CHAPTER 9. MEDICAL SERVICES The types of medical services needed for a film production vary depending on the locale, available local medical resources, and the types of medical risks. TYPES OF MEDICAL CARE There are two basic types of medical care of concern in film production: non-emergency medical care, and emergency medical services. First aid is not medical care, but is emergency supportive treatment. Non-Emergency Medical Care On any film production involving large numbers of people, there will be a variety of non-emergency medical problems such as cuts, bruises, allergic reactions, minor illnesses, etc. which are amenable to normal medical care. These types of medical problems can be treated by Family Practice Physicians who are trained in basic medical care, or by primary care physicians specializing in such areas as internal medicine or surgery. Preferably, they should have passed a series of examinations to become board-certified in their respective specialties. Further information on the training of Family Practice Physicians can be obtained from the American College of Family Practitioners (see Resources). Emergency Medical Care Medical emergencies are also a potential problem on any film shoot. These emergencies can range from minor problems like sprained ankles up to major problems like heart attacks, severe injuries, or even disasters. If there are hazardous stunts or special effects planned for the film, the risk of a major medical emergency is higher. Medical emergencies should be treated by Emergency Physicians who are specifically trained to handle these types of medical problems. To specialize in Emergency Medicine, a physician should undergo residency training in emergency medicine, and must pass a series of examinations to become Board Certified in Emergency Medi- cine. Most emergency departments of hospitals have Emergency Physicians on staff. First Aid The purpose of first aid is to administer emergency supportive treatment before the injured person can get to a physician. First aid is not medical treatment. It is intended to keep the person alive until they can get definitive medical treatment. First aid can also be used to attend to minor cuts, bruises, etc. where medical treatment is not necessary. In the United States, there are a variety of state-certified levels of expertise for first aid practitioners. The lowest level is certified first responder with 40 hours of training. In increasing order of training are basic EMT (Emergency Medical Technician), EMT intermediate, EMT critical care technician, and EMT paramedic. EMT intermediate and higher levels must work under a physician's supervision. This can be by radio or telephone, and most hospital emergency departments maintain facilities for such supervision. EMT basic and certified first responder can immobilize a patient for transportation, bandage wounds, do CPR and similar classic first aid measures. They cannot give oxygen or medication, give intrave- nous solutions, read electrocardiograms, use a defibrillator, or use most other resuscitation equipment. Nurses, although often used on motion picture sets, must work under a physician's direct supervision in order to do more than carry out basic first aid. Unless they have had special training in advanced first aid, nurses do not have the training or expertise of advanced EMTs. NEEDS ASSESSMENT The first step in planning medical care for a film shoot is to undertake a needs assessment to identify potential medical risks. This assessment and subsequent planning and implementation steps should be carried out by, or with the assistance of, an Emergency Physician. Non-medical personnel are just not qualified to make the necessary evaluations and decisions. In the United States or Canada, the production company should contact the American College of Emergency Physicians for information on local emergency medical services, and help in making an evaluation. The Chairman of the nearest Department of Emergency Medicine in a university hospital should be contacted to provide information on local standards of care, emergency services, and as a referral source for other medical specialties that are available in the community. In other countries, particularly underdeveloped countries, the level of emergency and even non-emergency medical care might be well below American standards. In such cases, medical service companies specializing in providing emergency and non-emergency medical services for motion picture production around the world can be of invaluable assistance. Information on medical care in other counties can be obtained from the Centers for Disease Control in Atlanta, Georgia, the State Department in Washington, D.C., and the World Health Organization in Geneva, Switzerland. (See Appendix 4 at the end of the book.) An adequate needs assessment involves looking at a number of crucial factors, as discussed below. Script The script should be reviewed to determine possible high risk situations, such as hazardous stunts, underwater activities, and other action sequences. Once these risks are identified, steps can be taken to determine safe procedures. This was discussed in Chapter 6. Location Once the filming locations are chosen, then there has to be an evaluation of the planned locations to determine potential medical hazards. Hazards related to the filming on location could include possible safety hazards, asbestos exposure, etc. in old, abandoned buildings; accidents in mountainous areas; heat-related diseases in deserts; frostbite in cold weather conditions; drowning in rivers; and a wide variety of other hazards. (See Chapter 3) When filming on location, there is also concern about unusual local health