NARRATIVE

Recent hurricanes have taxed EMS resources in the Charleston, South Carolina, region, even before making landfall. Facing large-scale evacuations, EMS has been tasked with the movement of nursing home and hospital patients and individuals with medical or mobility challenges. Some ambulances may be unavailable for hours while relocating patients inland, reducing emergency response resources, while also impacting receiving communities with the population increase. Changes in traffic flow related to evacuations and impassable roads also impact local EMS operations. Additional challenges result when medical providers, including staff from dialysis centers, clinics, and home health agencies, evacuate and leave patients with minimal support and little recourse other than accessing EMS to obtain critical services.

Shelters may impact EMS when individuals have medical needs not addressed by onsite services. GPS staff may have little to no medical training and may call EMS for assistance lifting patients or other minor medical emergencies. Further, occupants of shelters may not bring all needed medications and medical devices to shelters, resulting in requests for assistance. While the provision of medical support to community shelters is a critical responsibility of EMS, it can strain a system facing other operational challenges and decreased available personnel.

Once recent storms have made landfall, emergency operations have been further impacted. EMS stops responding when wind speeds are sustained above 39 miles per h and does not resume until winds subside. Any calls received in this period are held and triaged until EMS resources can safely respond. This backlog can initially tax responders, as can an increase in EMS volume after the storm. Extensive flooding and traffic impediments have presented additional response and transport challenges, often for extended periods. Simultaneously, local hospitals have looked to reduce patient volume in anticipation of a hurricane. These infrastructure challenges impact local shelters. For example, during Hurricane Florence, 13 SMNSs were activated with 1 shelter operating for 23 continuous days due to ongoing dislocation of residents.

With the myriad of challenges faced by emergency services, alternative approaches to care and operations are critical. Telehealth applications are increasing in use, especially in South Carolina.^{Reference Ford, Cristaldi and McElligott32} Local EMS has partnered with the academic medical center to use telehealth to link EMS with physicians and other health-care providers for various needs, including neurologic evaluations and psychiatric assessments.^{Reference McClain33}

Before Hurricane Florence, agencies collaborated to create a telehealth model to support local shelters and EMS operations, including mental health emergencies. Vidyo, a Health Insurance Portability and Accountability Act (HIPAA) -compliant meeting room, creates a virtual space where patients can connect with providers for a video assessment. EMS providers at the bedside can facilitate assessment by an emergency physician (EP) and assist with vital signs, physical examination, limited point-of-care testing, and cardiac monitoring. The EP can then implement triage decisions, limited interventions, and electronic prescribing of medications, if needed. In addition to hosting secure meeting rooms, Vidyo was also selected to take advantage of the H.264 standard for video compression, Scalable Video Coding (SVC), which is effective in rural areas with limited bandwidth.³⁴ The use of real-time video to assess patients is highly dependent on the quality of the cellular connection and bandwidth availability. During hurricanes and mass evacuations, cellular towers can become oversubscribed, which limits connectivity, although prioritized first-responder networks are available.^{Reference Hochgraf, Nygate and Bazdresch35}