It has been almost four years since personnel in the U.S. health care industry started talking about the need to be prepared for a pandemic influenza. Initially, it seemed, everyone was getting on the bandwagon and committing the resources needed to plan and prepare for the outbreak. With the passage of time, however, these efforts seem to have taken a back seat to other issues and the commitment seems to have become a lower priority. However, the risks are still as great, and the need to plan and prepare is still vitally important to the future public health of communities throughout the nation.
Although every segment of the U.S. public and private-sector health care community needs to plan and prepare, it is particularly important for fire and EMS (emergency medical services) units and personnel to do so. If and when a pandemic does occur, most Americans probably will do what they now do, every day, when faced with an emergency: They will call 911 and expect a quick and effective response. Health care providers have to be prepared for that contingency.
The preparations made should focus principally on the challenges that public-safety services at all levels of government probably will face in planning and responding to a pandemic. Those challenges can be grouped into four principal categories: planning; work-force issues; response; and sustainment. Following are a few important factors that should be considered in each of these planning and operational areas.
Planning: Quality Counts
The success in handling a major disaster such as a pandemic outbreak will be proportionate not only to the amount of time and effort spent in advance, but also the quality of the planning – which, for an event the magnitude of a pandemic, requires coordination and cooperation at multiple levels. Fire and EMS units will have to coordinate their efforts with the health-care community, other public safety agencies, and both state and local governments – and perhaps with other states in the same region of the country.
Small departments and volunteer agencies that lack their own planning resources should at least have representatives at important meetings so that as plans are developed they take into account the actual (as opposed to planned or hoped-for) capabilities of local fire-EMS resources. Those plans also must ensure that the resource needs of local providers are recognized and that the supplies and other materials required to meet those needs also are included in the planning process.
Local health agencies in communities throughout the country already are working with state officials to determine the protocols required for the distribution of antivirals and vaccines. Those plans may involve using public-safety departments to help in the distribution process, so it is important that fire and EMS agencies also be included in the planning discussions. Another reason why those agencies should be involved is to ensure that emergency-response personnel are high on the priority list of those who should receive the medications. The difficult issues of vaccine and antiviral prioritization and distribution are currently being researched and addressed at the national level, and should be given equal attention at the state and local levels as well.
Work-Force Issues: Social Distancing and Family Factors
It has been estimated that 30 to 40 percent or so of the nation’s work force may not be available for duty Firefighting and EMS work forces not only mirror the nation’s general work force but also – because of their exposure in caring for the ill – are high-risk groups themselves during a pandemic. One reason is that firefighting and EMS work forces not only mirror the nation’s general work force but also – because of their exposure in caring for and transporting the ill – are high-risk groups themselves. Here it should be noted that, although many businesses can limit face-to-face contact among employees and customers (through what is called social distancing), that tactic would be almost impossible to be used by emergency-response personnel.
Like almost every other factor involved in an effective pandemic-preparation process, work-force issues should be addressed during the planning phase. Also, individual workers should be involved so they have a true understanding of the situation and what the effect will be on them both personally and as members of a response unit. Involving firefighters and emergency medical technicians in the planning stage would help immensely in developing truly workable plans that could be used during an actual crisis situation.
One important factor that should be considered in the planning process should be the effect on emergency responders of their own family situations. If an employee’s family is well prepared and taken care of, that employee is more likely to report for duty. The plans for the families of emergency responders and health care employees should include provisions for, among other things:
- The care of sick family members (alternate care givers);
- The food, water, and other provisions family members probably will need to sustain themselves during a pandemic, and
- Training in the hygiene measures recommended to help reduce the spread of the disease.
Local fire and EMS departments also must work with the community’s health departments to ensure that vaccines and antivirals are available not only for emergency workers, but for their families as well. Feedback surveys from workers indicate that, unless their families are cared for, they may not be available to come to work themselves. Firefighters and EMTs are known for their bravery and dedication, but their families are likely to be their highest priority.
Another important factor in the planning process should be the development of schedules to address and/or facilitate possible reductions in the size of the work force during a pandemic. The use of alternate shifts should be considered, for example, as well as the possibility of using “non-traditional” personnel to help first responders by providing their own special services. One example of the latter would be a plan to use school bus drivers – because schools would be closed – to drive ambulances, thereby compensating for the lesser number of EMTs and paramedics likely to be available. Plans and provisions for emergency workers to remain at work between their shifts also should be considered – both as a way of ensuring that adequate staff would be available for the next working day and/or to see that they are not exposed to family members, friends, or neighbors who are already ill.
The planning phase also would be a good time to refresh first responders in universal precautions and good “housekeeping” (i.e., station and equipment) practices – and to enforce those practices to the maximum extent possible. Studies show that during most crises most people will fall back to what they are accustomed to doing, which is one reason that effective infection-control procedures should be followed at all times, not just during training sessions. Also, the supplies and other resources necessary for maintaining universal precautions should be obtained and stored prior to an outbreak, if only because most of those supplies are likely to be extremely scarce after an outbreak occurs.
The planning phase also is an appropriate time for fire and EMS departments to initiate discussions with their risk-management agencies about any workers’ compensation issues that might arise if and (more likely) when workers become ill during a pandemic.
