On Sept. 1, Hurricane Gustav made landfall in southern Louisiana, prompting the evacuation of 2 million people, the largest evacuation in the state's history. The size of the storm prompted the Federal Emergency Management Agency (FEMA) to activate American Medical Response's (AMR) national disaster contract in Mississippi, Louisiana and Texas.
While the Gulf Coast still recovered from Gustav, Hurricane Ike made landfall in Galveston and Houston, Texas, on Sept. 12. The diameter of Ike's forceful winds made it one of the largest Atlantic hurricanes on record, and FEMA called upon AMR once again.
"Never in the history of EMS has there been a deployment of this magnitude," says Steve Delahousey, vice president of emergency preparedness for AMR, the nation's largest ambulance service provider. "Last year we set a record, and this deployment doubled what we did last year, so we now have a new benchmark."
The government requested maximum EMS resources for both storms. Six hundred ambulances for Gustav and 533 ambulances for Ike were deployed from 35 states, with almost 50% of ground ambulances supplied by AMR's subcontracted network providers. More than two dozen fixed- and rotary-wing aircraft were also dispatched.
To complicate matters, Hurricane Hanna made landfall on the border between North and South Carolina Sept. 6. "AMR released all deployed ambulances from states affected by Hanna and backfilled with additional ambulances from non-vulnerable states," says Delahousey. "These contiguous disaster deployments are by far the largest mobilization of EMS disaster resources in U.S. history."
Department of Health and Human Services Lt. Commander Bruce Dell characterized AMR's performance by saying, "Deploying roughly 600 ambulances across three Gulf States is grossly equivalent to a U.S. Army Armored Division deployed across an area more than twice the size of Iraq."
Rescue & Recovery
In all, 12,154 people were deployed to handle the disasters, including EMS personnel, state personnel, National Guard personnel, incident management teams, law enforcement, fire-hazard management, and swift water rescue. Because the storm disasters were so close together, personnel typically stayed on, deploying every seven to 14 days.
"EMS personnel came literally from around the country through FEMA," says David Persse, MD, medical director of EMS and public health authority for the City of Houston.
Nursing home patients were evacuated with the aid of ambulances, buses and National Guard troops, according to Angela Copple, coordinator for the Emergency Management Assistance Compact (EMAC). ˙Texas has a lot of bus contracts, and they used a lot of buses.Ó
Once the storms passed, EMS personnel were kept busy, particularly inHouston, assisting people suffering from injuries sustained from downed trees, chainsaws, falls from ladders and roofs, and electrocutions. "The vast majority of chainsaw injuries are severe, and there were lots of them," says Persse. "We had people getting shocked because they didn't know what to do around power lines, and all of this went on for days because Houston is such a huge area and the city suffered so much damage."
For people with medical specialty issues EMS personnel stepped in to not only rescue, but care for these individuals, who were sometimes left without family. "This is the epitome of the demonstration of EMS personnel actually caring for their neighbors and being the safety net when everything else fails," says Persse.
Copple echoes that sentiment. "EMAC would not work were it not for the people who are so passionate about helping one another in times of disaster," she notes. "It amazes me how selfless people are when, in the face of disaster, they stop their lives to go help somebody else."
A Far Better Response
Response to large disasters, such as Gustav and Ike, becomes more efficient and streamlined as emergency medical personnel and various disaster agencies learn to communicate and cooperate together, according to Copple. "Communication, coordination and sharing information is a huge part of making it all work," she says. "And we've been doing much better at that."
Persse couldn't agree more. "When Hurricane Ike came through and Hurricane Gustav was headed our way, we got things done that in the past we would have only hoped would have gotten done," he says.
"When the storm hit, we were in a much better position to initiate the response and recovery phases."
Pre-planning and contractual agreements have also been key, especially between the states and the federal government. Without these plans, which were born out of previous disasters like hurricanes Rita and Katrina, states would be left to fend for themselves.
Still, Copple stresses that continuing education is critical as we prepare for the next large disaster. "I think we've got a long way to go to get to the point where everyone_s on common ground and following the incident command system," she says. "But the biggest lessons are always learned from the largest disasters."
Pro Bono: Trip to Grandma's House A Violation?
Some ambulance services provide free transports of skilled nursing facility (SNF) residents and other facility inpatients back to their homes, allowing them to visit with their families over the holiday season.These ˙Home for the HolidaysÓ programs are often viewed as a source of goodwill in the community. However, state and federal enforcement authorities, such as the U.S Department of Health and Human Services_ Office of Inspector General (OIG, which investigates Medicare fraud) see these arrangements as potential violations of a federal law called the Anti-Kickback Statute (AKS), which prohibits giving something of value to someone in a position to steer referrals of Medicare business to a health-care provider.
