure of a region where an event occurred or a building where a hostage situation may be unfolding, or becoming familiar with mountain topography for a high-angle rescue influences mobilization plans. International deployments based on first-world logistics may not apply when caring for casualties in resource-constrained settings.26 Anticipating public health needs, ideally, in a preplanned collaboration with the receiving institution(s)27 after an event, is necessary in mass-casualty events.28 This may involve efforts to improve institutional surge capacity29 or plan the transfer of patients to a prehospital transport provider; coordinating transfers to the appropriate facility should be designed to limit overwhelming a receiving institution,30 but having an alternate plan is vital if unanticipated problems occur.31 In remote areas with limited organized infrastructure, tactical medicine principles can help mission planning and execution succeed.32
Third P: Personal Protection
Traditional medicine teaches that patient needs are the priority. In austere or hostile environments, this thinking must be challenged because a jeopardized healthcare provider can endanger a patient. The care provider should have undergone proper physical and mental training and be in optimal health for the task at hand and also should have the proper technical expertise (eg, proficiency in rope rescue, wilderness travel, survival skills, and navigation to reach the patient), if applicable. Personal physical and emotional limitations should be addressed and controlled before participation in a relief effort and medications appropriate for the environment (eg, vaccinations, anti-infection medications) should have been obtained. Inadequate personal preparation, although infrequently publicized, can result in the care provider becoming a patient, competing for resources and potentially endangering the team. According to one observer sent to Haiti immediately after the 2010 earthquake, a deployed medical team was all too eager to deliver medical care; a key figure on the rescue team soon became ill, consuming time and resources intended for people injured in the quake (Zachary Child, MD, personal communication, March 2, 2010). A provider must ensure his or her own personal safety with proper precautions and proper safety equipment for the environment; reports of rescue operation accidents are replete with ill-prepared rescuers who are overenthusiastic to arrive at a scene and begin work.32 Personal protection also may mean there is a need for additional security personnel or self-defense devices.33
Fourth P: Partner Protection
Partner or scene safety can be established once personal protection matters have been arranged. Ignoring partner safety also can have catastrophic consequences, usually from inadequate preparation or miscommunication.34,35 Team members should adhere to the mission’s goals and follow a well-thought-out rescue plan under established leadership (eg, incident commander, recognized chain of command). Ideally, partners should be involved in deployment decisions with other partners or commanders because participants are potentially incurring risk. Such procedures may not be possible in a tactical or military application, yet in tactical medicine and certain high-risk disaster situations, providing rescuer security in a danger zone cannot be overstated.33 Disparate groups participating in the 2010 Haiti earthquake deployments attempted to deliver medical aid without proper leadership or partnership accountability. Many of these attempts were made by poorly organized but well-intentioned small nongovernmental organizations. One of the authors (D.M.) observed such events transpire in Port-au-Prince, when aid workers outside the disaster medical group became lost or ill or were assaulted; these events were potentially preventable, had group accountability been maintained.
Fifth P: Public Protection
Well-intentioned rescues may endanger public safety, from the public’s lack of awareness of a rescue situation, as the result of curious bystanders, or because someone simply “wants to help” with relief efforts. Rescue operators, as ambulances, have been implicated as the cause of significant automobile crashes.36 Thus, proper rescue control and crowd control can mitigate additional casualties and facilitate (rather than impede) relief operations.37
Sixth P: Patient Care and Protection
After the above sequences are fulfilled, patient triage, rescue, and initial stabilization can occur. It is beyond the scope of this article to discuss many of the methodologies of triage (eg, START [Simple Triage And Rapid Triage]) and stabilization [implementing models such as basic or advanced cardiac or trauma life support versus tactical and combat casualty care]. Classical disaster planning assumes that once patients are triaged and resuscitated, there should be ample medical resources, provided that evacuation can take place.6,7 In austere environments, prolonged contact with the patient, without the benefit of a “disposition,” is the rule, taking place for hours, days, or weeks. Expertise in acute emergency and ongoing critical care is necessary and commensurate with the skill level of the provider. Ancillary medical tools depend on the nature of the mission; in austere environments, practitioners must often improvise because of the limitations of transporting equipment reserved for hospital use, be it from the limitations of powering machines, equipment size, or adverse environmental conditions.6 Familiarity with diagnostic adjuncts, such as point-of-care laboratory testing devices or portable ultrasound, is necessary to facilitate patient care decisions and evacuation plans.6,38,39 It is important to ensure that a patient is adequately protected from the elements, from further injury and illness, or from security threats during a mission.
