In the past six years, the nation’s health-care infrastructure has been shaken by a number of man-made and natural disasters. These include the events of 9/11, the anthrax incidents that followed, the global severe acute respiratory syndrome (SARS) outbreak, and hurricanes Katrina and Rita. Superimposed on these events are the ever-present threats of pandemic influenza or some other contagion, and the ongoing risk of further acts of terrorism against our country. As first responders to all of the incidents,„EMS systems have been heavily impacted by these events.

To prepare for the next major incident, we’ve provided additional training for personnel, upgraded inventories and enhanced our communications capabilities. We’ve purchased stockpiles of personal protective equipment (PPE) and antidotes to chemical agents considered likely to be used by terrorists. However, despite these added efforts,„EMS systems and the populations served remain vulnerable because of a lack of surge capacity.

From a prehospital perspective, ˙surge capacityÓ refers to the maximum delivery of services that a system can provide if all available or potential resources are mobilized. It’s a resource every EMS system needs but few have, a point emphasized in the„Institute of„Medicine’s 2006 report Emergency Medical Services at the Crossroads. One of the report’s recommendations for achieving its ˙vision of a 21st century emergency care systemÓ was enhancing disaster preparedness of„EMS systems through increased funding and additional training of personnel. However, to make this vision a reality, a number of hurdles must be jumped.

Running at Full Capacity

First, a disproportionate number of federal and state grants are allocated to fire services, with„EMS getting a small share of what’s left. Therefore, upgrading equipment and supplemental training has been slow. In addition, renewal of grant money isn’t guaranteed. When supplies purchased with these grants run out, further funding to replace them may not exist.

Second, many„EMS systems are running at full capacity, or even above full capacity. Long waits for ambulances are increasingly common in rural parts of the country and in many large municipalities. In some cases, patients with high-priority medical complaints must wait for an available ambulance to be dispatched. This problem is further compounded by emergency departments (EDs) who divert ambulances when operating at full capacity, plus long waits for providers to turn over patients to ED staff without available rooms. Such circumstances are potentially hazardous to the patients and also hard on personnel.

The physical and psychological wear and tear on providers working in a system that constantly operates at full capacity can result in poor job satisfaction, injury and a premature ending to a career. It’s also a poor recruiting point for understaffed„EMS systems that are trying to attract or retain employees. Limited budgets for„EMS systems and a shortage of providers to hire in many parts of the country make these circumstances a continuing reality for the foreseeable future.

The public’s demand for„EMS continues to increase in many areas. The aging of the population, fragmentation of health care and lack of places to go (other than to EDs) for real or perceived acute medical issues results in increasing call volumes in many systems.

And this problem is on a good day. So what happens whenƒduring the busiest time of the busiest day of the week with all resources deployedƒthe unthinkable occurs? It could be a terrorist attack, bridge collapse, building fire or multi-vehicle crash. How should an„EMS system react, and where will it find that needed surge capacity?

No single answer will work everywhere. Each system ultimately needs to look within the organization instead of counting on the outside for a solution. Waiting for state, federal or other assets to solve immediate problems is unrealistic. Therefore,„EMS systems must make a heavy investment in their own personnel, policies and equipment. Surge capacity not only implies more ˙stuff,Ó it also implies making more of the resources you have. Providers need to be well trained, healthy and properly supervised to function more efficiently. Training should include an emphasis on multi-casualty scenarios: triage (including the use of triage tags), field expedient treatment, communications and interagency cooperation.

Drilling the Concepts

These concepts need to be drilled under a variety of conditions. An agency should try to encourage the physical health of its personnelƒpromoting fitness and healthy living habits, such as adequate rest and proper dietƒto prepare them for the physical demands of major incidents. Although physical fitness can’t always be mandated, it can be encouraged.

Finally, the agency’s supervisory staff must be well versed in the incident command system and know their own roles and responsibilities in a major incident so they can provide clear leadership.

Policy issues likely to arise during a crisis must be considered and frequently revisited. These include how the communications center will handle the inevitable increase in call volume, and what happens if call takers can’t keep up with the number of calls or if the system fails completely. Details related to calling in off-duty personnel and holding over employees who are currently on duty should be resolved.

In unionized systems, labor representatives are necessary in the planning process. The system should discuss with area hospitals an appropriate means for distributing patients based on current hospital capacities and resources. Mutual aid agreements with other„EMS systems should be established and interagency drills conducted so that issues, such as triage systems, communications and command structure, are worked out in advance.

To meet the surge,„EMS systems must have adequate supplies, with emphasis on BLS care. These include stockpiles of backboards and other spinal immobilization devices, trauma dressings, splints, and blankets in case of cold weather. Ample quantities of disposable gloves, gowns, facemasks and disinfectant agents should be available for response to an infectious outbreak, as well as appropriate protective clothing and respirators for chemical threats. There should also be a mechanism in place to restock ambulances as they run out of equipment.

In larger„EMS systems, surge capacity may involve pre-deployment of caches at several locations to minimize resupply times and a way to mobilize more transport vehicles. Most systems have at least some reserve vehicles to meet routine needs; however, if there’s a marked increase in patients needing transport, this reserve may not be sufficient. Because purchasing additional backup vehicles may be cost-prohibitive, identifying alternative means of transportation, such as the use of local transit buses or paratransits for lower-acuity patients, should be investigated.

Developing surge capacity is clearly easier said than done; it involves a significant commitment of money and time, public support and political buy-in. EMS systems should make the argument that it’s not just an„EMS issue; it’s a community issue. Having surge capacity will ultimately benefit the public under busy conditions and in the case of local or regional disasters that threaten the very survival of the community.


  1. Committee on the Future of Emergency Care in the„U.S. Health System. ˙Emergency Medical Services at the Crossroads.Ó„Institute of„Medicine of the National Academies,„Washington,„D.C.: National Academies Press; 2006.
  2. Kelen GD, McCarthy ML. ˙The Science of Surge.Ó. Academic Emergency Medicine 2006;13:1089-1094.„„„„
C.„Crawford Mechem, MD, is an associate professor and director of EMS for the Department of Emergency Medicine at the„University of„Pennsylvania (Pa.)„School of„Medicine in„Philadelphia. He also serves as the EMS Medical Director for the Philadelphia Fire Department (PFD) and is the Regional Medical Director for the„Philadelphia region for the Commonwealth of Pennsylvania Department of Health.