Volume: One     Issue: Three      December 2008

IN THIS ISSUE:

IS THE NAVY SHOCK TRAUMA PLATOON THE IDEAL FIELD MEDICAL UNIT?

THE ACADEMIC FELLOWSHIP IN MASS CASUALTY CARE UPDATE

A COMPARISON OF THE FEDERAL RESPONSE TO HURRICANES ANDREW AND KATRINA

Table of Contents

Is the Navy Shock Trauma Platoon the Ideal Medical Unit?

The Academic Fellowship in Mass Casualty Care Update

The Academic Fellowship in Mass Casualty Care

A Comparison of the Federal Response to Hurricanes Andrew and Katrina

What is NAAMCC?

The Fellowship in Mass Casualty Care

Call for Articles

Is the Navy Shock Trauma Platoon the Ideal Medical Unit?

Earlier this year (Volume One: No: 1) we examined the progress of up front in the dirt medical/surgical support from the Napoleonic Wars to the present from an Army view point. In that paper certain statistics were sited which could give a universal measure for whether a unit could meet the demands of moment. So let us return to that subject looking at a key formation not sited in the first paper.

The unit we will briefly review is the Shock Trauma Platoon. This formation has been functioning in the Navy/Marine environment of the 21st Century. In a similar if shorter period of transition (starting in the 90s) the Navy and particularly the Marine Reserve medical support provided by the Navy searched for solutions to provide a new deployable unit which would provide a useful battlefield function and not just a group of trained but independent corpsmen to be thrown in as needed to existing units. The result of this was a change from a classic medical battalion with a make up quite similar to an Army Medical Battalion before the Armys own reorganizations (Collecting and Clearing Companies, Surgical Company, Headquarters Co, etc) to a very streamlined organization still with the Surgical Company and Administrative units, but with a force multiplier embedded in what had been the Collecting and Clearing Companies which now fielded units called Shock Trauma Platoons.

The Shock Trauma Platoon (STP) brought the ability to stabilize fairly large numbers of casualties in battlefield/disaster situations through a more compact unit taking full advantage of the capabilities of emergency medicine physicians joined to a team of trained FMF Navy Corpsmen, anesthesia, physician assistants and in certain situations Navy Nursing. In the fluid battlefield imagined for the future the unit is fully mobile with self-contained transport and logistics, fine tuned toward the specific mission. Like other units sited in the previous paper, it can stand alone or supplement other units and when married to the Navys FRST ( a free standing surgical unit) it can reach the capabilities envisioned in the Ideal Field Medical Unit (IFMU).

In combat in Iraq and Afghanistan as well as in humanitarian missions in Africa the STP has proven its worth. Unified as noted above it has become part of the unofficial Surgical Shock Trauma Platoon. This ability to enhance capabilities of existing units has also been evident when paired with battalion aid stations and other formations. Plussed up or minussed the unit brings expertise in a very small package to the most forward situations and should be looked at by all services and perhaps all government organizations tasked with providing meaningful medical support in the worst of times.

The other key capability of the unit comes on the stand alone side. This may be its most valuable use. By serving as a unit in the most forward situations it brings a new level of care to the battlefield and equally to the disaster environment. This kind of stabilizing function potentially within yards of the action is of particular significance in the complex multi-system wounds that this war has generated. One must add that the Russians also in Afghanistan and the Israelis and Germans in peace and war have experimented successfully with truck borne modular surgical and stabilization units. And just as in Napoleons day the fact that the unit is there with them gives the soldier/marine an added morale factor, another edge that cannot be emphasized too greatly in the will of the soldier to fight.

The composite casualty statistics of the present war are not yet complete, but in one internet published study of an STP in combat the salvage rate (getting the casualty stabilized and successfully transferred alive to the next higher echelon of care was quoted as 97.5%. This is wonderfully close to the Combat Support Hospital statistic for surgery and emergency medicine of a 99.5% survival rate if arriving into the EMT with a pulse.

The Academic Fellowship in Mass Casualty Care Update

In the previous issue (no. 2) of Mascal, War, and Disaster we announced the new Academic Fellowship in Mass Casualty Care (FaMCC) along with a brief summary of submission procedures and selection process which is again reprinted below. The program is now in full swing and we urge members to look to their peers and instructors for candidates deserving this honor and recognition.

The Academic Fellowship in Mass Casualty Care

After many months of consideration the North American Academy of Mass Casualty Care announces the establishment of the FaMCC (the Academic Fellowship in Mass Casualty Care). This dignity is to recognize educational and innovative leadership in the areas of mass casualty care and disaster management. It will be awarded to candidates after review by the selection board of the Academy along with a life membership in the Academy.

The goal is to reach the teachers and educators in all fields of our domain. Requirements are simple: A nomination letter by a member of the Academy addressed to the administrative secretary by mail or email; Ten years of documented work in teaching or innovation in the field recommended; A positive review by the selection board of the Academy. There is no application fee nor any other cost than the time to nominate. Nominees do not need to be current members of the Academy. Let us all recognize the mentors among our ranks and honor them.

A Comparison of the Federal Response to Hurricanes Andrew and Katrina

In July of 1993 the United States Gen. Accounting Office on the request of Congress published a report entitled Disaster Management, Improving the Nations Response to Catastrophic Disasters After Hurricane Andrew. In September of 2005 the GAO again released a report titled, Providing Oversight of the Nation's Preparedness, Response and Recovery Activities as Regards Hurricane Katrina.

This article is a review and comparison of both these reports specifically emphasizing the area of healthcare which forms a very small part of both reports and yet a very major part of the initial phase of disaster mitigation. Healthcare as an entity is not even mentioned in the FEMA report of 1993 but numerous allusions are made to it. The general comments made by the GAO pertain to NDMS as well As ESF Eight as outlined in The National Disaster Plan. In both reports the area of command, control and communication was heavily emphasized. The 1993 report goes on to criticize FEMA in its ability and dedication to preparing for natural disasters, specifically citing the fact that there is much infighting within FEMA and lack of cooperation between the different divisions with no one wishing to be the lead in natural disaster preparedness. There is also a problem with pre-event deployment of resources and personnel as the Stafford Act requires presidential approval to be put in effect and is a post event enactment. This resulted in total inaction of the federal government prior to any catastrophic event such as hurricane Andrew and Iniki. The recommendations of the GAO included a specific natural disaster unit being developed by FEMA and closer communications between the president, the head of FEMA and the agencies tasked with response and recovery. Over the next few years these recommendations were followed and improved the agency's ability to respond to such disasters as the Northridge Earthquake, the Midwest Floods and Hurricane Marilyn.

In the post 9/11 world FEMA was again reorganized under the umbrella of Homeland Security (DHS) and effectually was castrated of all its powers with the results being the head of FEMA now reported to the Director of Homeland Security, and not directly to the President of the United States. Much of the agency's ability to quickly respond to a natural disaster was blunted. Much more specific to this article and the medical world in general, NDMS was taken out of the direct responsibility of FEMA and placed in Homeland Security.

Homeland Security is an agency that is more directed toward law-enforcement and antiterrorist activities than humanitarian response. Historically agencies of this nature are not as sensitive to the needs of medical necessity. The resultant ineffectual response to Hurricane Katrina both in shelter care and healthcare has been well documented in the literature.

Within the medical response arena one could see the results of this as NDMS and HHS placed redundant and dual medical systems in Texas and Louisiana resulting in confusion and in some cases ineffectual medical care for survivors. As many veteran Public Health Service Officers were involved in NDMS the USPHS was forced to place mid-level managers who had little to no experience in disaster management in the field. They approached setting up medical care as they did in their own agency systems and not on a crisis need. An example of this was placing PHS officers in freestanding neighborhood health centers to care for survivors when NDMS facilities already existed in the area. Since Hurricane Katrina NDMS has been placed back under the direct supervision of HHS. Recently NDMS has again been placed under the DHS umbrella.

