Medical Response Capabilities

Journal of Homeland Security and Emergency Management Volume 9, Issue 2 2012 Article 1 Medical Response Capabilities to a Catastrophic Disaster: “House” or House of Cards? Donald A. Donahue, University of Maryland University College, American Academy of Disaster Medicine, Diogenec Group Evelyn A. Godwin, Diogenec Group Stephen O. Cunnion, Diogenec Group Recommended Citation: Donahue, Donald A.; Godwin, Evelyn A.; and Cunnion, Stephen O. (2012) "Medical Response Capabilities to a Catastrophic Disaster: “House” or House of Cards?," Journal of Homeland Security and Emergency Management: Vol. 9: Iss. 2, Article 1. DOI: 10.1515/1547-7355.2029 ©2012 De Gruyter. All rights reserved. Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Medical Response Capabilities to a Catastrophic Disaster: “House” or House of Cards? Donald A. Donahue, Evelyn A. Godwin, and Stephen O. Cunnion Abstract Planning for a disaster is often influenced by the dual factors of perception of probabilities and current technology. Response design is built upon assumptions on the size, scope, and severity of the catastrophe. Yet, history documents myriad disasters that far surpassed even the direst predictions. Similarly, response mechanisms build upon what is in use at the time in terms of equipment, transportation, and employment. Current planning factors may prove inadequate to address a disaster of historical proportion. The authors offer a review of significant disasters as a measure of the potential scope of needed medical response and the inherent shortcomings therein. They call for a more comprehensive approach to medical response planning. KEYWORDS: disaster response, surge capacity, medical care Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 1 Background There is a natural predisposition to not prepare for disaster (Redlener 2006). What can be termed “disaster denial” permeates our culture. Preparedness malaise can be passive: coastal residents often fail to heed evacuation orders in the face of a hurricane (Dash and Hearn Morrow 2001); and despite robust recommendations by the Centers for Disease Control and Prevention (CDC) and the World Health Organization, less than a quarter of the U.S. population sought and received vaccination against the H1N1 pandemic—well short of even regular influenza season target rates (CDC 2010). Preparedness malaise can also take the form of active opposition that can be misinformed and, in the extreme, deadly. One of the many objections voiced against the anthrax vaccination program launched by the Department of Defense (DoD) was that it was unnecessary because no one had previously employed anthrax as a weapon. That assertion was proven tragically misguided in October and November of 2001 (U.S. General Accounting Office [GAO] 2003). The reality is that the unthinkable can happen. Contingency planners have been called “professional pessimists” (B. Maliner, personal communication, 2003). This outwardly dour perspective is born from recognition of the vast variety and scale of potential disasters. “I am often asked, ‘When will we be prepared for all the threats we face?’ My answer is—not in my lifetime” (Carmona 2004) This pragmatic portrayal of preparedness by Dr. Richard H. Carmona, the 17th surgeon general of the United States, highlights a looming crisis within a shrinking U.S. health system, an infrastructure that saw 19% of all hospitals close between 1975 and 2008 (American Hospital Association [AHA] 2010). As levels of preparedness have increased over the past two decades in terms of the broad spectrum of disaster response, capabilities in the areas of patient evacuation and treatment have arguably diminished or been found to be based on faulty planning assumptions (Franco et al. 2007). Evacuation of casualties can, to a certain degree, remediate immediate health care crises but may be neither possible nor sustainable because of logistical challenges or the limits of receiving locations (Franco et al. 2007). Moreover, the wholesale removal of sick or injured victims works counter to the goal of a rapid recovery within the community as it means dislocating residents to disparate locations (Donahue et al. 2012). In the face of a large-scale catastrophic disaster, the nation’s medical response edifice may prove to be a Potemkin village. Myriad potential contingencies are confirmed by recent history. The 1989 Loma Prieta earthquake caused extensive damage throughout California. In 2005, massive hurricanes destroyed vast swaths of the Gulf Coast. Epic floods inundated Saint Louis, Missouri, in 1993 and Iowa in 2009. Some natural events are almost beyond comprehension. Although occurring more than a century ago, Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 2 JHSEM: Vol. 9 [2012], No. 2, Article 1 the 1908 meteor strike in Tunguska, Siberia, illustrates an enormous event beyond man’s ability to mitigate. It is estimated to have produced an explosion equivalent to 500 kilotons of TNT, or approximately 60 times the explosion at Hiroshima (Hartman, n.d). Sadly, natural disasters do not represent the full scope of threats. Acts of human violence have produced significant numbers of casualties with alarming frequency: New York City in 1993, Oklahoma City in 1995, and New York and Washington, D.C., in 