Emergency Medical Training

With a syringe, Tostaine inflated a bulb at the end of the tube to open the trachea wider. Then he attached a valve mask – a sort of manual ventilator – and pumped it as Ken lay on the hospital stretcher. Ken’s chest visibly moved up and down.

“That helped,” a voice said.

What? Was Ken able to talk already?

Actually, no. The voice was only a simulation coming from a laptop hidden behind a green-and-white emergency-room curtain. Then again, Ken himself is also a simulation, a mannequin with squeezable rubber limbs and 70 sensors that provide a “pulse,” a “heartbeat,” the “breathing” that was restored by the tube, and other ostensible signs of life. People who are learning emergency medical techniques can practice on Ken before hitting real emergencies, ranging from fires to car accidents to terrorist attacks. (To understand why he’s called Ken, think about the physiology and missing organs of Barbie and Ken dolls.)

Ken is one small part of a 1 ½-year-old, super-high-tech, $1.2 million training center for emergency responders on the tenth floor of the Saint Vincent Catholic Medical Centers complex in New York City.

The hospital has trained more than 6500 paramedics and other responders since it began its program in1981, but this center, which opened in September 2008, brought together functions that had been scattered throughout the hospital’s eight buildings into a set of permanent, dedicated rooms.

Ken is one of six mannequins (plus a few scattered limbs) in a special simulation room designed to resemble an emergency room, with realistic touches like five stretchers, an electrocardiogram monitor, and the curtain around Ken’s bed.

John Bray, the hospital’s coordinator of paramedic education, says a special room like this – which took three years to design and build – is rare in training centers. “A lot of programs store the mannequins in a closet and bring them out into a classroom” when needed, he says.

From a tile-floored terrace running along one side of the building, across from Ken’s room, the students can look out at what used to be the World Trade Center site. That’s appropriate, because the September 11, 2001 terrorist attacks on the World Trade Center are a major reason this center exists.

During the first chaotic hours after the attacks, the few hundred injured survivors were sent to Saint Vincent’s, the closest trauma center to the site. Meanwhile, 4,000 miles away in Zurich, Switzerland, at the headquarters of the Swiss Reinsurance Company, Andreas Beerli, head of the company’s Americas Division, was frantically – but unsuccessfully – trying to reach his 100 New York-based employees. Luckily, all were safe, but the experience prompted the company to donate $1.2 million to Saint Vincent’s to help prepare – if necessary – for the next emergency.

A Swiss Re spokesman points out that the company has been providing insurance coverage for disasters – including the sinking of the Titanic in 1912, Hurricane Andrew in Florida in 1992, and Hurricane Katrina in New Orleans in 2005 – for nearly 150 years. “Our grant to establish the Swiss Re Center [at Saint Vincent’s] is an extension of that work,” he explains.

(Ironically, the two institutions share another disaster connection: Saint Vincent’s treated Titanic survivors after they were rescued and brought to New York City.)

According to Bray, the center trains would-be responders from “all walks of life.” A recent class of 40 included an unemployed financial consultant, a retired police officer, four active-duty members of the military, an 18-year-old technician who’d been helping the local ambulance corps since she was 14 and was now seeking higher-level certification, and various police and firefighters, all ranging in age from the 18-year-old tech to age 57.

Clearly, the emergency system needs all these graduates, and more. The arrest in September of a shuttle-van driver from Denver, Colorado, named Najibullah Zazi, suspected of being part of a bombing plot, shows that terrorism remains a threat, along with more traditional disasters like multi-car accidents, fires, and chemical spills.

Yet Bray estimates that there’s a consistent 30% shortage of trained personnel, in part because of high turnover: The typical emergency services employee stays on the job only five years. “It’s a very stressful job,” he points out. “It’s physically demanding, and you’re always moving.”

“After September 11,” Bray adds, “there was a big increase in people interested in going into emergency preparedness,” inspired by patriotism and a desire to help. That “kind of waned” after a while, but the recession spurred a renewal of applications from people like the unemployed consultant; after all, any paycheck looks good when the unemployment rate nudges 10%. “Being a paramedic is a recession-proof ­profession,” Bray quips. Still, that interest is expected fade as the global economy picks up.

Moreover, as the definition of “first responder” evolves, it means that more ­people need training. It used to refer only to professionals – police, firefighters, and paramedics. “After September 11, the term was broadened to anyone who responds first to the scene,” says K.C. Jones, a board member of the U.S. National Association of Emergency Medical Technicians (NAEMT) and also director of the emergency medical services program at North Arkansas College in Harrison, Arkansas.

The new, wider definition might include police, fire, paramedics (sometimes known as emergency medical technicians in the U.S.), doctors, nurses, hospital staff, hazmat ­specialists, and even ordinary civilians.

Along with the wider range of people to be trained has come a wider range of training possibilities – along with some confusion.

In the United States, the Department of Transportation mandates a set of standards for training professional paramedics and emergency technicians, which the Saint Vincent’s program follows. Depending on the level of the job, there are different curriculums. For instance, the lowest level – emergency medical responders – includes 48 hours of training in areas such as basic anatomy, lifting and carrying, how to maintain an open airway in a patient, how to evaluate a scene for potential hazards, and how to deliver a baby.

However, that’s merely the first step. Each U.S. state can add training requirements to those standards. Then there’s specialized training in topics such as weapons of mass destruction, and less-specialized training for the broader mass of non-professionals. Some might want a more macro view of the disaster scene, in addition to the Transportation Department’s focus on medical care.

Unfortunately, there is no consensus as to where these classes are taught or how much to charge. Sensing a growth area, some for-profit companies have jumped in.

