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Foreign Exchange DeTienne. “Their EMS, fi re, police, hospitals, the military, they’re all sort of one system, with everybody knowing what the end is and what they want to do today with this incident. They’ve done a lot toward having the same sort of sheet of paper about who does what, their national doctrine, and executing it in chaotic situations.” Single national police, fire and EMS systems facilitate integration in Israel, but the variety of players in the American model means we have to work harder at it. communication system and common database to facilitate sharing information. They train and drill together and appoint liaison offi cers for mass-casualty events. Plenty of practice keeps roles clear and joint operations running smoothly. Capacity building—The frequency of training marks one major difference between the Israeli and American systems. It’s a regular requirement for hospitals, EMS and volunteers. Each year, Israeli providers undergo simu- lation exercises and full-scale drills covering “ system is something we aspire to, but factors characteristic of our system—its variety of service providers and models; America’s loose- knit federalist approach to healthcare—inher- ently impede. We’ve come a long way with stan- dardization and coordination and learning each other’s languages in recent years, but there are still a lot of people doing different things different ways. “We have 1,061 EMS organizations in Pennsylvania alone,” says that commonwealth’s “The government agencies all seemed to have an excellent working relationship between them. It felt like the goals were uniform and everyone was headed in the same direction,” says Gary Wingrove, past president of NCEMSI and the National EMS Management Association. “It’s a much smaller place than the U.S., but it was interesting to see that everyone had plans that were well integrated and didn’t seem to have much duplication.” There’s one boss, and it drives things down very quickly... But how do I do that with 1,000 ambulance companies?” all the potential threats they face: conventional and “mega” MCIs, radiological and toxico- logical events, chemical attacks, biological outbreaks and natural disasters. The belief is that preparedness correlates: Being ready for a mass-trauma event helps prepare you for a mass-toxicological event, which helps prepare you for a biological event, and so on. The U.S. Perspective Much of this will sound familiar to American providers. Some will sound alien. The degree of integration and streamlining in the Israeli 8 JULY 2011 EMS WORLD EMS director, Joe Schmider. “Could we do a lot more with just one organization to deal with all the time? There’s no doubt about it. If they determine in Israel, ‘We have to do x instead of z,’ there’s one boss, one employer, and it drives things down very quickly. It would be a whole lot easier, but how do I do that with 1,000 ambu- lance companies?” “One thing I hope we can learn from, even though we’re a bigger country and have some different features, is the way they’re able to integrate responses among all the different agencies,” says Montana EMS boss Jim The Israelis describe their healthcare system as being on “constant alert.” That, America has found, is easier said than done. We’ve improved our planning and preparation greatly in recent years, but the reality is, a good surge today would throw many systems into chaos. Many of us still struggle to answer ordinary events, never mind extraordinary ones. “For a lot of us, surge plan is an oxymoron,” says Stein-Spencer. “We don’t truly have a surge capacity in our healthcare system, and it’s something we need to improve. It’s something we can’t defi ne narrowly, as just hospitals— we have to look at the healthcare system as a whole. We’ve started looking at utilizing things like long-term care facilities [in surges], but we’re not there yet.” “We basically don’t even have a lot of guide- lines for resourcing scarce things,” says Heilicser. “Say something big happens, and we need 50 ventilators right now. Who has 50 ventilators ready to run? If you have fewer, who gets them? Whom do you take off ventilators to accommodate those who can better use them? Those are things we think about and talk about, but we don’t always have down in policy so that it’s transparent for our communities.” If that’s you, now is the time to start working such matters out. Doing it on the fl y during a crisis will add to the chaos. And crisis can happen any time.