EMS: The Link Between Disaster Medicine and Sepsis

In order to save lives and protect Americans, we need to be prepared for any health security threat, including sepsis.

As disaster events increase in frequency across the United States, emergency responders are searching for ways to improve their response and protect their communities. In the Fall of 2021, four medical professionals from across the U.S. came together to address a critical gap in disaster medicine; identification and evacuation of sepsis patients. Runa Gokhale, MD, medical officer for the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention; Richard Catherina, MD, senior medical officer for the National Disaster Medical System and Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services; Timothy G. Buchman, PhD, MD, senior advisor for the U.S. Biomedical Advanced Research and Development Authority (BARDA); and Maj. Robert D. McLeroy, MD, Medical ICU Director, Walter Reed National Military Medical Center, came together under the Sepsis Alliance Institute to develop a program to help emergency responders and medical professionals improve care for highly vulnerable patients with sepsis during disasters.

Traumatic injuries are often the focus of triage, transport, and patient care during disasters and other large-scale emergency events. However, disasters often trigger or exacerbate medical issues that can be just as critical but far less obvious. Sepsis is one of the principal medical issues in this category. As front-line provider, EMS needs to be prepared for any health security threat. Paramedics and EMTs are the keys to identifying sepsis and other subtle but deadly complications, even in the midst of their field work in disaster operations.

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• Sepsis Early Recognition and Treatment in Prehospital Setting Vital for Patient Outcomes
• Assessing & Managing Sepsis in the Prehospital Setting

More than 250,000 people die from sepsis each year, more than prostate cancer, breast cancer and AIDS combined. ^1,2 Mortality from septic shock ranges from 40% to 70%.³ Sepsis is the body’s abnormal and extreme response to an infection that can disrupt the function of many systems in the body.⁴ While anaphylaxis may be triggered by, say, a bee sting; we don’t say that the patient died of bee venom. The sting hurts, but the real problem is the body’s severe over-reaction triggered by the bee venom (the allergen). Much like anaphylaxis is the body’s extreme over-reaction to an allergen, sepsis is an improper response to an infection, leading to shock (septic shock), tissue damage, organ failure and death.⁴ While sepsis is the leading cause of death in hospitals and the leading cause of hospital re-admission, this isn’t just an in-hospital or nursing facility problem.^5,6 First responders are the key to identifying and beginning care for sepsis patients early when treatment can do the most good.⁷

Why is it critical for responders to receive disaster training specific to sepsis? The challenge is that sepsis can easily be confused with other medical problems.⁸ However, if sepsis can be identified early the treatment is often simple and recovery is much more likely. If sepsis progresses until shock is obvious, it will be much more difficult to bring the patient to recovery. It is crucial for responders with the first patient contact (often firefighters) to remain alert for the clinical indicators of sepsis and to know what to do when they find them.

• Populations affected by disasters are exposed to a variety of health hazards such as trauma, burns, poor sanitation, and mass sheltering, all of which place them at increased risk of infection and, therefore, sepsis;
• Sepsis is a complex syndrome that can be difficult to recognize without the added complexity of disaster management;
• There is no single medical test or special assessment to identify sepsis. Sepsis patients are identified by clinicians and responders using their training to notice the correct clues and cues.
• In disaster settings with limited resources, it can be of particular importance to prioritize patients at the highest risk of developing sepsis;
• There are unique operational challenges associated with coordinating the evacuation of septic patients from a disaster site;
• According to the CDC, nearly 87% of sepsis cases originate outside the hospital;
• Recognizing sepsis patients early increases chances of survival. ^9,10 The chance of sepsis progressing to severe sepsis and septic shock rises by 4% to 9% for every hour treatment is delayed.¹¹

Not every infection will lead to sepsis, but when sepsis does occur, it can be a complex and deadly disruption of inflammatory, immune, and coagulation responses, resulting in a distributive, hypovolemic and obstructive shock. Sepsis often goes unrecognized until the patient is at a highly challenging, if not irreversible, stage of shock. Early recognition relies on a good systematic assessment and good clinical judgment rather than any one single identifying clinical marker or blood test.