The GAO report on Hurricane Katrina, as regards healthcare issues, states Hurricane Katrina raised a number of healthcare concerns and the preparedness of healthcare providers, their response capabilities, and healthcare agency and hospital capacity are all important in a major disaster. The national strategy for Homeland security had a specific initiative to prepare healthcare providers for catastrophic events such as major terrorist attacks. However in April 2003 we reported that many local areas and the supporting agencies may not have been adequately prepared to respond to such an event. Specifically, while many state and local officials reported varying levels of preparedness to respond to a bio terrorist attack, they reported that challenges existed because of deficiencies in capacity, communication and coordination elements essential to preparedness and response. These include workforce shortages, inadequacies in surveillance and laboratory systems, and a lack of regional coordination and compatible communications systems. Some of these challenges, such as those involving coordination efforts and communications systems, were being addressed more readily whereas others, such as infrastructure and workforce issues were more resource intensive. Generally we found that cities with more experience in dealing with public health emergencies were generally better prepared for a major disaster (such as a bio terrorist attack) than other cities, although challenges remained in every city. Almost a year later, in February 2004, we reported that all those states had further developed many important aspects of public health preparedness, no state was fully prepared to respond to a major public health threat. Specifically, states have improved their disease surveillance systems, laboratory capacity, communications capacity and workforce needed to respond to public health threats, but gaps in each remained. Moreover regional planning among states was lacking and many states lack surge capacity-- the capacity to evaluate, diagnose and treat the large numbers of patients that would present during a public health emergency.

In terms of healthcare agencies and hospital capacities, we also found major deficiencies. In May 2003 we testified that while efforts of public health agencies and healthcare organizations to increase their preparedness for major public health threats have increased significant challenges remain. Specifically we found most emergency departments across the country lack the capacity to respond to large-scale infectious disease outbreaks. For example, although many hospitals across the country reported participating in basic planning activities for large-scale infectious disease outbreaks, few had acquired the medical equipment resources -such as ventilators- that would be required in such an event. Further, because most emergency departments already were keenly experiencing some degree of overcrowding, they may not be able to handle the sudden influx of patients that would occur during a large-scale infectious disease outbreak. Regarding hospital capacity, in August 2003 we reported that the medical equipment available for response to certain incidents (e.g. as a biological terrorist incident) varied greatly among hospitals. Additionally, many hospitals reported that they did not have the capacity to respond to a large increase in the number of patients that would be likely to result from incidents with mass casualties. In our April 2003 report on preparedness we made a number of recommendations to help state and local jurisdictions better prepare for a bio terrorist attack and develop a mechanism for sharing solutions between jurisdictions. In response to this report , the Departments of Health and Human Services and Homeland Security concur with the GAO's recommendation.

We plan future work related to Hurricane Katrina regarding public health and health services, including mental health services issues. Specifically, we plan to conduct evaluations of evacuation plans for inpatient and long term care health facilities; federal, state, and local preparedness plans for dealing with the health consequences of natural and man-made disasters; and provision of mental health services for evacuees and first responders.

Conclusion: Although much progress has been made in the areas of command, control, communication and initial response to national crises there is much left to do including preparing small communities and individual hospital responses to local and national crisis. Upon examining and comparing both GAO reports we see improvement in our national response capabilities. The problem is that we tend to emphasize a bioterrorist threat, and the response to it, in our national policy. Terrorist activity is a continuing possibility. Another catastrophic natural disaster, of any of several types, is an absolute certainty. In fact natural disasters occur every year resulting in substantial social economic and financial losses, not to mention significant mortality and morbidity on the US population. At present our emphasis and preparation is not for these imminent disasters. Until we accept the fact that FEMA needs to step out of the antiterrorist and law enforcement role that it now embraces and return to a disaster response agency our country will not be prepared for its next great natural disaster.

FEMA should return to the status of an agency that reports directly to the president and is primarily responsible for response to natural disasters. Homeland Security on the other hand should primarily be involved in preparing the nation for response to bio-terrorist and terrorist activities and not be the lead agency in natural disaster response.

Editors note: The opinions expressed in this article are to spark discussion and constructive debate in the disaster management, mascal community and are not to be interpreted as the stand of the Academy, which remains interested in all views leading to improvements in mission performance and most importantly in results.

What is NAAMCC?

NAAMCC (pronounced namsee as you would guess) is the acronym for the North American Academy of Mass Casualty Care. The North American Academy of Mass Casualty Care is an academic and professional organization dedicated to the study of mass casualty care in the past and present as well as the development and discussion of new ideas to improve capabilities to provide that care now and in the future at every level. It is a sounding board for everyone in the multiple fields which interlock to save life, limb and eyesight in these most horrific environments. Membership is open to all who are or who have been involved in the active implementation of care, planning, logistics and communication related to the problems of disaster. In short from the medic, paramedic, fireman, police and military stabilizing the scene and the patient through all members of the health professions involved and all governmental officers carrying out or directing functions in this arena, this is your organization. MASCAL WAR AND DISASTER is the official journal of this organization. For additional information on joining and contributing to the purpose of NAAMCC please go to our website NAAMCC.com.

The Fellowship in Mass Casualty Care

This shall serve as the first announcement of another fellowship under development by the Academy, the Fellowship in Mass Casualty Care (FMCC). Sometime in 2009 the steering committee will complete evaluation of this project and the requirements for same will be published in this journal and on the NAAMCC website. Like the FaMCC membership in the Academy at the time of nomination will not be a requirement.

Call for Articles

Currently the journal is seeking articles from the participants in the Katrina hurricane disaster (especially those in the state and city agencies and hospitals prior to Federal arrival) and the West Coast fires of last summer and fall. The journal is interested in all accounts all the time of any incident which triggers a county, urban, or state disaster/incident plan. The journal is looking for papers on the development of the new medical reserve corps and the realignment of the Coast Guard and National Guard in disaster situations. As part of the Academy's goals the journal will also publish papers on historical disasters of the last 120 years. The emphasis will be on those where a lesson to our present or future may be evident.

Volume: One     Issue: Two      September 2008

IN THIS ISSUE:

CENTRAL GEORGIA MEDICAL RESERVE CORPS

AIR BURST NUCLEAR

UPCOMING ARTICLES

THE ACADEMIC FELLOWSHIP IN MASS CASUALTY CARE

CALL FOR ARTICLES

AND OTHER ITEMS OF INTEREST TO MEMBERS AND FUTURE MEMBERS OF THE ACADEMY

Table of Contents

Central Georgia Medical Reserve Corps

Air Burst Nuclear

Upcoming Articles

The Academic Fellowship in Mass Casualty Care

Call for Articles

Central Georgia Medical Reserve Corps

Diana Reidy, PA-C, Emergency Co-ordinator North Central Health District, Macon GA

The decisions to form a local Medical Reserve Corps unit in Central Georgia came as members in the community recognized the need to recruit, train, and maintain a data base of health care volunteers at the local level to respond to disasters or public health emergencies. The first phase in the creation of the unit began with an effort to gain community support, obtain funding, and create the framework of the organization. The CGMRC has now entered the second phase as it begins recruiting and training volunteers and continues to integrate the unit into community response plans.

Across the United States, communities experience responding to, or planning for disasters has created the realization that existing local health care systems may be overwhelmed initially, before state or federal assets arrive. Planning for some disasters, such as pandemic flu, envision scenarios in which little, if any, outside help would be available. Additionally, planning for mass dispensing or vaccination sites in response to bioterrorism requires the ability to mobilize large numbers of volunteers to staff the sites. All of these scenarios, as well as real life experience in Central Georgia with evacuees during Hurricane Katrina, underscored for public health, the need to have health care volunteers who are identified, trained and credentialed before an event.

In Central Georgia, the North Central Health District (NCHD) is one of eighteen public health districts in the state. The NCHD Office of Emergency Preparedness is responsible for emergency preparedness planning and response in thirteen counties in Central Georgia, with a population of just over a half a million people. In the event of a bioterrorist attack, or naturally occurring epidemic or pandemic, the number of health care volunteers that would be needed to dispense medication or give vaccinations to cover the population of Central Georgia far exceeds the number of public health workers in the district. This, as well as the experience during Hurricane Katrina, when a large congregate shelter was opened in the northern part of the District to house evacuees from the Gulf Coast, revealed the limitations of the district to provide the personnel to support health care and medical needs in large scale events. In addition, both public health and local hospitals realize that the ability to augment hospital surge capacity needs is another largely unmet challenge.

