It bears repeating that, particularly in the U.S., one EMS system is one EMS system. It's a rare solution that, upon working in one small corner of the EMS world, can be adopted wholesale in another and produce the same kind of benefit, without modification to that system's own unique circumstances.
So answers that work well for Israel aren't any more automatically applicable to your area than the answers of any other system. No one has it all figured out.The Israelis have certainly been through some trials, with the mass-casualty events and nonconventional threats. Maybe you can adapt some parts of their solutions to your benefit; maybe not. There's value to be had just by listening and finding out.
"The Israelis have had the misfortune to experience so many of these events we hope will never happen in the United States," says Hick. "I think they set an extremely good example in their willingness to take the time to share their experiences and what they've learned, so that those of us who are less likely to face those situations will have the benefit of their experience. It's a good reminder to us that we need to be sharing information, sharing our experiences, and trying to make sure best practices aren't held on to by individual communities. This is not an area for competition."
In that vein, here are some final thoughts about potential lessons, solutions and strategies based on the Israeli experience.
If there's a hospital or EMS service in America that can pull off major comprehensive monthly exercises around different threats, we'd like to hear from you. Most of us can't, but that doesn't mean we can't tap into some similar benefits.
Lesson No. 1 for all training, regular and special-event, is to incorporate a strong feedback loop. Debrief participants, take their input to heart, and keep working to improve performance.
"I think that's one of the reasons the Israelis are successful at this," says Stein-Spencer. "They debrief right away, they include everyone, and everyone's comments are important. They take feedback as a positive and use it to improve. We don't necessarily do that."
Related to that is this: Training's about learning. Don't be afraid to fail--that's how you improve.
Says Heilicser: "Lots of our drills are to satisfy requirements for funding. Lots of our drills are to look good for the media. Lots of our drills are to look like we're doing it the right way. I'd prefer to have a drill to learn what I don't know, as opposed to show off what I do know. Drills should be done at 3 in the morning on a Sunday, when you don't have the staff you'd normally have. Your weakest link is your most dangerous point. Let's show what we need to learn, as opposed to flaunting what we can do."
Finally, training need not be limited to regularly scheduled drills and exercises. Many services squander smaller opportunities every day.
"The opportunity to train our staff in bits and pieces is, I think, very readily available," says Hick, "whether that's by a small column in the department newsletter, or Web-based training, or incorporating disaster medical aspects into annual mandatory training, or just offering some special training on shift for 10 or 15 minutes. In the end, those are the trainings that really matter. You can shove people into a class at the start of their employment, but unless you're doing small bits of refresher training on a frequent basis, or unless it's something they're doing with daily practice, they're not going to remember it when the time comes."
We're not getting a single national EMS service or standardized coast-to-coast emergency healthcare system in our lifetimes. But that doesn't mean we can't achieve some of their benefits. We'll just have to work harder for them.
Elements to that end include everything from the National EMS Education Standards to the Incident Command System to interjurisdictional agreements aimed at facilitating regional response. We've come a long way toward making sure responders speak the same language and can function compatibly. But that work is far from finished.
"I think there's a lot of good planning going on among the hospitals, but in a lot of areas their coordination and cooperation is more around planning than having an actual response framework they can rely on during an incident," Hick says. "The same goes for EMS systems--a lot are relatively fragmented, whether that's between public and private or multiple private agencies not having a good way to coordinate. There are an awful lot of silos out there that still need to be broken down."
"One of the things we need to do at the state level is to coordinate better among all our partners," says Schmider. "For example, every hospital shouldn't have to go out and buy portable disaster hospitals. We have to build a resource pool and be able to share it. That's going to be important in our country, because there's just not enough money for everything. And we need to improve coordination among states."
That's the sort of regionalization that's at the heart of our current preparedness approach, and it can work very effectively in the right environment. A lot goes into that, though, and a big part of it is groundwork beforehand.