Disasters can make the usual methods of assessment and diagnosis difficult to perform. Disasters often require a more expansive approach to patient assessment that incorporates non-clinical indicators (such as environmental factors) to address disruptions of the standard management of septic patients. In addition, disasters can saturate facilities with large numbers of casualties and force unplanned relocation of aid stations, which can delay identification and treatment of sepsis.

“Accurate and comprehensive sepsis education for healthcare providers is one of our best tools in the fight against sepsis,” said Sepsis Alliance President and CEO Tom Heymann. “The Disaster Medicine: Sepsis module was created for disaster personnel facing tremendous clinical challenges in the field and offers them that comprehensive sepsis education directly.” The module emphasizes those “elements of patient management you might not normally consider under standard practice conditions,” as Dr. Richard Catherina, Senior Medical Officer for the National Disaster Medical System and one of the module’s instructors, summarizes in his opening remarks for the training. “For personnel in the field, the key to effective clinical management is recognizing how disasters will affect the entire spectrum of patient care—from initial assessment to ultimate disposition.”

Disaster Medicine: Sepsis:

• Is a virtual and free training module for disaster medicine professionals, housed on the Sepsis Alliance Institute;
• Was developed jointly by Sepsis Alliance and the Biomedical Advanced Research and Development Authority (BARDA), part of the Office of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services;
• Reviews the foundational principles underlying all sepsis care;
• Covers the recognition and rapid stabilization of septic patients in the field;
• Details the processes involved in identifying, assessing, and prioritizing patients at highest risk of developing sepsis, as well as the challenges associated with coordinating the evacuation of patients from the disaster site;

More from the Author

• National Association of EMS Educators (NAEMSE) Position Paper on Sepsis
• Three-Step Method for EMS Management of Bus Collisions
• How to Read and Interpret End-Tidal Capnography Waveforms

Consistently using the recognized assessment criteria and treatment recommendations in this newly available training program can help responders identify sepsis when others might miss it, begin treatment before others may start, and make a massive difference in the lives of some of the most challenging and rewarding patients you will ever encounter. Interested learners can register to take this free module at their convenience.

References

1.         Rhee, C. et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA 318, 1241–1249 (2017).

2.         Center for Disease Control and Prevention. FastStats. (2017). Available at: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. (Accessed: 14th December 2017)

3.         Hajj, J., Blaine, N., Salavaci, J. & Jacoby, D. The “Centrality of Sepsis”: A Review on Incidence, Mortality, and Cost of Care. Healthcare (Basel) 6, (2018).

4.         Sepsis Alliance. Sepsis Alliance: Sepsis and Blood Poisoning. sepsis.org

5.         Liu, V. et al. Hospital Deaths in Patients With Sepsis From 2 Independent Cohorts. JAMA 312, 90–92 (2014).

6.         Kathryn Fingar & Raynard Washington. Trends in Hospital Readmissions for Four High-Volume Conditions, 2009-2013 #196. (2015).

7.         Moser, I. Protocol Based Screening Tools to Identify Sepsis Patients Transported by Emergency Medical Services. Honors in the Major Theses 155 (2017).

8.         Seymour, C. W. et al. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med 186, 1264–1271 (2012).

9.         Wang, H. E., Weaver, M. D., Shapiro, N. I. & Yealy, D. M. Opportunities for Emergency Medical Services care of sepsis. Resuscitation 81, 193–197 (2010).

10.       Femling, J., Weiss, S., Hauswald, E. & Tarby, D. EMS patients and walk-in patients presenting with severe sepsis: differences in management and outcome. South. Med. J. 107, 751–756 (2014).

11.       Halimi, K. et al. Prehospital identification of sepsis patients and alerting of receiving hospitals: impact on early goal-directed therapy. Crit Care 15, P26 (2011).