To address the need for volunteer health care professionals, the North Central Health District began exploring the possibility of forming a local Medical Reserve Corps (MRC) in 2006. A Steering Committee, made up of representatives from public health, community emergency response partners, local hospitals, other community organizations, and the medical school was created to begin the task. The North Central Health District agreed to house the MRC unit and as such, supplied a MRC Unit Coordinator half-time, as well as office space and equipment. The NCHD applied to the Office of the Surgeon General for registration of the Central Georgia Medical Reserve Corps (CGMRC), which was granted in November of 2006 and became the thirteenth MRC in the state of Georgia. At this time, a grant was submitted to the National Association of County and City Health Care Organizations, for a $10,000, to support the MRC, which was approved early the next year.

In the spring of 2007 the Steering Committee met to discuss the next steps in the formation of the CGMRC. The Steering Committee, which numbered about twenty-three members, agreed that a smaller committee was needed, not only to meet regularly over the next six months to create the CGMRCs mission statement, organizational structure, policies and procedures, but to provide ongoing oversight for the units operations. The Steering Committee would continue exist as an advisory body to the smaller committee and would help to raise community awareness of the CGMRC and provide input about community needs. The new committee, known as the CGMRC Executive Committee, was created with two goals in mind; to be small enough to be manageable, while maintaining broad representation from the community. The ideal composition of the committee seemed to call for individuals from medicine, nursing, and other health care professions, representation from the local medical school and nursing schools, hospitals, various emergency response partners and non health care members to balance the health care component of the committee with other experiences and perspectives outside of the health care community. Ultimately, the EC was comprised of nine individuals representing three of the districts hospitals, five health care disciplines (M.D., R.N., EMT, R.T., PH), the school of medicine, one school of nursing, an EMA Director, Citizens Corps council member/CERT trainer, the CEO of the local non-profit foundation that supported the medical center, and a member from Robins Air Force base which was located in the district and is also the largest employer in the state. The only fixed membership on the committee was the North Central Health District Health Director, whose membership was considered to be essential as both the head of the NCHD and the individual with the authority to activate the unit.

With the EC in place, creating the outline of topics and a meeting schedule to address the issues of creating the unit structure, policies and procedures was the next task. This required research, organization and preparation by the Unit Coordinator because, although the members of the EC brought knowledge and experience from a variety of backgrounds, no one, including the new CGMRC Unit Coordinator, had experience with a Medical Reserve Corps unit. Guidance on the steps to form a new unit was available from the national MRC Program on the MRC website in a Technical Assistance Series, along with a wealth of other information. The Technical Assistance Series was useful, however, it was often more helpful to have concrete examples of handbooks and bylaws from MRC units that had been functioning for a few years. Some of these were obtained on the national MRC website and others by searching local MRC websites and contacting MRC units by phone and email and requesting information. Also, local units in Georgia were a better resource than the national program with respect to issues such as volunteer liability and other state specific topics. Other resources included a Regional MRC Coordinator and, as of September 2007, a Georgia State MRC Coordinator, both of whom assist units with questions or issues.

Even with preparation, well crafted agendas, technical guidance, and examples of other units policies and procedures, creating the unit was not a simple process of cutting and pasting existing documents into the a CGMRC product. While the national program offers guidance, local units create their own mission and purpose, composition, organization, and policies and procedures, based on the community needs and unit preferences. Therefore, even with guidance and examples from other MRC units in hand, the members of the Executive Committee had to discuss and make decisions on many different issues. The first meeting consisted of an introduction of the members, an orientation to the Medical Reserve Corps program, a review of the CGMRC program to date, and an overview of the work that the committee needed to complete. The committee began crafting a mission statement for the organization. The second meeting was devoted largely revising the mission statement and beginning the discussion of volunteer policies and procedures. Ultimately, the EC met six times for an hour and a half over the course of four months to finish the framework of the unit. Certain topics, such as the code of conduct, background checks, required training, volunteer selection, and dismissal of a volunteer, took time to discuss, often requiring debate and further research to gain a consensus. Ultimately, the meetings and debate created a stronger product that had the full support of all of the EC members and allowed the EC members to work together, becoming a unified team. This seemed to be confirmed by the fact that when the core work was complete and EC members were offered the chance to reduce meetings from one or two meetings a month to one every quarter, they opted for a more frequent, every other month timetable.

During the summer, as the EC was considering issues concerning volunteer application, database and notification, the state of Georgia unveiled its state volunteer website, SERVGA. SERVGA is Georgias version of the federal Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP). This created a secure online site for applications for volunteers in Georgia for a number of organizations, including MRCs. The creation of this site meant that MRC units in Georgia can have immediate access to a secure online system that has a detailed application form, performs professional licensure checks for individuals who hold medical, nursing, or other health care licenses in Georgia and will at some point have a notification system.

While the EC continued to work on the units organizational structure and policies, the Unit Coordinator was also working to try to secure funding beyond the initial $10,000 grant from NAACHO. Although the NCHD contributed the salary for the MRC Coordinator to work twenty hours a week, other funding beyond the initial NACCHO grant was needed to pay for expenses such as the Volunteer handbook, equipment, meeting support, training, etc. A second NAACHO grant and a grant through the Homeland Security Grant Program Citizens Corps Initiative were submitted. Notification that both were awarded for $5000 came in late 2007.

By the end of October, the EC finished creating the policies and procedures, which allowed the Unit Coordinator to complete the Volunteer handbook within a few weeks. In November, a meeting of the larger Steering Committee was held to update the members on the progress made by the EC, preview the handbook, and begin recruiting. Flyers were distributed at Robins AFB and to the Bibb County Medical Society. EC and Steering Committee members were asked to recruit members from their own organizations and to spread the word about the CGMRC.

Since that time, the CGMRC has formed a Credentials Committee to review volunteer applications and has held the first Volunteer Orientation Class. The process of recruiting members is ongoing with letters and flyers being sent to various schools and organizations. Two volunteers with clinical backgrounds, one with extensive deployment experience, have created a priority list of unit equipment. Two volunteers with mental health and/or deployment experience are working together to offer the units first Psychological First Aid class. The MRC Coordinator is continuing to look for opportunities for funding, recruiting, training and partnering with community organizations in disaster planning and exercises.

The Central Georgia Medical Reserve Corps has slowly been taking shape over the past year with the help of a dedicated Executive Committee, funding from various grants, support from the Steering Committee and from volunteers willing to donate their time and energy to bring the unit to life. More work still needs to be done in many areas and as the CGMRC matures, the Executive Committee, community, experience and the volunteers themselves will help shape its course and development.

Diana Reidy, PA-C, Emergency Co-ordinator North Central Health District, Macon GA.

Air Burst Nuclear

At 11:02 am on the 9th of August, 1945 the second nuclear bomb of the nuclear age was dropped and detonated at 500 meters above its intended target. Due to bad weather, enemy air activity, and low fuel, the target was actually a secondary one, but on the ground it was the then unimaginable event of the total destruction of the city of Nagasaki, Japan. At the time this event with the previous destruction of Hiroshima effectively ended World War Two.

In hindsight the Nagasaki Atomic Bomb Museum looks at this moment with continuing horror and considers it an act of terror. Its effects continue to this day. Rather than look at old civil defense plans from the 50s or projections of todays assessments, examination of this incident reveals several universal findings and challenges which are relevant to all disaster management in a nuclear environment and all disaster/mascal workers who find themselves on the ground in this environment.

Every city has a unique geography due to the actual topography of the area and due to types of buildings (and their general layout), the road, rail, and water arteries of transportation. There is also a distribution of industrial, business and home areas which affect what the effect of a blast of this type will consume.

Shortly after the event the blast was noted to be equal to twenty thousand tons of TNT. The megaton measure persisted long after the war, but the actual nuclear blast has several different characteristics from regular high explosives. The most significant being the pressure wave which lasts barely a millisecond for conventional high explosive, but lasts a whole second in an atomic bomb blast. Along with this is the combustion brought on by the instantaneous increase in heat at the center of the blast such that anything that can burn, boil or melt does. The long term effects of radiation exposure to a portion of the survivors carries additional and future injurious results.