Seventh P: Prognosis
The degree of patient care in a harsh environment can be important, depending on the patient’s condition, the provider’s training level, the well-being of the provider or providers, and the environmental circumstances. Although advanced life support can be carried out under such conditions,40 advanced life support may not alter mortality in selected wilderness settings.41 Guidelines for search and rescue groups, disaster medicine teams, or operational medical units vary and should be consulted for direction. Executing a plan to extract a viable patient from the scene should be done expeditiously, for the sake of patients, rescuers, and limited resources. Aircraft or boats can facilitate evacuation when roads do not exist. Rescuers should have a means of communication with the evacuation service and establish an easily located and safe rendezvous point, away from objective dangers or crowds. Ground crews should ensure a safe landing zone and patient transfer and must have good navigation skills and adequately understand technical map reading and coordinates to direct an evacuation crew to an appropriate meeting point. Communication with the receiving facility, either by preplanned agreement or live communication, also is essential.
S: Situational Awareness
Situational awareness is a person’s understanding of what is happening around him or her.42 A person may use his or her sensory data to assess danger (with rescuers observing the potential for avalanches, landslides, rock falls, floods, or earthquake aftershocks, for example) and information gathered previously, or he or she may use computerized surveillance networks (eg, hospital patient alert networks, surge capacity networks, the Centers for Disease Control and Prevention’s Health Alert Network).42 Participants in a mission, rescue, or evacuation must be alert for any environmental or manmade changes that could endanger the patient or crew. During emergencies, the tendency is to focus on the immediate needs, often at the expense of ignoring peripheral circumstances. In mountainous and similar environments, a lack of situational awareness has resulted in helicopter and plane crashes. One investigator found that nearly one in three emergency medical systems/search-and-rescue helicopter accidents occurs because of bad weather and/or poor visibility.34 The ill-fated “606 Mission” outside Santa Fe, New Mexico highlighted poor visibility during inclement weather with a large risk-to-benefit threat, in which a police helicopter pilot initiated a search for a lost, uninjured hiker; the mission ended in preventable fatalities.35,43 Complex operations such as helicopter emergency medical systems have significant requirements for situational awareness in the name of expedient patient care and should not be casually called upon for a rescue.
Accumulated data about rescue accidents conclusively demonstrate that the greatest risk for mission failure is from human bias.35,44 Performing poor risk analyses (taking chances) can leads to fatal consequences.44 There are several documented cases of these erroneous calculations in the context of “rescue fever”: a rescuer ignores simple safeguards or ignores external environmental cues not to deviate from a given task, only for it to end in tragedy. Emotions, fatigue, obligations, and poor training are among the circumstances that minimize good risk assessment and situational awareness.
Dangerous external situations are common in disasters. A news report detailed some of the urban threats in the aftermath of Hurricane Katrina, with New Orleans experiencing manmade threats as a result of the catastrophe and possibly from the initial rescue efforts. Attempted shootings and rapes were reported, as relief efforts continued to free residents trapped by floodwaters, corpses, and human waste. Charity Hospital, in an attempt to evacuate patients, was forced to halt efforts after coming under sniper fire.45
Civil chaos is possible during or after a disaster; thus, situational awareness and risk assessments must be anticipated commensurate with actual conditions during humanitarian aid efforts. Other potential threats, which may be obvious in calm situations, may escape notice during chaos. In the aftermath of the 2001 New York terrorist attacks, many healthcare providers were sent to Ground Zero without taking precautions for the possible involvement of nuclear, biological, or chemical weapons or even for the toxic byproducts of combustion.46 After the 2003 severe acute respiratory syndrome outbreak, a large percentage of the patients were healthcare workers, illustrating how insufficient infection control practices can be lethal.47
Using good situational awareness and risk assessment appears to involve three stages.48 The first stage is observing actual conditions (information gathering), in which attentiveness to type and frequency of situations is noted. Continuous vigilance, boredom, or fatigue can threaten awareness and must be recognized during this stage. During the second stage, previous training and experience are called upon to interpret a potential threat. The final stage of situational awareness is anticipatory in nature, projecting how the information already gained may affect rescue efforts in the near future. Hypotheses are formed and reformed as the situation changes, often in a worst-case scenario.48 Proper action must be taken when needed, and the continuous reassessment of circumstances is a priority. In reality, situational awareness is not simply the last step after the seventh P; situational awareness occurs from the beginning to the end of a deployment. Good leadership will ensure that such awareness occurs throughout all phases of the mission.
Participation in an austere mission is complex and success is predicated on the ability to safely confront the challenges inherent in a resource-limited environment. Although the mnemonic 7 P’s described may not describe completely the steps necessary to undertake all humanitarian missions, it is hoped that the 7 P’s will permit a better understanding of the basic steps needed to undertake a deployment in a wilderness, tactical, disaster, or other resource-limited setting, while appreciating the need for rescuer and patient safety measures. A future prospective study is warranted to validate this suggested framework, possibly by dividing rescue teams of a particular discipline into an intervention (the mnemonic) phase and a placebo (not providing stress training) and comparing the two groups in a double-blind, crossover high-fidelity computerized simulated study.
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