hazards. For example, in foreign countries, there would be concern about vaccination requirements, possible current epidemics or other local endemic diseases (such as dysentery, typhoid, etc.). In addition, there would have to be an evaluation of the quality of locally available medical care and medications, and an analysis of local hospitals, clinics and emergency transportation services. If the film or television production is shot in a major urban city like New York City - either on stage or on location - then the level of local medical care should meet modern standards of medical practice. The needs assessment would then primarily involve determining what accredited hospitals and clinics and emergency transportation systems are available. This would include the location of the closest Level 1 trauma hospitals in case of major accidents, or burn centers in case of severe burns. If the local facilities do not meet modern American medical standards, then more extensive on-site medical care would be needed, as will be discussed later. In addition, the location of the nearest source of quality medical care would have to be determined. Personnel The number of people working on the stage or location - including actors, camera crew, preproduction crew, grips, etc. - and the anticipated filming time also can affect the potential for medical problems and level of needed medical facilities and care. The use of any high risk actors, such as children, the elderly, disabled, etc. should be identified so special precautions can be developed as needed. PRE-PLANNING PHASE After the initial needs assessment is done, then a detailed analysis of major hazards and risks is necessary, followed by the design and implementation of a comprehensive plan of action. Emergency Planning An essential step is the development of a plan for emergencies, which can range from individual problems, such as heart attacks, to disasters affecting many people, such as a stunt car driving into a crowd or a building collapse. This should involve meeting with local police and fire departments and other relevant authorities concerning required permits and the coordination of emergency procedures. This is especially important in connection with stunts and special effects involving fires and explosions. Meetings should be arranged with local hospital and emergency transportation authorities to arrange and coordinate speedy medical care in case of emergencies. Steps should be taken to eliminate lengthy waiting periods in hospital emergency rooms through expedited arrangements well in advance of filming. Also particular emergencies might mean transporting injured or ill individuals to different hospitals. For example, different hospitals might have intensive care units for heart attacks, trauma centers, and burn centers. If these are not available locally, then arrangements should be made in advance for emergency transportation and treatment at appropriate hospitals in other locations. If local emergency transportation systems are not adequate or speedy enough, then private arrangements will have to be made. Non-Emergency Medical Care As discussed earlier, there will be a variety of non-emergency medical problems on a film set which are amenable to normal medical care. Arrangements should be made with local hospital authorities and perhaps private physicians to provide this medical care. These arrangements should include what types of care will be provided, at what cost, and how it will be paid. If such care is not available within a short distance (e.g. in the country), then on-site medical care might be arranged. Besides providing prompt treatment, this has the advantage in many instances of decreasing costly lost time. Foreign Locations When filming in other countries, a number of other potential medical problems and risks can arise. Vaccinations, immunizations, health screening and certificates of health might have to be arranged and provided. Local medications might not be in the same dosages as in the United States and the quality might not meet current American standards. Water sources might have to be tested and perhaps arrangements made for providing safe water. The level of medical care in the foreign country might not meet the American standard of care, possibly requiring a more complete on-site medical presence than would otherwise be necessary. ON-SITE MEDICAL CARE The level of on-site medical care that is needed depends on the risks and the availability of adequate emergency and other medical treatment. Availability of Emergency Medical Care In cases of severe injuries, the time taken to receive qualified trauma care is critical. Most emergency medical service experts believe that emergency or trauma care should be available within 10 minutes. If proper medical care can be reached within this time, then first aid facilities may be all that is needed on-site for all but the most hazardous situations. This would be true, for example, in most urban settings in the United States. If reaching medical care would be delayed, then a board-certified Emergency Physician would be needed on-site. Guidelines for Medical Care on Location As mentioned, the level of on-site emergency medical care needed depends on the degree of risk and the availability of emergency medical treatment. If the risk of injury is high, for example, in a stunt involving exploding cars, and if it would take more than 10 minutes to reach a Level 1 trauma hospital, then properly qualified Emergency Physicians, and supporting equipment and personnel, should be on location in order to be able to provide crucial emergency medical treatment. If the risk is high, but proper emergency medical facilities can be