How do Home for the Holidays programs potentially violate the AKS? In some cases, the ambulance service may be offering this free program to induce an SNF to select it as the primary or exclusive provider of ambulance services for the facility. In such a case, or in any similar situation where these free holiday transports are tied in with any type of business arrangementƒeither explicitly or implicitlyƒin which the ambulance service receives Medicare or other federal health-care program business,it may appear to the OIG or other enforcement agencies that the free transports are merely an inducement to secure other business from the facility.And this could be viewed as an AKS violation. In addition, these free trips could be seen as a potential inducement to the patient, because their value would far exceed the OIG_s ˙de minimisÓ threshold for items of value that may be given to a Medicare beneficiary ($10 ˙one timeÓ gifts or $50 annual aggregate value).
Of course, other factors suggest such a free transport program at the holidays may not always pose a substantial AKS risk. For instance, some programs are run by non-profit services that regularly provide 9-1-1 emergency service to the facility, which usually means the facility can_t be ˙steeredÓ or influenced in their choice of 9-1-1 provider, so there_s no nexus between the free holiday transports and the facility_s selection of a primary provider. It_s also possible that the OIG would, in the absence of any explicit or implicit tying of the free transports to any other referrals, view the arrangement as harmless under the AKS where these programs are limited in scope and duration and other safeguards are put into place. The OIG also issues Advisory Opinions on whether specific arrangements violate the AKS, and anyone involved in such a program may request an Advisory Opinion on this subject. To date, no Advisory Opinions on this point have been issued by the OIG.
In short, although we_re not necessarily advocating that you abandon your home for the holidays program if it_s not tied in any way (explicitly or implicitly) to any other referrals, you should have it carefully reviewed by legal counsel knowledgeable in this area of the law. They can determine whether any potential red flags in your program may require your attention in order to be fully compliant with federal and state laws.
1. Office of Inspector General Special Advisory Bulletin: ˙Offering Gifts and Other Inducements to Beneficiaries.Ówww.oig.hhs.gov/fraud/docs/alertsandbulletins/SABGiftsandInducements.pdf
Pro Bono is written by attorneysDoug WolfbergandSteve WirthofPage,Wolfberg & Wirth LLC,a national EMS-industry law firm. Visit the firm_s Web site atwww.pwwemslaw.com for moreEMS law information.
Expert Tipfor Stress-FreePediatric EPI Dosing
Calculating and drawing up 0.01 mg/kgƒthe standard doseƒof epinephrine using the 1:10,000 solution (0.1 mg/mL) during a pediatric resuscitation can be a daunting task for any health-care provider. The next time you_re confronted with a pediatric resuscitation and need to quickly and confidently draw up and administer a standard dose of epinephrine, all you have to do is remember the acronym ˙PEDS=SD,Ó which stands for ˙Pediatric Epinephrine Dosing Story=Slide the Decimals.Ó
So what_s the story? In any code scenario, first responders need to quickly draw up the proper volume of epinephrine. To do this, start with the child_s weight in kilograms. To quickly draw up the proper volume of standard dose epinephrine, slide the decimal one point over to the left.
For example, for a 13-kg child, you would draw up 1.3 ml of the 1:10,000 epinephrine solution.
Once the epinephrine is given, in order to correctly document the amount of epinephrine administered in milligrams, start with the volume of epinephrine in millimeters that was given, and then slide the decimal one more point to the left.
For example, for 1.3 ml of epinephrine administered, document 0.13 mg of epinephrine on the code sheet.
If you remember ˙PEDS=SDÓ and the examples cited here for drawing up, administering and documenting epinephrine doses during a pediatric code, you_ll never have to endure another stressful pediatric epinephrine calculation.ƒAlson S. Inaba, MD, FAAP
Quick Take:Physio Replaces 249 AEDs, Physio-Control recently gave new 249 LifePak CR Plus automated external defibrillators (AEDs) to 41 customers to replace devices recalled by the FDA. Physio-Control spokesperson Ann Devine says the recalled devices were designed to shock a patient automatically when appropriate, but a ˙software problemÓ incorrectly directed rescuers to push a shock button (which was hidden). Physio-Control also makes a semiautomatic LP CR model that does require someone to push a shock button.JEMS
Know Your Patients:The Killer in Granny_s Purse
According to a study recently published in Annals of Emergency Medicine, between 2003 and 2006, 9,179 children under the age of six were reported to poison centers as having been exposed to prescription opiates. Most of the poisonings occurred from hydrocodone or oxycodone (Vicodin and Percocet), among other drugs. Eight of the children diedƒall of them under the age of three; 43 sustained life-threatening or disabling events; and 214 experienced prolonged but non-life-threatening events. ˙Young children are naturally curious, and most of our reports indicated that the accidental overdosing occurred when children found lost or discarded tablets, an opencontainer orpar_tially filled cups of medication,Ó says the study_s lead author J. Elisa Bailey.