Health Service Support Considerations

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Health Service Support Considerations in Complex
Crisis Operations Responding to Catastrophic
Casualty Events
A National Preparedness Initiative
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Roles and Responsibilities of a Medical Planner

• Determines Population-at-Risk (PAR)
• Assesses Threats in the Operational Environment
• (Disease, Weapon Systems, Order of Battle,
  etc.)
• Applies Casualty Rates to Forces During the
• Execution Cycle
• Constructs the Heath Service Support (HSS)
• Architecture to Support PAR
• Conducts a Requirements Analysis to Determine
• Adequacy of HSS Construct
• Develops Resources to Support Shortfalls

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The Spectrum of Warfare
The Traditional (Symmetrical) View of Events -
Thermo-nuclear War
Global War
Low Intensity Conflict
Small Scale Contingency
Major Conflict
Casualty Production
HA/DR
Tactical
Strategic
Operational
Level of Impact
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CBRNE Agents
The Asymmetrical Perspective -
Smallpox
Nuclear Weapon
Anthrax/Plague
Casualty Production
TIC/TIM
HE Event
Sarin
Tactical
Strategic
Operational
Level of Impact
5
The New Spectrum of Warfare
No longer Linear in the same respect
In the Asymmetrical Arena -
Chemical, Biological, Radiological, Nuclear,
and High Explosive (CBRNE) Weapons of Mass
Destruction (WMD) can cross the linear spectrum
Impact based on Type of Agent and Dose (size)
used Dispersion/Delivery Method Population-at-Risk
(PAR) Concentration Weather/Ambient Conditions
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From here on in -
The New Assumptions

• What used to be absurd - in terms of threats - is
  now
• possible

2. Another attack could occur at any time,
anywhere
3. At present, were not collectively prepared
At the end of the day, we (the Medical Community)
better be prepared for our role in conducting
Consequence Management
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Medical Planning in Consequence Management
Consequence Management Defined
The a priori objective of consequence
management is to provide timely, appropriate, and
effective support in order to save lives,
relieve suffering, and assist in the mitigation
of further harm to an affected population.1
1 CJCSI 3125.01 Military Assistance to Domestic
Consequence Management Operations
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Medical Planning in Consequence Management
Wheres does the Medical Community fit in?
Considering the definition of CM, right smack
in the middle of the entire CM mission!
Many players in CM (security, engineering,
transportation, logistics and supply), however.
If the primary focus is minimizing the
effects on the human population, then
none is more important than the
medical community.
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Medical Planning in Consequence Management
New Set of Challenges for the Medical Planner
1. No Casualty Rates Based on Empirical Data
2. The Very Nature of Terrorism Mandates Response
in Crisis Mode
3. Potential for Catastrophic Casualty Events
High
4. Stress on Response and Support Resources
Should be Assumed
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Medical Planning in Consequence Management
First We Frame the Scenario
Catastrophic Casualty Event (CCE) Levels
Level I - Up to 1,000 Casualties
(Tactical) Level II - Up to 10,000 Casualties
(Operational) Level III - Above 10,000
Casualties (Strategic) Level IV Up to 100,000
Casualties Level V Above 100,000 Casualties
Then We Develop the Strategies
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Medical Planning in Consequence Management
Level I CCEs

• Requires local response
• Will stress but (may) not overburden regional
  medical
• infrastructure
• Uses pull concept for additional support
  requirements
• Difficultbut manageable deliberate planning
  prior
• to an event occurring is the key to successful
  CM

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Medical Planning in Consequence Management
Anything above a Level I CCE
Defense Executive Intelligence Review (UNCLASS)
from 12 March 2004 "The 11 March train
bombings in Madrid resulted in a mass casualty
incident that would have overwhelmed even the
best prepared disaster response system. Local
ambulance services and hospital emergency
department resources were woefully inadequate to
handle the estimated 1,500 casualties, many with
serious trauma and burn injuries."
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White House-Directed Initiatives
On-going efforts to address CCEs to date -

• Catastrophic Incident Supplement (CIS) to the
  NRP -
• Accelerates delivery of Federal resources (Push
  Packages)
• Assigns responsibilities to Federal departments
  agencies
• Provides planning assistance/coordination to
  cities
• DHHS Lead for Emergency Support Function 8
  (ESF-8), Public
• Health and Medical Support -
• Rapid delivery of the Strategic National
  Stockpile (SNS)
• Creation of national medical surge capability
  ongoing
• DoD assisting HHS with the development of
  Medical Planning
• Strategy for NSSEs and CCEs. Why? No other
  FPA has formal
• Medical Planners.

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CBRNE Agents
Addressed by CIS DHHS initiatives
Smallpox
Nuclear Weapon
Anthrax/Plague
Casualty Production
TIC/TIM
HE Event
Sarin
Tactical
Strategic
Operational
Level III CCE
Level II CCE
Level I CCE
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Problem Statement

• National Response Plan (NRP) defines an
• expectation for response to catastrophic events

• States have yet to articulate how theyll meet
  
• their own Consequence Management (CM)
• mission

• Support requirements not fully assessed

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National Preparedness Initiative
For Level II III CCEs, Consider a
Pre-established construct for Health Service
Support
Assumes -
WMD and large-scale mass casualty events
over-burden available medical facilities,
resources and personnel...
The Solution -
Pre-established, Regionalized Hospital/Clinic
Support Networks
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National Preparedness Initiative
At Execution, the Pre-defined Network-centric
Approach Leads to the Concentric Ring Concept
of Medical Management
As HSS requirements gt, concentric rings of
networked resources take on overflow requirements
to support CASTREAMs
MASCAL or WMD Event
Precludes any one group of assets from collapse
due to overburden
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National Preparedness Initiative
A Strategy Emerges -
We Need a CM Strategy that Leverages a
Bottoms-up, Pre-established Mutual Support
Approach

