Have Hospital, Will Travel

When Tropical Storm Allison swamped Houston and its massive Texas Medical Center in June 2001, the rainy deluge also disabled much of the city's emergency capabilities. To take care of the day-to-day emergency needs of the city, the Federal Emergency Management Agency set up a temporary emergency department in the Astrodome. Today, however, the Carolinas Medical Center has come up with a better idea— a 1,000-square-foot, Level I trauma center housed in two tractor trailers. This trauma center on wheels has 14 patient beds, an operating room, an intensive care unit, a pharmacy, and x-ray and laboratory facilities. The brainchild of Thomas Blackwell, MD, the medical director for the Center for Prehospital Medicine under the department of emergency medicine at Carolinas Medical Center, or Carolinas MED-1, as it has been dubbed, is designed to meet the needs of patients in all kinds of emergencies, from a disaster like the tsunami that swamped southeast Asia to an incident of mass terrorism. “We've been planning this and working on it since the year 2000, way before Sept. 11,” said Dr. Blackwell. “Then it was the concept of just having a mass casualty bus where we wanted to avoid tying up a lot of ambulances going to the scene and transporting a lot of patients to hospitals. Maybe we could come up with a bus and take them there all at once. We were looking at the Toronto emergency medical system that has a concept like that.” “What we are not well prepared for uniformly across the country are the mass casualty events. It requires a mobile response.” NHTSA Administrator Dr. Jeffrey Runge Historical incidents such as the sarin gas attacks in the Tokyo subway had shown that many people could be treated at the scene, he said. “Then there was 9/11, anthrax, and discussions of quarantine and isolation. We began to ask, what does this mean for a community?” he said. “We now have 1,000 to 5,000 patients who may be isolated in a shelter. They are displaced from their homes, often without their regular medications such as those for diabetes or high blood pressure. If you can't take them to the hospital, you can bring health care to them.” Disaster Readiness “It's all about readiness,” said Jeffrey Runge, MD, the director of the National Highway Traffic Safety Administration in the U.S. Department of Transportation. “The issue is that we prepare for everyday occurrences, and our capacity for delivering medical care is based on what happens every day and every week with occasional peaks and troughs. What we are not well prepared for uniformly across the country are the mass casualty events. It requires a mobile response. In the past, the country has relied on the Public Health Service and disaster medical response teams, but I think that people are realizing that who has the biggest stake in the lack of capacity for a mass casualty event are the hospitals. One case of smallpox in an urban emergency department could wreak havoc on a hospital's ability to deliver care.”Figure: Inside the trailers are 14 patient beds, an operating room, an intensive care unit, a pharmacy, and x-ray and laboratory facilities.Dr. Runge, who was at Carolinas before assuming his federal role, said MED-1 is an interesting concept. “Enter Tom Blackwell, who has this vision that no matter where there is a need for increased medical capacity, he can deliver it,” he said. “MED-1 was designed by Dr. Blackwell from the ground up for a bargain in terms of what is usual for federal dollars. You can roll it on transport plane, and be anywhere in the world in a half a day. The challenge will be to use it properly.” Dr. Blackwell already has an idea of when the MED-1 unit would be most useful. “Hospitals would be at surge capacity,” he said. “We could relieve some of that burden. What if a hospital were the site of an attack?” Something similar happened in Florida when a hurricane wiped out three hospitals, he said.Figure: One of the two tractor trailers that house the 1,000-square-foot Level I trauma center.“That's how this thing was created. It's not just a treatment shelter,” he said. He wanted something more substantial than the tents that FEMA uses in an emergency. “We drive up, open out, and start taking care of patients,” said Dr. Blackwell. When he took MED-1 to Washington, D.C., this past June for a congressional ribbon-cutting, he and the team that staffs the unit set the hospital up in 42 minutes, “from the time the Capitol police said, ‘Set it up here’ to the time the door opened.”Figure“It's not just a treatment shelter. We drive up, open out, and start taking care of patients.” Dr. Thomas Blackwell “We could get that time down as we train,” he said. “Our goal is 20 to 25 minutes.” Not only that, the unit is designed to fit inside a cargo plane. It can be flown anywhere in the world, driven off the plane, and set up in less than an hour. That was one of Dr. Blackwell's dreams. Federal Grant A $1.5 million federal grant from the Office of Homeland Security funded the construction of the unit, but Dr. Blackwell said he anticipates that the cost now would be closer to $2.4 million with everything (anesthesia machines, ventilators, pharmacies, the laboratories, and ultrasound). An individual deployment of the Med-1 unit would include three to four doctors, 10 nurses, five paramedics, and two police or security personnel. “Who we take depends on the mission and where we are going,” said Dr. Blackwell. For example, he will be setting up the unit at Lowe's speedway in May as a training exercise to practice seeing patients. He anticipates seeing between 20 to 100 patients during the Coca-Cola 600 race. He can draw from a staff of 75 trained people that includes eight law enforcement officers who also can help set up the unit. All are part of a terrorism response team or a SWAT team and have been deputized as U.S. marshals. Dr. Blackwell said he sees a host of uses for the Med-1 unit, and as a physician in the White House medical unit said, it might be a great resource if the President traveled to an area without good medical care. “This could be used for an incident involving weapons of mass destruction that resulted in mass casualties, he said. An awning system that extends out from the hospital includes an environmentally-controlled tent that can house 100 beds. There are 14 beds inside the Med-1 unit itself. Dr. Blackwell sees the unit as a prototype upon which other communities can build to fill their own needs. Dr. Runge said that's a good idea, but he warns that planning is critical. “I think the ‘build it and they will come’ theory won't work for this particular unit. There has to be a federal deployment plan. This is not the only mobile hospital around. There is a plan for ones under control of the federal government.” However, planning is lacking for the use of the community-based units, and that concerns Dr. Runge. In mass casualties, if patients can't reach a hospital or the hospital is damaged, MED-1 comes to the site The answer will have to come from the Department of Homeland Security, he said. “Right now there is a coordination issue at the federal level among the departments of Homeland Security, Health and Human Services, and Transportation. There are several offices responsible for some aspects of EMS and first responder preparedness,” Dr. Blackwell said, adding that he hopes to be able to work out those issues to enable the departments to make best use of units such as MED-1 if a disaster strikes. At present, Dr. Blackwell is basking in the success of MED-1. Last January, he took it to Naples, FL, for the annual meeting of the National Association of EMS Physicians. “I was standing there watching people walk through the front door,” he said. “I was struck by how quickly they would say, ‘Wow!’ or ‘Oh, my.’ You could walk in and not know you were in a tractor trailer. Many said it was nicer than their hospitals. The response has been incredible.”

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