EMS, Casualty Evacuation


Article Author:
Brandon Koser


Article Editor:
Maureen Suchenski


Editors In Chief:
Ron Feller
Grant Goold
Kyle Cohen


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
1/13/2019 5:34:58 PM

Introduction

One of the most important roles of emergency medical services (EMS) is in-transit medical care for patients. It is what has transformed the role of the EMS provider from the “ambulance driver” in the early days of the specialty to the modern professional with varying scopes of practice and protocols. It has helped to reduce morbidity and mortality and extended the reach of medical care out away from the hospital setting. There are many situations, however, when traditional medical evacuation is not feasible, possible, or ideal.

Casualty evacuation can be defined as the movement of the sick or injured by means other than those designed for medical transport and in which in-transit medical treatment is limited or unavailable. Recognizing advantages and disadvantages of casualty evacuation along with when it will or may be utilized is essential for the EMS professional in planning for, moving or receiving patients, and implementing proper policies and training for its optimization.

Issues of Concern

The old paradigm of medicine included bringing the medical providers to the sick and wounded rather than bringing patients to providers. This made the most sense in small, close-knit communities where the risk of communicable diseases was higher if patients were clustered, even if it was not cognitively recognized as such. Transportation and infrastructure were also generally limited; therefore, moving one person around made more sense than the intricate networks established in most modern systems today. Furthermore, medicine was not logistically intensive, requiring simple, often unclean, tools and ingredients for the remedies of the day. Interestingly, there is an increasing movement toward home delivery of care in modern healthcare delivery models with advanced EMS systems leading this charge.

In those instances where home care was not possible, or patients remained at risk if they stayed in place, such as a battlefield, casualty evacuation remained the only means of evacuation for patients until very recently in medical history. The Crimean and American Civil wars brought out radical advancements including the organizing of the first ambulance corps, dedicated litter-bearer teams during battles, and educated nursing care for those brought to casualty collection points and field hospitals.[1] As time and wars advanced, care was pushed further into the field with first aid, analgesia, and preventive medicine provided during the evacuation (now considered the standard of care) giving rise to mobile advanced life support and critical care teams, providing expert treatment in route.[2]

Many do not recognize that casualty evacuation is still present and often plays a vital role for patients and medical systems. Every time someone drives their loved one to the emergency department while they are having a heart attack, they are technically performing casualty evacuation. Historically, the patient did not receive  intravenous (IV) fluids, an electrocardiogram, or other standard treatments such as aspirin and nitroglycerin – all typical in modern medical evacuation. What they did presumably get was a timely transportation to a higher level of care.

Any means of conveyance can be utilized for casualty evacuation –  dragging patients out of a danger zone, personal vehicles, watercraft, city buses, and attack helicopters that pick up the wounded on their way out of an engagement area.

Recent mass casualty events have demonstrated the resourcefulness of the public and first responders when trying to remove patients from the scene of an incident. During the Las Vegas mass shooting of 2017, more patients were brought to emergency departments by crowd sourced ride services similar to taxis than by ambulance. There were known pickup locations near the event with cars and drivers waiting. This occurred not because the system failed, but because patients and the public were trying to do everything to get away from a horrific scene as quickly as possible. Even with mutual aid assistance and activation of emergency protocols, there were simply not enough ambulances to handle an event of that scale. One can imagine a number of scenarios in which local resources are exhausted, and the systemic use of casualty evacuation is not only possible but preferred and necessary.[3][4]

Clinical Significance

Recognizing when and how casualty evacuation occurs, it is important to understand the limitations and challenges this can present. Following are two common situations to demonstrate this point.

Police are often the first to arrive at a scene. During shootings, many police officers will provide first aid on site such as applying a tourniquet and then proceed to drive the patient themselves to the ED.[5] Similar situations are also arising with the recent opioid epidemic after first responders administer naloxone and again transport immediately.[6]

While first aid and treatment were appropriately provided, patients do not continue to receive medical care and reevaluation in the back of the police squad car that they would in the back of an ambulance in either of these scenarios.

Trauma centers and the military have utilized the "Platinum 10 Minutes" and "Golden Hour" rules to help guide planning for protocols and emergency disaster responses for several decades. The general principles include on scene stabilization for no more than 10 minutes prior to beginning evacuation to definitive care and arrival at a qualified care facility that can treat surgical injuries within an hour of a traumatic event. Recent reviews have cast doubt on the validity of the specifics for these time frames, but there is little disagreement that evacuation should not be needlessly prolonged.[7] Resources in many areas such as ambulance crews and mutual aid compacts and disaster plans are managed in such a way as to facilitate meeting these goals, not just for trauma but medical emergencies as well.

Resources are finite. When ambulances are not available, medical providers must be able to utilize casualty evacuation appropriately, and planners must account for their use.

Looking at this from the receiving end, hospitals and medical facilities must anticipate that patients will arrive by casualty evacuation. This probably means that the receiving facility did not receive a report of inbound patients. It is also likely that evacuation triage was not completed on scene in order to ensure the sickest arrive first. When receiving patients, the facility must ensure they have a system in place that allows for rapid triage of all patients arriving by all means.