• Enhance response capabilities at the city and
• county level gt enhances/better integrates
• response capabilities at the state and
  regional level
• Follow this planning initiative throughout
• the medical and emergency response
  architecture,
• and eventually overall regional response
  capabilities
• are enhanced

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National Preparedness Initiative
DoD Example of Approach
San Diego Area Population 2,906,660 DoD
Population 600,000
Nellis AFB
Sacramento Area (Travis AFB) Population
1,305,082 DoD Population 87,000
Travis AFB
LA Clinic
Las Vegas Area (Nellis AFB) Population
478,434 DoD Population 66,000
San Diego
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National Preparedness Initiative
Example of Approach

Nellis AFB
Travis AFB
LA Clinic
San Diego
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National Preparedness Initiative
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National Preparedness Initiative
Creating Networks Requires Close Coordination -
Inter-agency Coordination and Communication is
the Key.

• Understanding mutually exclusive roles and
  missions
• is vital
• Defining areas of responsibility prior to
  response
• is essential

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National Preparedness Initiative
Need to expand existing structures

• Existing Regional Emergency Planner programs
  (DoD,
• DHS/FEMA/NDMS, VA) can facilitate regional
  medical
• response plans

• So far, DHHS Concurs with Initiative
• Creating Regional Emergency Coordinators (RECs)
  
• Creates Opportunity for Regional Inter-agency
  response

• Partnered with existent state, local and
  federal regional
• assets, a bottom-up seamless architecture to
  provide
• timely and effective emergency response
  emerges

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National Preparedness Initiative
Policy Implications

• Provides Architecture to Work Readiness,
  Exercise
• Preparedness Objectives
• Raises the Issue of Apportionment of Assets for
  the
• FPAs to support the Domestic Mission
• Creates Impetus to Define Homeland Readiness
• Metrics ( helps refine risk and cost
  assessments)
• Mobilization of Reserve Component Forces for
• domestic missions
• Legislative Revisions May Be Required (e.g.,
• Expansion of Homeland Security Act)

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Initiative Summary
National Preparedness Initiative

• Dramatic Paradigm-Shift Consequence Management
  
• Bottom-up preparedness starting at the
• base/installation level
• Leads to regional construct of preparedness

• Emphasizes leadership is local

• Concept Supported by Federal Partner Agencies

• At the macro-level, consider the analogy of the
  quilt
• Prepare the patch, when stitched together the
  quilt
• becomes a seamless architecture of
  preparedness

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Medical Planning in Consequence Management
WARNING Previous Conceptual Approaches Only
Useful in Certain Scenarios!
Sudden or Rapidly Developing CCEs (e.g., Nuclear
Detonation, Fast-bloom BW Events) that Progress
to Level II or III CCE will Very Quickly
Overwhelm and/or Collapse Available HSS
Resources and Infrastructure
Get Ready for the Rock-back Moment.
Why?

• Theres no such thing as available
  hospital-based
• resources
• Managed Care keeps all U.S. Hospitals at an
  average
• 94 occupied

MUST CONSIDER ALTERNATIVES TO HOSPITALS
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Medical Planning in Consequence Management
WMD EVENT
Regional MTFs source Treatment Personnel
for TRIAGE and Bed-down Sites
Casualty Stream
MTF
MTF
TRIAGE And MASCAL MGMT AREAS
BED DOWN SITES
BED DOWN SITES
Gyms, Schools, Malls
BED DOWN SITES
BED DOWN SITES
BED DOWN SITES
Bed-down Sites are Minimal Care Beds Heavy
Reliance on Self Buddy Aid
MTF Medical Treatment Facility (Hospitals)
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Medical Planning in Consequence Management
Additional Alternatives to Meet Surge
Requirements -
Requires significant community investment

• Deployable Tent Systems
• Positive Pressure Semi-rigid Hull Systems
• Polymer-panel Hardened Modularized Systems

Plus personnel, Supplies, Equipment and
Sustainment Resources
Surge Capacity Planning is the National Imperative
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Planning Pearls

• Individual Behaviors Drive MASCAL Response
• People in crisis situations often assumed to
• be irrational and panicky - FALSE
• History shows that people are usually selfless,
• often heroic, uniformly positive
• WMD events are the great unknown - but it
• will be our training that gets us through!

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Planning Pearls

• No Plan Withstands Contact with the Enemy
• Flexibility will always be the key to success
• 9-11 altered ALL existing plans BE PREPARED
• Each event will be different, each event will
  be
• unique, all will be UNPREDICTABLE
• Ability to rapidly assess and adapt to very
  fluid
• situations critical

Assess.
Adapt.
Tailor Available ResourcesRESPOND
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Planning Pearls

• Must Have Access to a Variety of Resources
• and a Wide Spectrum of Service
• Nearly always a Come as you are party
• Inter-agency coordination trust is all
  important
• Planners best weapon The Rolodex
• Effective communications with appropriate
• respondents is critical

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Summary
Medical Planning in Consequence Management

• Times have changed planning for calamitous
  events essential
• Medical Planning is a priority for consequence
  management
• related to complex emergencies
• Observing principals of the Deliberate Planning
  process improves
• response in Crisis Action events
• Developing succinct Medical Plans for disasters
  (symmetrical or
• asymmetrical) ensures the improved provision
  of HSS
• Developing Network Centric medical plans
  levels the playing
• field in emergency response situations
• Break-point events drive consideration of
  alternative HSS strategies
• Inter-agency coordination an important key to
  successfully
• mitigating crisis events

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Medical Planning in Consequence Management
Questions?? Comments???
Advice????
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