The situation is even less structured in Canada. According to Jones, training for the least-experienced level of paramedics (equivalent to the Department of Transportation requirements), “is all over the spectrum, from a low of eight hours to a high of 16 hours.”

“The entire matter of preparedness and response training is very much in a state of flux,” says Jack A. Horner, executive director of the National Disaster Life Support Foundation, a U.S. nonprofit based at the Medical College of Georgia in Augusta, Georgia – one of many groups offering training programs in North America.

To get an idea of what the confusion can lead to, consider the question of triage.

Trying to decide who gets priority for treatment in a mass emergency is a touchy topic in itself. But in addition, there is no agreement on how to communicate the priority levels. According to Horner, there are at least eight different systems for labeling patients. Some paramedics use color-coded tags, some use numerical ranking, some use an alphabetical system, and others use words like “serious” or “minimal.”

“The issue came to light as a real deficiency in response to Hurricane Katrina,” Horner adds. “Teams were coming from multiple states to help, but they were trained differently.”

The U.S. Federal Emergency Management Agency (FEMA) website lists a whole alphabet soup of training organizations. Some have clear-cut, specific functions – such as the Center for Domestic Preparedness, which is the only federally chartered facility for teaching responders how to handle weapons of mass destruction. But there seems to be a significant overlap between the Emergency Management Institute (“emergency management training to enhance the capabilities of federal, state, local, and tribal government officials, volunteer organizations, and the public and private sectors to minimize the impact of disasters”) and the groups listed under Training and Exercise Integration/ Training Operations (to serve “the Nation’s first responder community, offering more than 125 courses to help build critical skills that responders need to function effectively in mass consequence events”).

What about non-professionals who want some training in order to pitch in? While the Transportation Department curriculum is aimed at professionals, Jones says that “any person who might find themselves in any emergency situation, any ­reasonable person, could take this class and pass.”

Or they could turn to Horner’s organization. Horner says his foundation was created after Hurricane Katrina by four colleges in Texas and Georgia, working with the American Medical Association and with funding from the U.S. Centers for Disease Control. Their aim is to create a standardized curriculum that would augment the Transportation curriculum by helping professionals and nonprofessionals understand the broader issues of disaster management, such as “the health professional’s role in incident management systems” and what to do at an accident scene.

The foundation established three levels of courses. Community officials, business owners, and other laypeople, along with health workers, social workers, police, and firefighters, can take a four-hour introductory class. The next level class, which runs seven and a half hours, is aimed at a wide range of medical personnel, including doctors, nurses, physician assistants, dentists, pharmacists, veterinarians, and medical students. Doctors, nurses, physician assistants and paramedics can then move up to the two-day, 15-hour advanced class, which includes practice drills in emergency tactics like decontamination.

Horner says 80 training centers so far have used the program to train 79,000 responders – including, in Canada, an Ottawa-based for-profit training company, Disaster and Emergency Management Solutions Inc. In addition, according to Horner, a consulting company in Vancouver is considering the program.

Joining the fun this past spring, a nonprofit called the Board of Certified Hazard Control – which already had certification programs for healthcare safety professionals, product safety managers, patient safety officers, and hazard control – announced a new credential program for certified healthcare emergency professionals, aimed at emergency preparedness officials.

In its announcement, the board, based in Helena, Alabama, said that it “received input from practicing healthcare emergency and disaster professionals when developing this designation” and that it relied “on information, standards, and best practices from reliable sources,” including the U.S. National Fire Protection Association, American Society for Testing and Materials, American Society for Healthcare Engineering, Department of Homeland Security, Environmental Protection Agency, and FEMA. To gain the new certification – which comes in three levels – applicants must pass a multiple-choice test of at least 100 questions. Private firms immediately sprang up to offer classes to prepare for the test.

Such a wide plethora of sites for all this training leads to another question: Where should training ideally take place?

The majority of programs now are offered by colleges and universities. Horner says that 42 of his 80 training centers are educational institutions such as medical, nursing and dental schools, which often give hour-for-hour college credits. Jones’s campus, North Arkansas College, teaches the Transportation Department class.

Even Bray of Saint Vincent’s agrees that there are benefits to learning at a college rather than a hospital like his. “At a college, it’s more of a formal education,” he says. “You have better instructors, and you can have a degree path.” Or, as Jones puts it, “I feel that education is best provided at an educational facility.”

Yet Bray argues that medical facilities have their own advantages. “You can come to a state-of-the-art training center, and then you can take your skills and work inside the hospital,” he says. “A student can go up to a doctor and follow a case throughout the hospital. You can do clinical rotations in the emergency room and practice IV access. All the people that teach also work here.”

Firefighters and police, of course, can train in their own academies, plus the U.S. Fire Administration, under FEMA, runs the National Fire Academy. However, many end up at places like Saint Vincent’s because there aren’t enough spots in their own academies.

Less common are for-profit institutions like Disaster and Emergency Management Solutions in Ottawa. A total of six teach Horner’s program, but Jones says he hasn’t heard of any others doing the Transportation Department training.

“Where you take the program doesn’t matter,” Horner sums up. “Properly done, the courses can be anywhere.”

Of course, the best situation of all will be if there is never again a mass disaster to test the $1.2 million training donation that Swiss Re provided to Saint Vincent’s. However, with natural disasters occurring with increased frequency, we’re better off if we are well trained.

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A freelance writer for The New York Times and other publications, Fran Hawthorne has covered medical and security issues for over 20 years. She is the author of the books “Inside the FDA: The Business and Politics behind the Drugs We Take and the Food We Eat” and her latest, the award-winning “Pension Dumping.”
© FrontLine Security 2009