At Nagasaki the geography both favored and cursed the city. The target center was in a basin with low hills surrounding most of it and water on one side. The effect was to center and intensify the blast rather like a bowling ball landing on an indention that fits it. However this same feature blunted some blast and temperature effects and at Nagasaki the fire breaks already in place worked and the firestorm, which was a major contributor to results at Hiroshima, was avoided here.

The communication, electric, water and transportation resources of the city were destroyed in an instant. Medical resources to include the Nagasaki Medical University and several hospitals were likewise destroyed or severally damaged. Some concrete structures in these facilities survived as well some personnel. Having tried to treat themselves they were rapidly treating patients under extreme conditions. A great many were terminal but death was delayed for days. The loss of transportation was addressed within 24 hours with the restoration of rail service at least sufficient to move thousands of wounded civilians to surviving hospitals outside of the blast environment. These outlying hospitals were naval hospitals and each had a designated team for response to Nagasaki if needed. They were dispatched within the next 12 hours. As they were self contained with their own transportation they were in action rapidly though the size of the disaster dwarfed their efforts. The blackout of communication of the city did not effect getting the message out of the disaster for the same reason and this also differed from Hiroshima.

Descriptions of the wounded in their thousands with severe burns and orthopedic and fragmentation injuries of a magnitude which veteran physicians, nurses and hospital orderlies had never seen anything like during the whole war up to that time are heart wrenching even at sixty plus years later. Care provided was limited in the city by the remnant of supplies and beds and equipment and the knowledge base. Painfully simple but kind triage was observed with an emphasis on alleviating suffering where nothing else could be done.

Taking the opinion of the Nagasaki Atomic Bomb Museum the true numbers of casualties will never be known because the censuses of the time were incomplete; the city had a large transient work force due to the war and many of the injured left the area as soon as they could regardless of condition to get to areas of family or aid. The city could do little for itself. Estimated numbers by the museum are 150,000 split roughly evenly between dead and injured.

Other sources at the time coming in soon after the wars end placed the numbers at 195,000 for the population at that time, 39,000 dead and 25,000 injured. 95% of deaths were considered to have been due to burns. The long term radiation exposure effects were unknown.

Rounding the numbers the mortality from ground zero out to one mile was 50%. At a little less than 2 miles out from ground zero it was zero. Transposing these findings to the present this would amount to the destruction of a mid size city or the significant and perhaps mortal wounding of a large city depending on the geography.

In the present resources to communicate, triage, transport and treat will be limited or non-existent in the victim city. The resources to care for 20,000 plus significant burn patients will be staggering, absorbing far more than a regions available beds. Two or three incidents could lead to as many as 60 to 80 thousand such cases. And this is not full scale nuclear war.

References used in preparing this summary include:

The Avalon Project: The Atomic Bombings of Hiroshima and Nagasaki original text doc.
The Manhattan Engineer District Survey, June 29, 1946 www.yale.edu/lawweb/avalon/abomb
Nagasaki Atomic Bomb Museum online http://www.nagasakiatomicbombmuseum.org
Kosugel, N.M. Prompt and Utter Destruction: The Nagasaki Disaster and Initial Medical Relief. International Review of the Red Cross (2007) 89: 279-303 Cambridge University Press

Upcoming Articles

In upcoming issues of Mascal War and Disaster we will look at hurricanes Katrina and Andrew in comparison to the most recent storms as well as the old killer hurricane Camille. We will look at Shock Trauma Platoons from the perspective of small unit disaster management. We will continue to review and examine the developing Medical Reserve Corps. We will review two very different combat medical experiences in Iraq pre and post The Surge.

Most importantly we will continue to seek answers and opinions on critical questions in mascal and disaster management from the most basic unit on the ground to the highest levels of leadership and administration.

The Academic Fellowship in Mass Casualty Care

After many months of consideration the North American Academy of Mass Casualty Care announces the establishment of the FaMCC (the Academic Fellowship in Mass Casualty Care). This dignity is to recognize educational and innovative leadership in the areas of mass casualty care and disaster management. It will be awarded to candidates after review by the selection board of the Academy along with a life membership in the Academy.

The goal is to reach the teachers and educators in all fields of our domain. Requirements are simple: A nomination letter by a member of the Academy addressed to the administrative secretary by mail or email; Ten years of documented work in teaching or innovation in the field recommended; a positive review by the selection board of the Academy. There is no application fee nor any other cost than the time to nominate. Nominees do not need to be current members of the Academy. Let us all recognize the mentors among our ranks and honor them.

Call for Articles

Currently the journal is seeking articles from the participants in the Katrina hurricane disaster (especially those in the state and city agencies and hospitals prior to Federal arrival) and the West Coast fires of last summer and fall. The journal is interested in all accounts all the time of any incident which triggers a county, urban, or state disaster/incident plan. The journal is looking for papers on the development of the new medical reserve corps and the realignment of the Coast Guard and National Guard in disaster situations. As part of the Academy's goals the journal will also publish papers on historical disasters of the last 120 years. The emphasis will be on those where a lesson to our present or future may be evident.

Volume: One     Issue: One      March 2008

IN THIS ISSUE:

BREMSS DOES IT RIGHT

REVIEW OF THE NATIONAL RESPONSE FRAMEWORK

THE IDEAL FIELD MEDICAL UNIT

AND OTHER ITEMS OF INTEREST TO MEMBERS AND FUTURE MEMBERS OF THE ACADEMY

Table of Contents

BREMSS Does it Right

What is NAAMCC?

The National Response Format Reviewed

Goals and Purpose of the North American Academy of Mass Casualty Care

The Ideal Field Medical Unit

Call for Articles

BREMSS Does it Right

Most EMS organizations are ready all the time for the immediate threats to the populations they serve. All are required along with the counties they serve to have and exercise a disaster plan. Some can move smoothly between the two. How do the best do it and what makes it work? To answer that question our staff contacted one of the Souths older, larger, and continuously innovative EMS organizations.

BREMSS (Birmingham Regional Emergency Medical Services System) serves a seven county area with a total population of around one million seven hundred thousand and an operating environment ranging from extremely urban to completely rural. They cover this with approximately 2500 emergency personnel. We are using them as an example because we are now in a period of great preparation driven by federal guidelines and local needs to face threats that in some ways have not been seriously considered since the 1950s. The Birmingham Regional Emergency Medical Services System (BREMSS) does it right as we see it and to show how they got there we are interviewing Mr. Joseph Acker, EMT-P, MPH, and Executive Director of BREMSS to gain an insight.

This interview took place on Oct 30, 2007.

Interviewer Question One: What do you consider the three most important factors in BREMSSs success?

Mr. Acker: Well first let us define. Are you asking about BREMSS as a regional EMS agency or are you asking about BREMSS in the sense of the operation of the stroke and trauma system and syndromic surveillance and so forth?

Interviewer: Well the interest is in all of it, but the emphasis, as you will see in these later questions is in the way you successfully integrated into the whole rest of police, fire, etc. Our main emphasis is mass casualty. We are not trying to turn this away from your main objectives, but that is where our main interest is.

Mr. Acker: Alright that helps me then. So we are really looking at the system as a whole and thats fine. What do I consider to be the three most important factors? Im not sure were successful; I can say that too off of the front end, but if you consider what we are doing a reasonable degree of success (which I question on occasion), then the three most important factors from my standpoint are:

1. We are part of a medical school or an institution (UAB) that has a tremendous amount of depth in it and that allows us to utilize those resources whether it is the medical school, the school of public health, the school of engineering, or health inframatics. It gives us a lot more depth than if we were a free standing agency.

2. Second is the longevity of BREMSS. BREMSS has been around since the late 60s. It has a good healthy history within the community, a lot of respect because of the membership on our boards and our executive committee. Our policy makers are the policy makers in the community. The hospital administrators, the physicians, the nurses, the fire chiefs and so forthit is all of that broad based respect built up over the years and with the current membership within the community.