Patients also may not be taken to the most appropriate facility to start with. There may be multiple facilities within proximity of one another, and each is designed in certain ways that medical evacuations with ambulances use to their advantage. Ambulances may bypass a slightly closer facility for a more appropriate one for instance. One center may be PCI capable for a STEMI and another facility is a stroke center with TPA and neuro intervention readily available. Medical evacuation crews are able to do this because they are aware of the differences but also because they are continually reassessing their patients and managing interventions which allows them to make on the fly decisions and utilize online medical direction to redirect if necessary. The public, which is utilizing casualty evacuation, may not be able to do this and proceed directly to another center because it was marginally closer or they were simply unaware of the differences. Those facilities subject to Emergency Medical Treatment and Labor Act (EMTALA) must appropriately stabilize the patients and perhaps arrange a transfer to another facility if appropriate.[8][9][10]

Those responsible for moving patients from one scene to another must also be aware of the pros and cons of casualty evacuation. EMS personnel, first responders, disaster planners, and anyone else who may be tasked with evacuating patients must recognize all the options available to them. The key to every scenario, both planned and impromptu will be understanding three essential components: 

  1. An honest appreciation of the current situation
  2. Knowing all the resources that are available and their capabilities
  3. Understanding the desired end state and effective communication of the same.

The decision to use local, on-scene, resources such as cars or trucks to move patients may be the most efficient and most appropriate for a given scenario. If reliable personnel are in abundance but medical transport vehicles are in short supply, a system can be organized to ensure patients are brought to the right facilities. Casualty collection points and ambulance exchange points can also be established to maximize the effectiveness of medical transport and personnel. These topics will be discussed further in other articles but the appropriate use of casualty evacuation can be a major asset to improve patient care.[11][12][13]


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EMS, Casualty Evacuation - Questions

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Which of the following patients is most appropriate for aeromedical evacuation from a freestanding emergency department?



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Which of the following is not a risk of non-medical casualty evacuation?



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Which of the following is an example of casualty evacuation?



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What is the greatest advantage of casualty evacuation?



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Which of the following is not necessarily required for an efficient and viable response to an event causing the need to evacuate patients?



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EMS, Casualty Evacuation - References

References

Protas M,Schumacher M,Iwanaga J,Yilmaz E,Oskouian RJ,Tubbs RS, Treatment of Gunshot Wounds to Spine During Late 19th Century. World neurosurgery. 2018 Jul     [PubMed]
Galvagno SM Jr,Mabry RL,Maddry J,Kharod CU,Walrath BD,Powell E,Shackelford S, Measuring US Army medical evacuation: Metrics for performance improvement. The journal of trauma and acute care surgery. 2018 Jan     [PubMed]
Brown JD,Goodin AJ, Mass Casualty Shooting Venues, Types of Firearms, and Age of Perpetrators in the United States, 1982-2018. American journal of public health. 2018 Aug 23     [PubMed]
Klassen AB,Marshall M,Dai M,Mann NC,Sztajnkrycer MD, Emergency Medical Services Response to Mass Shooting and Active Shooter Incidents, United States, 2014-2015. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2018 Aug 30     [PubMed]
Rothschild HR,Mathieson K, Effects of Tactical Emergency Casualty Care Training for Law Enforcement Officers. Prehospital and disaster medicine. 2018 Aug 31     [PubMed]
Paul L, Meeting Opioid Users Where They Are: A Service Referral Approach to Law Enforcement. North Carolina medical journal. 2018 May-Jun     [PubMed]
Schroeder PH,Napoli NJ,Barnhardt WF,Barnes LE,Young JS, Relative Mortality Analysis Of The     [PubMed]
Safaee MM,Morshed RA,Spatz J,Sankaran S,Berger MS,Aghi MK, Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care. Journal of neurosurgery. 2018 Aug 3     [PubMed]
Hsuan C,Horwitz JR,Ponce NA,Hsia RY,Needleman J, Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions. Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management. 2018 Jan     [PubMed]
Petkovic D,Wongworawat MD,Anderson SR, Factors Affecting Appropriateness of Interfacility Transfer for Hand Injuries. Hand (New York, N.Y.). 2018 Jan     [PubMed]
Redman TT,Mayberry KE,Mora AG,Benedict BA,Ross EM,Mapp JG,Kotwal RS, Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals. Summer 2018     [PubMed]
Stong GC,Kalenian MH,Hope JW, Medical evacuation experience of two 7th Corps medical companies supporting Desert Shield/Desert Storm. Military medicine. 1993 Feb     [PubMed]
Fitzpatrick D,McKenna M,Duncan EAS,Laird C,Lyon R,Corfield A, Critcomms: a national cross-sectional questionnaire based study to investigate prehospital handover practices between ambulance clinicians and specialist prehospital teams in Scotland. Scandinavian journal of trauma, resuscitation and emergency medicine. 2018 Jun 1     [PubMed]

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