"Every state and local entity has a known framework for cooperation and resource requesting and other things that need to be carried out during a disaster," says Hick, whose Twin Cities area has worked out a metropolitan hospital compact by which 30 area facilities work together in emergencies. "Making sure all those things work in advance of an event is critical but can be easily done. It just requires time and effort to get to the right meetings, meet the right people, and make sure the technologies are in place."
Meanwhile, local leaders also need to hone their familiarity and efficiency with the common coins of front-line response.
"One thing the Israelis do well is that they have the same sort of doctrine whether it's a car crash or a big MCI," says DeTienne. "They understand that the technique they use for two patients is no different than that they use for 200 patients, and I get the sense, with the integration of the services, they can expand a little more easily than we're able to. And that's difficult without some more education and drilling here. From a rural perspective especially, we have so few chances to practice this stuff and learn from it."
A solution many U.S. systems are employing is to utilize ICS with any incident involving more than one patient. This familiarizes responders with its concepts, terminology and basic setup before it's forced upon them in a big one.
"Learn how to do disaster response every day," suggests DeTienne. "We don't always have to talk about the big earthquake or the big fire. If we get better at doing MCIs with two patients, 10 patients, 20 patients, we'll become better at the really big stuff."
Healthcare is a system, and no part of it works in a vacuum. EMS in particular goes hand-in-hand with hospitals in a sort of yin-yang of capabilities and responsibilities. That means, if you're going to be clearing scenes rapidly and leaving things like decon for the hospitals, your hospitals better be 1) rapidly ready to receive and care for patients, and 2) prepared and effective at doing that decon and other care themselves.
"It's impressive to clear a large-scale incident in a short amount of time, but what that does is shift a fair amount of burden to the hospitals," says Robinson. "Do our hospitals have the ability to ramp up like that? I think some do. But I think that sort of approach would bring other hospitals to their knees."
Of course it's critical that communications to hospitals from the field occur early and continually in big incidents. Appointing EMS liaison officers can be a great way to maintain those channels.
"If that's doable within the constraints of an incident, that's a phenomenal way to make sure you have good, up-to-date information coming to the hospitals," says Hick. "If that's not possible, then make sure you have a Web- or radio-based mechanism by which alerts and updates can be sent, so the hospitals don't operate in a vacuum."
It was a casual comment over lunch late in the trip that stuck with Schmider.
"It was the woman who told us how she didn't go shopping at the mall with her husband," Schmider says, "because she was worried about her kids, and who would take care of them if both their parents got killed."
That's a chilling off-the-cuff comment. But it suggests a mind-set that's in many ways positive. It reflects a family that is aware of its community's threats and has taken a sensible measure to mitigate them, without sacrificing the daily acts of living.
Wouldn't EMS be easier, in major events and every day, if more Americans did likewise?
"I think our citizens can learn a lot from them in the way of preparedness," says McCaughan. "The idea in Israel is to be prepared. Be ready to stand on your own. Have a plan, have food, have a radio, have a flashlight, be prepared to take care of yourself. And while you're taking care of yourself, check on your neighbor or that elderly person around the corner. I was really struck with their willingness to look out for and support one another--neighbors, friends, people you don't even know."
There are good reasons behind that. But as desirable as it might be as an outcome, Americans should dearly hope those reasons are ones we never endure.
Conference in 2012
In the spirit of exchanging good ideas, Israel has established a new emergency response conference, IPRED, the second occurrence of which is planned for 2012.
IPRED stands for the International (Conference on Healthcare System) Preparedness and Response to Emergencies and Disasters. Scheduled for January 15-19, it will be hosted by the country's Ministry of Health and Home Front Command.
Aims of the show include providing a platform for the exchange of ideas; promoting international networking between healthcare professionals in emergency preparedness and response; and enhancing international research collaboration in disaster medicine and public health preparedness. This year's inaugural show featured a special biological event drill; a radiological drill is planned for 2012.
For more see www.ipred.co.il.