3. The third thing is that we have a relationship with the oversight authority, the body that has the legislatively mandated authority to cause people to act when maybe they wouldnt want to act, i.e. the Alabama Department of Public Health, because they have the regulatory authority through the State Board of Health. Our material, whether we are building a trauma plan, or a mass casualty incident plan or anything else that we do ultimately goes through and is blessed by the State Board of Health. While that may be very problematic and very bureaucratic, it gives us the legal authority to do a lot of the things that we do, but also protects the EMS community when they function to that standard of care or to a given policy.

Interviewer: That makes good sense, moving from that Question Two: What do you think are the greatest challenges that BREMSS will face in the future?

Mr. Acker: I think the first challenge that we face is like any agency and thats continued solid funding. Because we do not have a solid funding base for the Regional EMS Program we depend on the legislature. Our primary source of income comes annually with a legislative appropriation and that means youve got to fight for it every year. We need to establish a more solid funding base thats dedicated just to Regional EMS.

The second greatest challenge that we are going to face in this region is the issue of not enough available resources for acute event patients and by acute event we define patients as trauma, stroke, and cardiac. Even now we do not have enough available resources to meet the demands of not just this region, but the rest of the state and not just this state but some of the surrounding states depend on this region and the hospitals in this region to provide their tertiary care.

And if you do things in threes our third issue is that we do not have a supply of trained pre-hospital personnel that is going to be adequate to meet the needs of the region. Currently we have a large unmet need for paramedics in this region. And we cant continue at that level with that unmet need. We are already seeing some degradation of care where we have been an all Advanced Life Support System and because of the lack of paramedic availability we have some places that have sled back to Basic Life Support. We are very unhappy about that.

Interviewer Question 2a: What is your total of EMS Personnel currently?

Mr. Acker: For the region it hovers around 2500.

Interviewer Question 2b: What is your patient population?

Mr. Acker: I can tell you for Trauma and Stroke it is averaging around 4000 Level One Trauma Patients and about 1500 Stroke System Patients per year. I do not know what they are going to be for cardiac cause we are just starting this.

Interviewer: Now we are going to move a little bit away from your situation which looking from the outside we think is fantastic and you deserve the accolades. Question 3: What do you recommend as a good starting point for other EMS units in midsize communities and counties who do not have a major urban and medical center to build on?

Mr. Acker: I think they have got to put together a group of interested individuals that are willing to tackle the EMS issues. It has to be broad based. You must have EMS involved at the table obviously, but you also must have emergency management, the hospitals, and 911 at the table and they have to be willing to put together a group that will work with each other and seek the support of the state EMS, and the agency at the state level that is given the responsibility for the development of the system.

Interviewer Question 4: Do you think a return to federally mandated and funded Trauma Regions has any role in the future?

Mr. Acker: No I dont. I would put a caveat; if it is an unfunded mandate it only creates chaos. If the Federal Government is willing to put adequate funds in or increase reimbursement for hospitals who treat trauma patients then yes there is a role for that. But if it is unfunded, we dont need it.

Interviewer Question 5: Your communication and bed tracking systems are pioneers in the field. Do they warrant the cost in smaller communities?

Mr. Acker: Yes, definitely they do. And the reasoning in cost is that you look at cost not just in dollars and cents but in overall quality of life of the patients in those communities. If you know that a small hospital does not have the resources to treat a trauma or stroke patient today at two oclock, but they may have the capabilities to treat that patient tomorrow at two oclock, then it is advantageous for that hospital to get that patient when they have the available resources to treat that patient. If they do not have the available resources to treat that patient then that patient (and statistics tell us this clearly especially with trauma but they also do with stroke patients) is better served transporting to a hospital with the service even if they have a transport time of up to 90 minutes then if they go to a hospital that does not have the resource availability. And so for those smaller communities that are worried about keeping their patient load, if they have the resources and there is a communication and coordination system that allows that hospital to make its resource availability aware then it is advantageous to leave that patient in that community hospital. It is better for the patient, better for the family and better for that rural hospital. If that hospital does not have the resources to treat that patient then the reverse is true. There will be more complications, morbidity, and mortality. That is going to mean more cost for that hospital when they cannot treat that patient. So it is advantageous to allow smaller hospitals to participate.

Interviewer: Agreed and would you mind mentioning the main asset you use for that system?

Mr. Acker: We use a software system built by Forte, (in Alabaster, Alabama) and that system continually polls the hospitals as to their service availability not just beds. We do not care how many beds the hospital has. What we want to know is can a given service line in that hospital whether it is trauma, stroke, cardiac, critical care, or med-surg receive patients. Beds do not tell you that. You can be licensed for a lot of beds and not have the personnel or the equipment to maintain those beds Just posting beds does not make a difference. The issue is: you must have that service line available and everything it takes to work for the patient.

Interviewer: An excellent point let us go to the next question which takes us back into the mass casualty realm. Question 6: Are you prepared for electromagnetic pulse damage to your system?

Mr. Acker: We think so. The system has four levels of redundancy. We go hard line, wireless and through the internet. Now in addition to that if the pulse destroyed our computers, we have four levels of redundancy as far as our computer system is concerned. Two of those four levels are always turned off. Depending on who you talk to some will say that if the device is turned off at the time of the pulse and turned on afterward, it will function. We also have the ability to go to the old grease board and maintain record and communications capability that way if we have to do it.

Interviewer Question 7: How does your system integrate into the National Response Plan?

Mr. Acker: We are a part of the National Disaster Medical System. We keep track of the Hospital Resource Availability in this region, all of those hospitals that are contracted with NDMS, and we do the triaging of patients and arrange for transportation to the air site if there was a need to move patients out of Birmingham and the loading of patients on. For in bound patients we do the resource availability of the hospitals to receive patients. When patients arrive via NDMS (we got some during Katrina) we do the initial triaging and oversee the complete transport function to the hospital.

Interviewer Question 8: What do you consider the correct mix of professionals on a response/incident team?

Mr. Acker: Well I will give you an actual example of what we do when we have patients that come in from NDMS. We set up a reception center or re-triaging point. We set it up with two emergency medicine physicians to see and tag them right then. After this they go to tarps which are our location areas, staffed with nurses and paramedics, but primarily paramedics except for our pediatric area. In our pediatric area we will bring the Pediatric Intensive Care Transport Unit with respiratory therapists and emergency medicine pediatricians and nurses. They will maintain that tarp. Patients can be re-triaged off a tarp such as downgrading to green or yellow. And then we provide an overall coordination with the transport team and route those out on the basis of that. Bottom line is two emergency medicine physicians if we have the availability of it for initial triage, nurses and physicians for pediatric, but primarily nurses and paramedics for all others. ALS personnel will maintain the rest. If we did not have the two physicians to do our triage then we would put two paramedics in there.

Interviewer Question 8a:. What did that total out to when you did it?

Mr. Acker: We were running about 30 people by the time we staffed all of those tarps including the records keeping people and not counting the transport crew.

Interviewer: You have managed to do something that a lot of cities still cannot not do, you have interservice communication. I could name several major cities right now where the Police, Firemen and EMS cannot talk directly to each other.

Interviewer Question 9: How did you unify your interservice communication?

Mr. Acker: We have two levels of that. We are in an interesting situation because the Southern Company which is Georgia Power, Alabama Power, Gulf Power, and Mississippi Power put in a communication system and made their system available to us. It is an industrial grade communication system; it has several fail safe drops in it. It is also an 800 charging system, a trunk line that gave us the capability to put every one into the same 800 system before people started building out their own creating fragmentation. The other thing we have within the Trauma Communications Center is consoles that allow immediate intraoperability even to those places that elected to stay with vhf communications. We can tie them in to the 800 trunking system and tie them in even though they do not have that. We have centralized that. We do it on a daily basis so people are used to working with the system.

Interviewer Question 11: Several years ago a couple of federal agencies looked at the possibility of major flooding or earthquake destruction in several southern regions including your own. In the event of major flooding or earthquake destruction of the road system how will you move your resources?

Mr. Acker: Meaning how would we move patients to the appropriate hospitals or how would we move patients out of here?

Interviewer: All the above.

