Surge planning for EMS (emergency medical services) duties and responsibilities focuses primarily on four separate but inter-related resources required for a typical mission: personnel; equipment; support/materials; and vehicles.
Staffing is perhaps the most problematic resource issue to resolve because an agency can seldom if ever “stockpile” enough people to deal with any and all possible contingencies. But that problem can be finessed to some extent – by recruiting, in advance, trained professionals who are not already in the regular staffing pool, a ready force for expansion can in fact be maintained, at least theoretically. Unfortunately, because many people qualified to work in and/or from an ambulance already serve in the emergency field (but for other agencies and/or in different fields of specialization), the number of such “reserve” personnel would have to be very large, somewhere on the order of 5:1 or even 10:1.
Moreover, there are a number of potential problems that must be resolved prior to implementation of a call-up, including, for example: labor issues related to calling in “outside people” to fill staff positions; the additional pay and liability insurance required; providing workers’ compensation for the additional recruits; and the possible policy problems involved in assimilating them into the existing system.
A further complication is that, because of financial constraints, it is unlikely that an agency has significant underused support resources available, such as extra mechanics and communications staff. It is possible, of course, to write additional contracts with car dealers and mechanic shops, but such contracts should be negotiated very carefully, in advance, to ensure that the “outside” vendor has agreed to the specific terms of service that might be required. This could be a difficult negotiation when a major event actually occurs because the purchasing rules would still apply, even under the most arduous circumstances imaginable.
Specialized Problems, Surge Capacities & the Stockpiling Dilemma
Several other support functions are too specialized to be contracted out, and must be dealt with in-house – communications, for example, which may be dealt with either in-house or contracted out to another government agency. In either case, maintaining an acceptable surge capacity for the support functions should be approached in the same way used for augmenting other in-house EMS resources.
The stockpiling of “things” rather than people presents a different type of complication. Many, perhaps most, perishable EMS supplies have an expiration date, and that unavoidable circumstance adds a new level of complexity to any plan to stockpile them. There are two approaches that should be considered in maintaining a surge capacity in supplies: one is maintaining a relatively large in-house stockpile; the other is using a vender-controlled stockpile. (Some agencies prefer a combination of these two options – using the in-house stockpile first, but having a vendor-controlled stockpile “on call” when the in-house supplies run out.)
An in-house stockpile of perishable supplies requires that staff use the supplies closest to their expiration date, a common-sense principle that will require some discipline on the part of the supply and line staff alike – but will, or should, work with little or no additional cost following the initial outlays for the various types of goods and/or equipment in the stockpile.
The point at which the stockpile quantity exceeds what is calculated to be the “normal” use of the item over its expiration period is the point where planners have to ask if the current level of the various resources stockpiled is excessive. Whether it is or not, it is highly probable that at least some items in the stockpile will from time to time have to be discarded and replaced. This is especially true of items that are not used in day-to-day operations – nerve agent antidotes, for example.
Fly Cars – A More Affordable Necessity
One of the major constraints in maintaining an all-purpose surge capacity involves vehicles, most of which are too expensive to stockpile – but also too necessary to ignore. Many systems use non-transport vehicles outfitted with paramedic gear and staffed with paramedics in their day-to-day responses. In systems that typically transport their paramedic units in ambulances, additional units can shift into so-called “fly cars” – SUVs and/or station wagons, for example, that have ample carrying capacity but are not equipped with the medical gear that is standard equipment in most ambulances.
The fly-car option allows the thrifty planner to augment, at a reasonable cost, the transport capabilities with the paramedic ambulances initially available. In addition to using all available spare vehicles, including those not normally thought of as spare – e.g., parade pieces and other display vehicles – the fly-car/SUV/station-wagon pool is the most likely source of additional vehicles.
If either of these options is contemplated during the surge-planning sessions, it is important to ensure that the theoretically “spare” equipment is fully maintained so that all vehicles, the fly cars as well as the ambulances, are up to the minimum operational standards required.
In the long run, the principal and most common-sense measure of success for a surge plan are three relatively simple questions: (1) “Was the surge invisible to the patient?” (2) “Did the ambulance arrive in a timely manner?” (3) Was it adequately staffed with trained professionals who had with them the tools and supplies needed to do their jobs?” After all, the patient requires the same care whether he or she receives it from a line unit or a surge unit. In either case, it is the responsibility of the EMS agency responding to the emergency call to provide that care.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.