Another important issue that should be considered in work-force planning is the development of a comprehensive and effective communications plan. Fire and EMS workers must be kept informed about all of the planning efforts as reassurance that their leaders not only are properly concerned about the communications requirements but also proactive about the safety and well being of individual employees. The communications plan should include the simultaneous and deliberately redundant (but well-controlled) use of several methods of communication – e.g., web-based information postings; hotlines; toll-free call-in voice recordings; and an alert notification system. Information on the various communications tools available has to be provided to users at frequent intervals to avoid rumors, inaccuracies, and misperceptions.
Another often overlooked work-force issue that deserves greater attention in the pandemic-planning stage are the possibilities of workers losing family members and perhaps some deaths within the work force itself. Members of public-safety departments are usually a very close-knit group, and members of the same unit often are considered “family.” How the deaths of family members will be handled should be determined before the situation arises, if only because, if not managed properly, such tragic occurrences might well have a crippling effect throughout the department and impair the ability of other responders to properly serve the community.
Response: No More Business as Usual
One of the biggest challenges facing firefighters and emergency-care personnel during a pandemic will be responding to an increased demand for services with a reduced work force. Emergency responses during a pandemic will not and should not be “business as usual” – and in any case will never be the same even after the pandemic is over.
In order to meet the demand for service, some system of patient triage may well have to be instituted, or expanded, at 9-1-1 centers. Protocols also have to be developed, therefore, that will triage not only the calls from citizens suffering from flu-like symptoms, but also permit a more thorough triaging of other calls for assistance. During the height of a pandemic some situations that EMS staff normally respond to may have to be put on hold for an indefinite period of time. In other situations, service may have to be denied, if the problem is not life-threatening, or alternate service may have to be offered. To handle these and other problems, provision may have to be made to have a more experienced medical person assigned to the 9-1-1 center to carry out the triage plan – and to make some exceedingly difficult decisions as to how limited resources will be dispatched and used.
It is vital that plans be developed for the triaging, treatment, and transport of victims of the flu. Working with the system’s medical director, health department and hospital protocols have to be developed to identify alternatives for care. Those protocols must be specific as to who will be treated and left for home care; who will be treated and transported to alternate care sites; and who will be treated and transported to hospitals. Also, community plans should identify possible care alternatives, such as the availability of home care and/or the establishment of “fever centers.” The latter could be facilities where individuals who are sick could be taken for short-term rehydration and symptomatic care. (Many contingency planners say that hospitals should be used during a pandemic only by the most critically ill who require ventilator support.)
The fire-EMS community should coordinate their plans with other health care providers in addressing all the issues that will arise if decisions are made by the local health department for the isolation or quarantine of certain individuals or segments of the population. There would be significant public fear and anxiety, understandably, during a pandemic outbreak. Public-safety agencies therefore should work, in advance, with public information groups to ensure that, although there may be many voices speaking to the public, they all not only deliver much the same message, but also that that message includes such information as what citizens can expect when they call 9-1-1 (if only because the response during a pandemic may be considerably different from what it is at other times).
Sustainment: Waves of Despair – and Signs of Progress
A pandemic outbreak will differ in numerous ways from the disaster situations that the United States and other nations have experienced in the past several decades. To begin with, a flu pandemic would spread across the nation in several waves. The first wave probably would be the worst, because most people will not have the benefit of being recently vaccinated. However, the second and third waves probably would not affect as many people, and therefore would not stress health care and other systems as severely. It is important, though, that fire and EMS departments capture the lessons learned during the first-wave experience to improve their response capabilities during the later waves.
Another difference during a pandemic would be the lack of mutual aid as most Americans know it. Because the pandemic will be widespread, outside resources will probably not be available. Each community would have to rely, therefore, on its own resources – and on other resources that were determined in the planning phase would be needed, and were actually obtained during the preparation phase.
To summarize: fire and EMS agencies throughout the nation should already be involved in planning and preparing for a pandemic influenza outbreak. There are many issues specific to the planning for a pandemic outbreak – but many of the planning decisions made would be applicable, fortunately, to the management of other hazardous situations. Departments that have not yet been involved in the planning efforts must reach out to the health departments and emergency-services agencies in their community and become involved – as fully and as quickly as possible.
Fortunately, new information that could assist public safety agencies with their planning efforts is becoming available every day. To cite but one example: The Office of Emergency Medical Services of the National Highway Traffic Safety Administration is supporting stakeholder meetings for the development of “EMS Guidelines for Pandemic Influenza.” This document should be available later this year. There is considerable information also available on the internet to assist in planning. Some other excellent sources of information with numerous links to the most current data are listed below.
Mary Beth Michos
Mary Beth Michos, chief of the Fire and Rescue Department of Prince William County, Virginia, was recognized in 2003 by Fire Chief Magazine as “Career Fire Chief of the Year.” She started her career as a critical care nurse and for 21 years worked with the Department of Fire and Rescue Services of Montgomery County, Md., where she was the department’s assistant chief when she left to assume her current position. She is a member of the EMS and Metro Chiefs Sections of the International Association of Fire Chiefs; immediate past chairman of the Board of Directors of the National Registry of Emergency Medical Technicians; and a member of the Virginia State Fire Chiefs Board of Directors and several other professional and community organizations. She holds a bachelor’s degree in business administration, and a master’s degree in leadership and innovation from Marymount University, and serves on several committees of the National Fire Protection Association. In addition to her Career Fire Chief Award, she was the recipient, also in 2003, of the James O. Page Award for leadership in emergency medical services.