2001. Oversight or neglect can result in catastrophe or, in some cases, in a near miss. Consider the case of the Citicorp building, a landmark New York City skyscraper. A student research project identified a structural flaw in the 59-floor, 915-foot-tall building in midtown Manhattan. Analysis revealed that the edifice, built in 1977, would be unable to withstand a 70 mph wind from a 45-degree angle. The approach of the 1978 hurricane season presented an urgent situation: structural failure would endanger the estimated 300,000 people within a six-block radius at midday (Morgenstern 1995). An emergency reinforcement project remedied the deficiency, but not before anxious contemplation of the potential consequences. Acts of human violence entail physical injuries to life and property. Further danger is posed by a panoply of pestilence; severe acute respiratory syndrome (SARS), H5N1, H1N1, and anthrax—both the postal attacks of 2001 and the 2011, inexplicable rash of deaths among heroin users in Europe—are among the latent threats faced. The deceptively mild outcome of the 2009–2010 H1N1 outbreak belies the potential for massive casualties from an influenza pandemic (see Table 1). Modeling by the CDC projects the need for more than ten times the number of hospital beds currently existing in the United States (CDC 2006; AHA 2009). HHS Health Outcomes Characteristic Moderate (1958/68-like) 90 million (30%) Severe (1918-like) 90 million (30%) 45 million (50%) 45 million (50%) Hospitalization 865,000 9,900,000 ICU care 128,750 1,485,000 Mechanical ventilation 64,875 742,500 Deaths 209,000 1,903,000 Illness Outpatient medical care Table 1. Number of Episodes of Illness, Health Care Utilization, and Death Associated with Moderate and Severe Pandemic Influenza Scenarios (Office of the Assistant Secretary for Preparedness and Response, 2008) Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 3 These dire circumstances are exacerbated by waning capacity in the health delivery system and inherent structural challenges. Emergency department overcrowding severely limits the ability to respond to a sudden event (Eastman 2006). The number of inpatient beds is shrinking; between 1995 and 2008, hospitals eliminated 129,556 (12%) of all operational beds (AHA 2010; Cantrill 2007). From 1995 to 2001, 20% of intensive care unit capacity was lost (Cantrill 2007). Most health care is in the private sector, not under state governmental or municipal authority (Cantrill 2007), thereby limiting the motivation to establish robust expansion capabilities and precluding opportunities for standardization and coordination of surge capacity (Franco et al. 2007). The widespread employment of “just in time” supply processes creates the potential for shortages and single points of failure. Various preparedness monitoring programs report bed availability, but the functional extent of this status is far from clear. Is an available bed simply the piece of equipment or does it include adequate staffing, supplies, and ancillary support functions? The lack of surge capacity in American hospitals is such that few, if any, hospitals could handle a sudden influx of 100 patients needing advanced life-support care. In most locales, even the combined resources of all hospitals in a metropolitan area could not handle such a demand. No city in America, and no contiguous geographic region could handle 1000 patients suddenly needing advanced medical care. (Senate Committee on Government Affairs, 2001) Defining the Need The Microsoft Word thesaurus suggests “unforeseen event” as a synonym for “contingency.” But are contingencies truly unforeseen (Joint Commission 2003)? Hospital planning factors have for years emphasized not evacuating in the face of a disaster but, instead, expanding capacity to “surge in place” to accept greater numbers of patients. Recent history demonstrates, however, this approach is not always feasible. Hurricanes Katrina and Rita have shown us that having plans to “surge in place,” meaning expanding a functional facility to treat a large number of patients after a mass casualty incident, is not always sufficient in disasters because the health care organization itself may be too damaged to operate (Joint Commission 2006, iv). Depending on the nature of the disaster, a surging hospital has three operational alternatives: expand current capabilities, replace extant infrastructure, Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 4 JHSEM: Vol. 9 [2012], No. 2, Article 1 or create extended isolation capacity. Augmenting current capacity is typically well considered in institutional disaster plans. Often less developed are plans for using buildings of opportunity (i.e., existing structures) and temporary structures, and for replacing damaged or destroyed infrastructure (Barbisch and Koenig 2006). Perhaps most vexing—operationally and ethically—are the challenges in addressing highly communicable diseases such as SARS. Few hospital administrators would be willing to functionally rebrand their institution as “St. Smallpox.” While the partial or total loss of a hospital may seem incomprehensible to health care leadership, such a potentiality must be considered. It is likely a major disaster will strike. Consider the New Madrid fault and its known history. This fault traverses and directly