Mr. Acker: We would fall back to the public transit system. We have the ability to utilize the max bus capabilities here. We would transport patients that way if they could be transported by ground. If they are going to have to be transported by air then we would depend on NDMS and the ability to move these patients to the air site which would be one of the three main airports here. We will become very innovative. This will sound funny to a lot of people but one of the biggest potential dilemmas we face is inclement weather like a major blizzard like we had in 1993. 18 inches of snow to people who are used to taking care of snow is not much. But for us in the South we were moving people with tractors and four wheel drive vehicles, things we had never had to be involved with. So we worry about that probably more than anything else.

Summary

In summary BREMSS owes its strength to a strong working relationship with the city and state governments and services formed over decades, a unique and highly productive relationship with the UAB Medical School and Hospitals, a common communication system for fire, police, and EMS as well as a dedicated and redundant tracking system for key lines of hospital service (capability to treat). As all of these are exercised all the time, the move from daily operation to mascal is likewise automatic. Indeed BREMSS does it right.

What is NAAMCC?

NAAMCC (pronounced namsee as you would guess) is the acronym for the North American Academy of Mass Casualty Care. The North American Academy of Mass Casualty Care is an academic and professional organization dedicated to the study of mass casualty care in the past and present as well as the development and discussion of new ideas to improve capabilities to provide that care now and in the future at every level. It is a sounding board for everyone in the multiple fields which interlock to save life, limb and eyesight in these most horrific environments. Membership is open to all who are or who have been involved in the active implementation of care, planning, logistics and communication related to the problems of disaster. In short from the medic, paramedic, fireman, police and military stabilizing the scene and the patient through all members of the health professions involved and all governmental officers carrying out or directing functions in this arena, this is your organization. MASCAL WAR AND DISASTER is the official journal of this organization. For additional information on joining and contributing to the purpose of NAAMCC please go to our website NAAMCC.com.

Review of the National Response Framework

History

No comprehensive plan for federal emergency response existed until 1979 when President Jimmy Carter signed an executive order creating the Federal Emergency Management Agency (FEMA). Prior to that, national emergencies were handled by the federal government based on military districts and contingency hospital plans. FEMA was created to absorb domestic emergency response duties from multiple government agencies and begin to unite existing response plans. In 1988 another step forward was taken with the passage of the Robert Stafford Act. This act established a system and pool of monies allowing the federal government the ability to offer assistance to state and local agencies. By law FEMA was the only agency that could distribute federal assistance through the Stafford Act and was also tasked to develop and administer a Federal Response Plan (FRP) bringing multiple federal agencies under a single response umbrella during times of crisis.

In direct response to the attacks 9/11/01 The Department of Homeland Security (DHS) was established and absorbed FEMA as part of the massive reorganization of governmental agencies and resources. This removed the head of the agency as a cabinet level post and reduced its ability to rapidly and efficiently respond to domestic disasters as illustrated by its performance during hurricane Katrina, Wilma and Rita. In an effort to further streamline and enhance the ability of federal response during a time of national crisis the National Response Plan was created to replace the FRP and the Director of Homeland Security was tasked to implement and administer it. This year to continue the evolution of our ability to respond to crisis of national import the National Response Framework was released and goes into effect March 22, 2008.

DEFINITION

The National Response Framework (NRF) is an all Hazards plan built on the concepts of the National Incident Management System (NIMS). The plan establishes a comprehensive approach to domestic incident management to prevent, prepare for, respond to and recover from terrorist attacks, major disasters (both man made and natural) and other national crises. The National Response Framework is based on five guiding principles: 1. engaged partnerships, 2. Tiered response, 3. Scalable, flexible and adaptable operational capabilities, 4. Unity of effort through unified commands; and 5. Readiness to act.

NIMS creates a doctrinal framework for all agency and jurisdictional levels (regardless of the cause, size or complexity of the emergency), which require a clear-cut, transparent chain of command and delegated strategic and operational responsibilities. The NRF and NIMS integrate the capabilities and resources of Federal and local agencies, nongovernmental organizations and the private sector into a seamless national framework for domestic incident preparation, response, mitigation, and recovery activities. The NRF is conceived and designed with the idea that incidents are best handled at the lowest jurisdictional level allowing first responders and specific authorities to perform their responsibilities without impediment.

CONCEPT OF OPERATION

The implementation of the NRF is both scalable and flexible. This allows sections of it to be activated in response to the needs of a particular situation. Actions may range in scope from situational reporting and incident management to full implementation of Incident Annexes and other coordination and response mechanisms as outlined in the Base plan. The plan is designed to be activated when State and local resources and capabilities are overwhelmed. When this occurs the Governors of individual States may request Federal assistance. The Stafford act requires that initiation and activation of Federal resources must be done only on specific request from local authorities.

NRF ORGANIZATIONAL ELEMENTS

The NRF establishes multi-agency coordinating structures at the field, regional and headquarters levels that integrate Federal, State, Local, Tribal, nongovernmental organization and private sector (the plan has an annex on private sector coordination) efforts. The plan addresses site specific, regional and national actions needed to avert or prepare for individual or multiple incidents and potential subsequent events.

HEADQUARTERS ELEMENTS AND FUNCTIONS

Domestic Readiness Group (DRG): This group develops and coordinates national policy in anticipation of, and response to crises that cannot be resolved at lower levels. The DRG meets on a regular basis with the White House but may also be convened at the request of one of its members.

Incident Advisory Council (IAC): The IAC is a tailored group of senior federal interagency representatives that adjudicates matters at the level of the National Operations Center and provides strategic advice to the Secretary of Homeland Security during an actual or potential incident. Affected states may be represented in the IAC through a state liaison to the IAC.

National Operations Center (NOC): The NOC links key headquarters components and is comprised of 5 sub-elements: Interagency watch, National Response Coordination Center, Information and Analysis Component, National infrastructure Coordination Center and the Operational Planning Element.

The Interagency Watch (NOC-Watch) fuses law enforcement, intelligence, emergency response and private sector reporting. This is a standing 24/7 interagency organization that facilitates information sharing and operational coordination with other federal, state and local agencies and their Emergency Operations Centers (EOC).

National Response Coordination Center (NRCC): The NRCC monitors developing incidents and supports the efforts of regional and field components in coordination with Regional Response Coordination Centers (RRCC) including deploying national level specialty teams, initiating mission assignments and reimbursable agreements with other federal agencies. It also resolves resource support conflicts forwarded by the Joint Field Office (JFO).

National Infrastructure Coordination Center (NICC): The NICC monitors the nations critical infrastructure and key resources (CI/KR) on an ongoing basis. During an incident the NICC provides a forum for information sharing across key resource sectors. This requires close communications and coordination with the private sector, local and national resource agencies.

Interagency Planning Element (Planning): Planning conducts strategic level operational incident management planning and coordination. This includes all activities relating to the preparedness, prevention and protection operations of an Incident of National Significance.

Strategic Information Operations Center (SIOC): The SIOC is an FBI led initiative that is the operational control center for all federal intelligence, law enforcement and investigative activities related to domestic terrorist incidents or credible threats, including leading attribution investigations. The SIOC serves as a clearinghouse to help collect, process, vet and disseminate information relevant to law enforcement and criminal investigations in a timely manner. The SIOC maintains direct connectivity with the NOC and IAC.

Principal Federal Official (PFO): The PFO is the Federal official designated by the Secretary of Homeland Security to act as his/her representative locally to oversee, coordinate and execute the NRP responsibilities as outlined in HSPD-5. The Secretary is not limited to selecting a DHS employee for this position. A PFO may be designated in a pre-incident mode based on threat or other considerations. PFOs are usually incident specific and occupy no other roles or responsibilities that will detract from overall incident management, although, in other than a terrorist activity, the role PFO and Federal Coordinating Officer (FCO) may be merged to facilitate synchronized federal activities.

Field Level or Regional Activities: A large number of incidents can be managed utilizing Regional resources with only headquarter level monitoring. In large scale incidents a multiagency coordinating facility will be established to manage and monitor the delivery of Federal Resources to the affected area.