quickly reached, then currently certified paramedics on-site would be acceptable. Even when there are not specific high risk situations, accidents and severe illnesses such as heart attacks requiring quick medical attention can occur. If emergency medical treatment is not quickly available, such as on remote locations (especially in foreign countries), then properly qualified Emergency Physicians are recommended, just as for high risk situations. These physicians can also provide routine medical care for non-emergency situations such as minor accidents and illnesses which, although not serious, can result in costly lost time. If adequate medical treatment is readily available, then certified EMTs should suffice for possible emergencies like heart attacks. For this situation, an EMT intermediate level would be sufficient. Although not mandated by law, supervision by an Emergency Physician is recommended. The following summarizes minimum recommendations based on the type of filming situation. These recommendations are based on discussions with Emergency Physicians and other physicians familiar with the medical needs of motion picture production. 1. Sets with no stunts, special effects or other high risk situations. U.S. - within 1 hour of adequate medical care: EMT intermediate level, preferably physician supervised. Remote U.S. or other developed countries: Board Certified Emergency Physician Underdeveloped countries: Board Certified Emergency Physician, preferably trained in tropical medicine/infectious diseases. 2. Sets with hazardous stunts or other high risk situations. U.S. - within 1 hour of adequate medical care: State-certified EMT paramedics in radio communications with a supervising physician. Remote U.S. or other developed countries: Board Certified Emergency Physician. Underdeveloped countries: Board Certified Emergency Physician, preferably trained in tropical medicine/infectious diseases. Emergency Transportation It is crucial that adequate emergency transportation be available for accidents and other medical emergencies. An ordinary car, station wagon or helicopter is not adequate. The emergency vehicle should have an advanced life support unit and must be staffed by trained personnel. In stuntman Dar Robinson's fatal accident while filming a motorcycle scene in 1983, part of the reason for his death was that he was transported a great distance in a station wagon by untrained personnel who did not know how to immobilize him properly. For high risk situations, it would not be advisable to rely on local ambulance services because of the delay in their reaching the scene of the accident. There should be one on location in case of accident, even in major cities like New York. For normal situations, it should be possible to rely on local ambulance services if they meet appropriate standards. However, arrangements should be made in advance to meet possible emergencies. In remote locations, a properly equipped emergency vehicle like an evacuation helicopter should be on hand for high risk situations, if an ambulance could not reach proper medical facilities quickly enough. Emergency transportation services should be on call for normal emergencies, unless it would take too long for them to reach the location; in that case the emergency vehicle should be on hand. Most states have regulations concerning emergency transportation vehicles. In New York State, for example, both the emergency equipment on board and the mechanical safety of ambulances must be state-certified. The ambulance must also have a 10 inch side sticker stating it is NYS certified and a signed certification logo. In addition the ambulance personnel must consist of a driver plus at least one (and preferably two) state-certified EMT Basics. Evacuation helicopters should meet the similar standards. In New York State, ambulance standards are also applied to evacuation helicopters. COST OF MEDICAL CARE Besides the effect on an individual's health, accidents and illnesses can have a variety of practical and financial repercussions, including the cost of health care, possible lawsuits, increases in liability and workers' compensation insurance rates, and cost overruns due to delayed production. A properly designed on-site medical care program can save money in a variety of ways: 1. In case of a major accident or injury, the availability of trained emergency medical personnel and needed equipment can mean the difference between a fatality and a simple filming delay. 2. Proper preventive measures and on-site medical care can prevent illnesses from breaking out or minimize the loss of production time if they do occur, especially with respect to minor illnesses and injuries which can be treated on-site. Proper and prompt medical treatment can also shorten periods of more severe illnesses, again leading to decreased downtime. 3. Decreases in work-related illnesses and injuries can lead to reduced workers' compensation rates and lower overall medical costs. 4. A professional emergency medical program can lead both to decreased liability insurance rates and to overall lower liability risk. Such a program is good faith evidence that a production company is trying to provide high quality medical care. 5. A comprehensive approach to emergency medical care can also lead to reduced costs for medical goods and services. The cost of medical care on a case by case basis is usually more expensive than a properly planned medical program with many costs worked out in advance. In addition, many production companies have spent money on equipment and supplies that were not needed. REFERENCES McCann, M. (1988). Emergency Medical Care on Set and Location. Center for Safety in the Arts, New York.