threatens parts of seven American states: Arkansas, Illinois, Indiana, Kentucky, Mississippi, Missouri, and Tennessee. Impact of a major quake can be expected to extend far beyond these states, however. Beginning with an initial pair of very large earthquakes on December 16, 1811, the 1811 and 1812 New Madrid earthquakes are the most intense intraplate earthquake series to have occurred in the contiguous United States. According to some estimates, the earthquakes were felt strongly over roughly 130,000 square kilometers (50,000 square miles) and moderately across nearly 3 million square kilometers (1 million square miles). The historic 1906 San Francisco earthquake, by comparison, was felt moderately over roughly 16,000 square kilometers (6,000 square miles) (Applegate 2007; Atkinson 1989). These were not isolated instances. Comparison of the geographic impact of earthquakes of similar intensity—the 1895 Midwest and 1994 Los Angeles basin earthquakes—reveals that the former event had a significantly larger footprint (see Figure 1) (Hildenbrand et al. 1996). As the footprint is significant, so too would be the consequences. Figure 1. Comparative Scope of Earthquakes (Hildenbrand et al. 1996) Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 5 Critical infrastructure and lifelines will also be heavily damaged and most likely out of service for a considerable period of time after the earthquake. Such mass outages are likely to affect a region much larger than the eight states cited above. Many hospitals nearest to the rupture zone will not be able to care for patients, indicating that, absent a rapid expansion of local capabilities, those injured during the event as well as pre-earthquake patients will have to be transported outside of the region to fully functioning hospitals. It is doubtful that the transportation system will be functioning to a level that allows such mass evacuation. Police and fire services will be severely impaired because of damage to stations throughout the affected region. Many schools that serve as public shelter will also be damaged and likely unusable after the earthquake. Transportation into and out of the areas near the fault rupture will be difficult, if not impossible: airports will be damaged; bridges will be damaged and not passable or their stability suspect; and some ferry facilities and ports will be out of service. The massive loss of functionality of transportation systems and facilities will prevent displaced residents from leaving the region and also make it difficult for ground-transported aid workers and relief supplies to access the most heavily damaged areas (Elnashai et al. 2008). As will be discussed later in this analysis, existing incremental surge capabilities would prove insufficient to meet post-disaster health care needs following a major event. It has been estimated that 60% of Memphis, Tennessee, will be devastated, with 6,000 fatalities in that city alone (Elnashai et al. 2008a, 2008b). A Recurring Theme Recent natural disasters have highlighted shortfall areas in current hospital disaster preparedness. These areas include (1) insufficient coordination between hospitals and civil/governmental response agencies, (2) insufficient on-site critical care capability, (3) a lack of portability of acute care processes (i.e., transporting patients and/or bringing care to them), (4) education shortfalls, and (5) the inability of hospitals to align disaster medical requirements with other competing priorities (Farmer and Carlton 2006). We suggest that a significant disaster will eventually strike the United States, causing overwhelming patient load, physical destruction, or both. While many, if not most, post-disaster needs can be met by state and local assets, this would not be the case should the regional health system fail, the very occurrence of which would negate local surge capability. One of a governor’s primary disaster response resources is the National Guard. Despite significant capabilities and capacity in terms of transportation, law enforcement, civil engineering, and myriad other functions needed in the wake of disaster, however, the Guard Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 6 JHSEM: Vol. 9 [2012], No. 2, Article 1 possesses limited comprehensive medical capabilities, there being no hospitals in the Army National Guard and limited e-Med1 assets in the Air Guard. A catastrophic failure of a region’s health care infrastructure will inevitably prompt federal action, with multiple agencies providing substantial response and deployable assets. DoD and the Department of Veterans Affairs (VA) will play a prominent role in domestic disaster response (Piggott, n.d.). The operational assumption here has been that patients would be transported, via coordination within the National Disaster Medical System (NDMS), to definitive care via capabilities in regions beyond that affected by the disaster. This is problematic in terms of both the ability to move large numbers of patients and where those patients will go. The military medical transportation system could transport only limited numbers of patients. Long-haul transportation of patients is a federal responsibility but is constrained by the limited aeromedical evacuation capacity of the U.S. military. Although almost all of the more