REGIONAL RESPONSE COORDINATION CENTER (RRCC)

The RRCC is a standing operation maintained by FEMA that manages regional response efforts, establishes Federal priorities and implements local federal programs until a JFO can be established. The RRCC establishes communications with the affected State Emergency Operations Center (EOC) and the NOC, deploys and supports the Emergency Response Team-Advance Element (ERT-A), assesses damage, writes and disseminates initial situational reports (sit reps) and issues initial mission assignments.

Joint Field Office: The Joint Field Office is a temporary Federal Facility established locally to provide a central point for Federal, State, Local and tribal executives with responsibility for incident oversight, direction and/or assistance to effectively coordinate protection, prevention, preparedness, response, mitigation and recovery activities. The JFO is central to the NRF initiative and is a scalable organizational structure of the NIMS during pre-incident and post incident management. The JFO does not manage on scene operations, instead the JFO focuses on providing support to the Incident Command Structure (ICS) on scene and conducting broader support operations that may extend beyond the incident site. The JFO is divided into the following sections: Unified Coordination Group: JFO activities are directed by a Unified Coordination Group chaired by the PFO and may include the Senior Law Enforcement Official (SFLEO), Federal Resource Coordinator (FRC), and/or other Senior Federal Officials (SFO). This group has the responsibility to establish priorities, allocate resources, resolve policy issues and provide strategic guidance.

JFO Coordination Staff: The JFO structure is normally divided into the following areas based on the magnitude and type of incident. Safety: Ensures the safety and health of personnel in the JFO Legal Affairs: Serves as the primary legal advisor to the PFO and JFO Coordination Group Equal Rights Officer: Serves to promote a discrimination-free workplace Security Officer: is responsible for safeguarding JFO personnel and the facility Infrastructure Liaison: is the principal advisor to the PFO regarding CI/KR related issues. Defense Coordinating Officer (DCO): serves as DODs single point of contact at the JFO. External Affairs Officer: supports the JFO as the contact point for all communications with external audiences.

JFO Sections: A typical JFO contains four sections (the JFO may expand or contract based on the needs of an ongoing situation). Operations Section: The Operations Section coordinates operational support to on scene incident management efforts. This section is divided into three branches: security, law enforcement investigations and response and recovery. It may add or delete branches as called for by the magnitude of the situation being responded to. Planning Section: The Planning Section provides for overall situational awareness, and the determination of areas requiring long term attention. The planning section also provides for technical and scientific expertise. Logistics Section: provides for and coordinates resource ordering and accountability, facility setup and maintenance, facility and transportation operations, information and technology services and other assorted management services as needed. Finance and Administration Section: is responsible for fiscal management, tracking of all federal costs while adhering to all federal statutes related to the management of federal funding. The chief of this section is usually the FCO.

At the heart of the National Response Framework are the Emergency Support Functions (ESF) and the annexes which outline them. ESFs are a carry over from the original Federal Response Plan and are the means by which missions are tagged and carried out by the various agencies involved in the mitigating incident. Each ESF is assigned a particular role during a national crisis and representatives of the coordinating agency (usually senior management personnel) may be duplicated at each level of response e.g. NOC, JFO, EOC etc. ESFs may be individually activated dependent on the size and magnitude of the incident being responded to. ESFs may also have multiple agencies/organizations supporting their mission as outlined in the NRF. At this time only one NGO is tasked in the NRP/NRF and that is the Red Cross for shelter management. Current emergency response functions are:

ESF 1: Transportation, Coordinated by the U.S. Department of Transportation ESF 2: Communications, Coordinated by DHS/ National Communications System ESF 3: Public Works and Engineering, Coordinated by DOD/ Army Corp of Engineers ESF 4: Firefighting, Coordinated by the Department of Agriculture ESF 5: Emergency Management, Coordinated by DHS/FEMA ESF 6: Mass Care, Housing and Human Services, Coordinated by DHS/FEMA ESF 7: Resource Support, Coordinated by the General Services Administration ESF 8: Public Health and Medical Services, Coordinated by the Department of Health and Human Services ESF 9: Urban Search and Rescue, Coordinated by DHS/FEMA ESF 10: Oil and Hazardous Materials Response, Coordinated by the Environmental Protection Agency ESF 11: Agriculture and Natural Resources, Coordinated by the Department of Agriculture ESF 12: Energy, Coordinated by the Department of Energy ESF 13: Public Safety and Security, coordinated by the Department of Justice ESF 14: Long Term Community Recovery, Coordinated by DHS/FEMA ESF 15: External Affairs, Coordinated by DHS

Other major teams and functions that are authorized by the NRP include:

Emergency Response Team (ERT-A): provides rapid response to the event and collects damage reports, gauges Federal support needs and gives an overall assessment of the situation;

Federal Incident Response Support Team (FIRST): The FIRST deploys to the situation to support state and local functions in the early part of a crisis;

Numerous other task related teams may be deployed by individual agencies or DHS in the course of a disaster.

The actual tactical, on the ground operations, in a man made or natural disaster is located in the Incident Command Post (ICP). The structure and actions of the ICP are outlined in FEMA independent study program 100 and 200 which is available on the FEMA website http://fema.gov.

SUMMARY

In an catastrophic event that requires Federal intervention, and on the request of state, tribal, or local authorities the NRF is activated bringing together the combined forces and financial resources of multiple government agencies under a single operational umbrella. This allows for vertical and horizontal communications and control of federal, state and private sector resources. It is very important to understand that Federal intervention does not supersede or usurp Local Authorities as they respond to the emergency, but is rather a plan to supplement the nations ability to handle events of a catastrophic nature beyond the resources that are available to individual communities or states.

Goals and Purpose of the North American Academy of Mass Casualty Care

First the academy shall be an academic and professional organization which unites all participants in disaster management from the standpoint of recovery and care of patients (casualties).

The academy will divide for organizational purposes into independent but allied colleges of each area of concentration (i.e. medicine and surgery, allied heath, fire and hazardous materials, law enforcement, logistics, administration, etc).

The one requirement for membership is to be in or to have been in mass casualty care either in an applied or teaching environment. By definition training in disaster care or management of any kind so qualifies the individual for membership.

The academy is and will remain supportive of but independent from other organizations, government, academic and business which are involved in the disaster/mass casualty environment.

Members of the academy will maintain and develop the official cyber journal of the academy in a manner that delivers useful information and concepts at all levels of mass casualty care and disaster management.

Editors note: From time to time Mascal War and Disaster will reproduce a lecture for our readers if the content and theme appear uniquely appropriate to purpose of this journal and the goals of NAAMCC.

The Ideal Field Medical Unit

Taken, adapted, and expanded form a medical grand rounds lecture given in Iraq

At the end of a career it is appropriate to take ones body of knowledge and where it is useful to pass the information and recommendations to those who come after. Having spent most of my active duty time in field environments both for war and training I suggested this topic when the Chief of Professional Services wanted a subject for presentation from the emergency services.

This is not a history, not a wire diagram, not a permanent fix; but a flexible solution to present and evolving military medical and surgical threats. Historically governments provide medical support to their armies at the point that the Army is no longer a mass levy and the time to raise, train, and equip such a force is greater than the time to raise the levy.

Preserve the Fighting Strength, this tradition predates the Roman army surgeon and persists to this day. Modern military medicine and organization begin with Napoleons Armies through the efforts of his surgeon general, Dominique-Jean Larrey, later Baron Larrey. His service with Napoleon started in Egypt and ended at Waterloo.

Realizing that rapid access to medical and surgical care saved lives and improved morale he developed a three tiered system consisting of dressing stations, regimental medical hospitals, and convalescent hospitals. The first two of these were connected with the fighting line by the famous Flying Ambulances. While most of us have only seen pictures of these lying shattered on the snow covered roadsides depicted in various paintings of the retreat from Moscow, in action these light weight purpose built carriages could get a wounded soldier from the site of pick-up to the site of life saving surgery in minutes, a breakthrough for the time which allowed both decreased time to surgery as well as the opportunity to study some conditions such as pneumothorax which had not been possible before. The first two medical units noted were mobile. The convalescent hospital was fixed and adapted to the structures available in a campaign area.