than 1,000 cargo planes in the U.S. Air Force, Air Force Reserve, and Air National Guard can be reconfigured for medical transportation (GAO 1998), trained aeromedical personnel needed to transport patients are limited in number. Most (65%) of the military aeromedical personnel are in the Air Force Reserve (Air Force Reserve 2007) and would likely take some time to be called up in a crisis. For critical care patients, not only is there a limited number of highly trained personnel, but each three-member Critical Care Air Transport Team can only accommodate three ventilator patients or six nonventilator critical care patients per flight (Carter 2006). Thus, even if the CRAF [Civil Reserve Air Fleet] were activated to supplement the number of airplanes available, the staff limitations would likely preclude a significant immediate increase in the medical lift capacity (Franco et al. 2007, 322–323). The reliance on private assets to augment those of the military would also prove problematic from the perspective of responsiveness. Some 1,400 airframes, including 45 Boeing 767s identified for aeromedical evacuation, are available to the federal government on short notice via the CRAF program. It would take 60 hours to reconfigure the first CRAF aircraft, however; others would become available over a period of weeks, as all the planes must go to one contractor in Galveston for the conversion (Wilhite 1996). There is also the question of available crew members, as a percentage of commercial airline pilots hold 1 eMed (Expeditionary Medical) is the Air Force Medical Service’s modular hospital configuration designed to support forward-deployed Air Force assets and patient evacuation missions. Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 7 commissions in the Guard and Reserve and may be mobilized in support of the state or federal relief effort. Additionally, the availability of adequately staffed beds may be limited, owing to both budgetary and manpower constraints and a lack of awareness in the receiving institutions. In a survey of training needs at NDMS-participating hospitals, 25% of respondent hospitals were unaware of their designation as an NDMS hospital (VA 2005). NDMS planning relies on 110,605 precommitted beds (McCann 2008), 11.6% of the total 951,045 U.S. hospital beds (AHA 2010). In 2008, the national average for hospital bed occupancy was 68.2% (AHA 2010). While this would appear to indicate sufficient bed capacity, it must be noted that hospitals staff for that occupancy. Therefore, a report of an available bed may be exactly that: an empty bed sans attendant staffing, supplies, and support services (housekeeping, food services, linens, etc.). Moreover, this availability is spread across the nation’s 5,815 hospitals, so while some institutions may be operating at 50% occupancy, others—especially urban medical centers—are at near or over capacity (AHA 2010). Delivering Surge Capacity The prospect of transporting several thousand casualties to myriad treatment facilities poses a tremendous temporal, transportation, and sustainability challenge. In this scenario, the needs will include deployable facilities, additional personnel, or a combination of both to establish a meaningful spectrum of care within the disaster-stricken region and to foster recovery. Delivering surge capacity entails multiple operational issues, including physical space, organizational structure, medical staff, ancillary staff, support (nutrition, mental health, etc.), supply, pharmaceuticals, and other resources (Texas A&M Health Science Center 2004). The operational paradigm is to focus on target capabilities that meet current standards of care, as depicted in Figure 2, moving to alternative delivery venues—assuming they are inherently substandard—for as little time as possible (Joint Commission 2006). The implication is that surge capabilities will be necessary for a short duration. Following a catastrophic disaster, however, this may not be the case. Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 8 JHSEM: Vol. 9 [2012], No. 2, Article 1 Figure 2. Alternative Standards of Care Model (Joint Commission 2006) The NDMS provides effective but limited augmentation resources (Flacks 2007). For example, 55 Disaster Medical Assistance Teams (DMATs) furnish emergency medical response with civilian medical teams. Each DMAT can keep 30 medical/surgical noncritical inpatients stable pending evacuation, prepare 200 patients for evacuation, and stage (i.e., move to evacuation transport) up to 100 patients. DMATs deliver quality primary and acute care in an austere environment: triage, emergent, acute life support, laboratory, pharmaceutical services, medical ward, and evacuation preparation (National Medical Response Team [NMRT], n.d.; Piggott, n.d.). They can begin limited operations upon arrival at a disaster site and then take several hours to establish full operations, typically from tents (Piggott, n.d.). They focus on the movement of casualties to definitive care in hospitals outside of the affected region (NMRT, n.d.; Piggott, n.d.), a process that may not be sustainable or even possible following a catastrophic disaster. Once set up, DMATs are limited in the amount and type of care they can provide. If providing only minor treatment preparatory to the release of ambulatory