The second great advance in the 19th century occurred during the Crimean War as military nursing through the efforts of Florence Nightingale and her associates revolutionized British Army Medicine through basic sanitation and clean dressing changes. At this time the two main medical units are the evolving regimental hospital and the larger convalescent hospital. Then came Americas Civil War.

Two gigantic mobs thrashing at each other as they bumble their way across the countryside, the elder Field Marshal von Moltke described the two armies fighting. Medically however the situation is much better, fully equipped units on both sides have Regimental Hospitals and behind and in support of these are Field Hospitals and larger convalescent hospitals variously named. The largest Southern one is in Richmond and is considered by both sides the best during the war. It has a multi-thousand patient population. Soldiers and POWs get the same operations performed by the same surgeons. Post-ops are different due to locations.

In hindsight some believe that the Regimental Hospital was not ready for the next challenge to the Army, the Spanish American War. As has happened before the institutional memory had been lost and the impetus to aggregate and move large forces overcame caution. Disastrous camp fevers secondary to poor sanitation and supply led to the deaths of thousands of soldiers and animals before leaving the US. Taking the 71st New York Volunteers as an example regiment 1000 men mustered for the war. According to preserved records 80 plus a few men (going to and from the battle) are lost at San Juan Hill in dead and wounded, their only combat losses.

Yet the regiment musters out at the end of the war only 350 men. The rest are casualties of fevers and tropical disease. In truth the regimental hospital was alive and well organized for the mission it was expected to perform. Manned by 1-2 surgeons, 1 physician, hospital orderlies, a dentist, and 1 veterinarian (ideally) it had performed for over 30 years of sputtering combat in the west. It rated 40 beds. Perhaps the dryness of the West had obviated the need and therefore the capability to treat tropical disease even to the standards of the time. Research by the direct ancestor of the Medical Research and Development Command subsequently solves the problem of the major tropical fevers and sanitation requirements for the Army.

The next advance occurs in the First World War. Static warfare unintentionally allows the development of a more sophisticated form of medical support. In the Second Infantry Division three regimental hospitals combine to form the first Medical Battalion (2nd Med Battalion, 2nd Infantry DIV). Dressing/Aid Stations are with or directly behind line battalions, collecting and clearing companies man additional points concurrent or just behind these. Field Hospitals are close to the front, but ideally out of field gun range and behind these are convalescent/General Hospitals.

Post World War One there were excellent plans for subsequent medical support, but the major disarmament which followed the war also de-emphasized the necessity of implementing these. World War Two changed all that. Now war was mobile with huge numbers of combatants and equally huge casualties. By the end of the war a five tiered system of hospitals stood in theater starting with the MASH, then CSH, EVAC, Field Hospital, and General Hospital while back in the states giant convalescent hospitals like the 20,000 patient facility at Tuscaloosa, Alabama continued care and needed surgery for the returning wounded. At this time the Augmented Surgical Team also called auxiliary or augmentation surgical team also came into being. The cold war followed the hot so the organization maintained this time and so when the war went hot again in Korea Army Medicine was ready with a proven organization.

The same multi-tiered system was used in Korea and again augmented surgical teams proved their worth. And the Flying Ambulance was back, and really flying now, as a helicopter, with the same advantage of getting the wounded to surgery faster. Then came Vietnam.

In some ways this was an anachronism, mobile warfare with fixed facilities. The helicopter ambulances started over flying front and mid-level medical formations when possible cutting again the time from wounding to life saving surgery. This leads to a major rethinking of what is needed in modern battle in the post Vietnam period.

During the period between Vietnam and Desert Storm, the Medical Battalion is replaced and the Field, EVAC and MASH are slated for retirement. An effort is begun to derive a new small, easily transportable surgical unit. Two lines of development occur.

The Medical Research and Development Command looks at adapting an existing organization labeled the FPSU (French Parachute Surgical Unit). This is an originally US airborne unit given to the French at the end or the WWII and utilized and modified by them for the next 30 plus years. It is designed to function for 72 hours in support of a brigade. It is self sufficient except for water and commo. It has a 20 bed capacity and stores on 2 standard pallets. The unit as provided has a proven combat and humanitarian mission record.

The FST (Forward Surgical Team) is derived at Fort Sam Houston from a surgical committee drawing up list of required combat operations and then a list of supply and personnel sufficient to do them, also aimed at 72 hours of function. Both of these proposed units amount to an equipped augmented surgical team. In the competition between the FST and FPSU the FST drops all holding capacity allowing its original equipment requirement to fit on one airborne pallet. The FST is subsequently fielded by the AMEDD and the FPSU is taken by Special Forces who are hampered in its fielding by budgetary constraints.

Then came Desert Storm.The Gulf War was again a multilayered medical support environment. 20,000 medical troops were dispatched to theater. The casualty model used was the German Eastern Front. Preparations were made for 2000 casualties a day in major tank battles. But the casualties were minimal. The hospitals were too immobile. The FSTs were underutilized. A new wave of reorganization began.

Post Desert Storm slices of Combat Support Hospitals were sent to Somalia and Bosnia. Based on their experience the Forward Support/Surgical Hospital (FSH) was briefly considered. This unit capability was then designed into the MRI CSH. The Medical Re-organization or Re-engineering Initiative originally envisioned a 100% mobile hospital that could kick out an FST like unit in front of it, behind that an FSH like unit (a mini-MASH), and behind and repeatedly closing up with these a 164 bed hospital unit with a 30 day self contained supply for everything. Modules for combat and humanitarian missions would be provided dependent on purpose.

But to borrow from the old Monty Python show, Now for something completely different..

What percentage of US combat soldiers involved in close combat actually fire their weapons at the enemy?

What percentage of troop casualties render a unit broken?

Based on the HERO studies (often challenged, but never disproved) begun in World War Two and re-substantiated in the Korean War the answer to the first question is 7 to 10%. Dupuys studies in understanding defeat indicate over a wide range of units and times that a 10% loss over a 24 hour period is sufficient to break a unit, though much larger losses can be absorbed if spread out over a longer period.

Now suppose a 2000-4000 man assault force sustains 200 to 400 in killed and wounded, assume 30% of these dead (60-120) and 70% wounded (120-280). For argument ½ require surgical intervention (60-140) and ¼ to 1/3 require emergent surgery or procedures (15-46). We are looking at two operating rooms, 4 tables, 2 general surgeons, one orthopedic surgeon and a full days work. The 164 bed unit and above is too big and the FST an attached is too small. A 40-44 bed unit with the above capability fits just right.

It will be said by some that we are doing this now. But the truth is we are still taking slices and a true re-design with an appropriate TOE including 100% mobility with all requirements self contained at this level does not exist. In a sense this is a return to the regimental hospital (augmented) and used as a building block to derive a medical unit of size to fit mission. Can this be carried further to enter into the civilian disaster/mass casualty environment?

I would say yes. Looking at the make-up of the old DMAT teams and subsequent non-military medical reserve units now evolving under the auspices of Homeland Security we see a similar though slightly larger (in personnel) unit and again these large convalescent hospitals. If instead one considers the IFMU manned under state public health authorities for training and deployment within state and under the direct authority of the National Guard for interstate use voluntarily as many states do for fire services now one can develop a medical network which is sustainable as well as flexible due to size. As the military already does, one can add Public Health and Sanitation units, Epidemiology, medical ward units etc as needed. These units can be prepositioned not in the cities of concern but near them and kept small enough and light enough to minimize the lift required to move them. Because when major disaster occurs, natural or manmade, this early ability to get to the scene with a real capability will be essential to improve survival that is other wise just a sorting out of who will live or die.

Call for Articles

Currently the journal is seeking articles from the participants in the Katrina hurricane disaster (especially those in the state and city agencies and hospitals prior to Federal arrival) and the West Coast fires of last summer and fall. The journal is interested in all accounts all the time of any incident which triggers a county, urban, or state disaster/incident plan. The journal is looking for papers on the development of the new medical reserve corps and the realignment of the Coast Guard and National Guard in disaster situations. As part of the Academys goals the journal will also publish papers on historical disasters of the last 120 years. The emphasis will be on those where a lesson to our present or future may be evident.