patients, all the DMATs in the country working together could handle about 5,000 patients per day. If, however, the teams are providing inpatient-type care, such as managing continuous intravenous fluids, pain control, or antibiotics, their capacity would be only about 1,400 patients per day (Piggott, n.d.). Moreover, many DMATs are not equipped or trained to provide specialized care for patients in shock or respiratory failure or for burn or pediatric patients (Franco et al.). Further surge capacity is offered via a Federal Medical Station (FMS), a facility that evolved from the Federal Medical Contingency Station. An FMS is modeled for all age populations and is focused on nonhospitalized, ambulatory patients with medical needs aggravated by disaster. Scalable to the incident, Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 9 modular in configuration on, and mobile for maximum geographic distrib ribution, an FMS is designed to be qquickly integrated with on-site resources. By definition, d this assumes a degree oof predictability of available resources, the absence ab of which can seriously hind inder operational capabilities. The FMS is design igned to be operational in three dayss from the request for deployment—requiring 24 4 hours for travel and another 48 hoours for set up—and to use buildings of oppor ortunity. It encompasses 250 beds (in in 50-bed units) and can deliver quarantine or lower low levels of care (Franco et al. 2007 07). While the designn of the FMS is its greatest strength, it is also the he station’s most significant shortcom oming. An FMS is typically set up in a large space ace, such as a sports arena, hangar,, or armory (see Figure 3). This results in issues es of crowd control, infection contr ntrol, communicable disease spread, patientt property management, space ma management, and a homeless shelter atmos osphere—a demoralizing baseline ha hardly conducive to the psychosocial recovery of o disaster victims (Cantrill 2007). M Moreover, as Franco and colleagues note, “Th The Federal Medical Stations (FMSs) s) would take even longer to deploy [than DMA MATs] and are limited by the equipm ment and staffing available” (322). ical Station in an Aircraft Hangar (Cantrill 2007) Figure 3. Federal Medica ignificant logistical support requirements, many y of which The FMS has sign may be unavailable foll ollowing a catastrophic disaster. To provide utility, ut the building of opportunity m must offer 40,000 square feet of enclosed space ace per 250 beds. An electrical po power source and distribution are required red, as is communications support rt. Additional support functions that must bee furnished include perimeter securi urity, waste removal, medical waste disposal, al, laundry, potable water, ice, refri frigeration, food service for patients and staff, ff, latrines, showers, local transporta rtation, and billeting for 150 personnel per FMS S (Trabert 2006; Cantrill 2007). Th There are also significant operational concerns, including Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 10 JHSEM: Vol. 9 [2012], No. 2, Article 1 staff flow, supply management, sustainability, communicable disease control, and privacy. The extent to which an FMS can respond to a major disaster is likely to be determined at the time of need. According to the CDC, “When Hurricane Katrina struck Louisiana on August 28, 2005, only a few prototype Federal Medical Stations existed. DSNS [Division of Strategic National Stockpile] took the program from prototype to reality almost overnight. Over the next few weeks, DSNS sent nine FMS sets with 5,500 beds to hurricane-affected areas” (n.d.). While a significant response for less acute conditions, the time line of weeks is problematic in terms of rapid recovery for the amelioration of injuries and illness directly caused by the disaster. Depending on the nature of the disaster, structures once considered viable candidates for surge capacity can become buildings of inopportunity. During the San Fernando earthquake of February 1971, a portion of Olive View Hospital collapsed, effectively eliminating a valuable asset and actually increasing the surge requirement in terms of number of patients to be placed. Similarly, the F5strength tornado that struck Joplin, Missouri, on May 22, 2011, effectively destroyed St. John's Regional Medical Center. The inherent challenges in planning for dependable surge capacity have led many jurisdictions and health care provider organizations to experiment with alternative augmentative systems. One response to the need for capacity that can be deployed at varying locations is the self-contained mobile hospital. Carolinas MED-1 is a prime example of this approach (Carolinas Medical Center 2010): The first and only hospital of its kind in the world, Carolinas MED-1 incorporates an emergency department, surgical suite, critical care beds, and general treatment and admitting area. Consisting of two 53-foot tractor-trailers, the unit expands to a workspace of 1000 square feet and supports an environmentally-controlled awning structure that incorporates up to 130 beds. It carries its own generators, oxygen, x-ray and ultrasound capability, and diagnostic lab (American College of Emergency Physicians 2006). This modality offers distinct advantages in responding to a disaster; for example, it takes less than an hour to set up upon arrival. While it can deliver critical characteristics necessary for comprehensive disaster response, however, it is hardly a national asset owing solely to its uniqueness. There is also the issue of return on investment. The price tag for such a system can easily climb into the millions. Few hospitals or health systems are likely to have the available resources to dedicate to extensive surge capacity absent a viable or routine alternative use. Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 11 One such alternative utility has been suggested by Paul K. Carlton, MD, the former surgeon general of the Air Force and current member of the faculty at Texas A&M University. Dr. Carlton envisions dual-use mobile facilities where clinical platforms, such as the semitrailers of the Carolinas MED-1, are designed as inserts to a fixed structure (Carlton 2007). The incorporation of mobile clinical assets within a physical plant would represent a significant capital investment and require coordination with facilities management staff, architects, and certificate of need issuing authorities. But by nesting the movable asset within a building that has a daily clinical mission, organizations can mitigate issues that arise with dedicated surge equipment, such as nonemergency use, supply maintenance, and defraying the cost of acquisition. Even given the “fly-away” configuration of the nested clinical platforms, however, significant logistical support requirements inhibit the effectiveness of this approach. Each mobile platform requires a prime mover (i.e., a tractor for the trailer). To be effective, a large number of these units must be available. Plus, the owning institution must plan for replacement of the deployed clinical assets for continuing operations. The ongoing scenario, therefore, entails the availability of limited augmentation assets for a discrete period of time. In virtually every contemplated disaster scenario with an overwhelming number of casualties, the default, lastchance option is to draw upon the largest pool of equipment and expertise in establishing comprehensive medical treatment facilities in austere environments—in short, the military. The problem with this as a safety valve is that available resources fall far short of the perceived capabilities. Although DoD does boast considerable deployable medical assets, when it comes to rapid response to an immediate domestic crisis, the proverbial admonition of the Maine farmer applies: “you can’t get there from here.” Gold Standard or Rube Goldberg? The abundant capabilities and significant achievements of the DoD medical system are beyond the scope of this analysis. They are generally acknowledged for advances in trauma care, an ability to respond globally, and success in establishing effective operations in the most hostile of environments. As a movable capability, DoD deployable hospitals and medical support units demonstrate characteristics that make them ideal for their intended military support mission but less ideal for domestic disaster response. The configuration, modularity, and mobility of the separate services’ deployable hospitals necessarily vary in accordance with each service’s operational mission. Army assets are designed to support sustained land warfare, the Navy employs a combination of land and shipboard clinical configurations, and the Air Force leverages its Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 12 JHSEM: Vol. 9 [2012], No. 2, Article 1 mobility via a series of accumulative modules that address the various phases of area medical support. Despite their considerable differences in focus, shelter systems, and transportability, deployable military hospitals have several characteristics in common. Most have a large footprint, needing tens of acres of level ground at full operational capacity. Recent use (combat, stability, and humanitarian relief operations) has seen partial, mission-configured deployments that rely on robust evacuation capabilities, an approach that may not be possible in a disaster scenario (Franco et al. 2007). Most mobile military hospitals require utilities support (e.g., water, waste disposal), which necessitates additional staff or external support to install and maintain these functionalities. Movement of land-based systems also demands considerable transportation support. An Army combat support hospital needs 43 C-141 sorties to move, plus the attendant ground transportation for reaching the final destination. Given the sustained buildup that typically precedes major combat operations, this support requirement is an acceptable burden that is factored into the force deployment plan. Applied to the need for rapid response to a domestic disaster, however, this model proves to be woefully slow. Continuing with the Army example, most of that service’s mobile hospital sets are in depot storage, and each would require several months to unpack, configure, update, and move. The belief that deployable military hospitals will arrive in the nick of time like the cavalry in Western movies is dangerously misplaced. Organizational disparities further degrade the rapid response capacity of DoD. Deployable military hospitals are designed for war casualties, with capabilities focused predominantly on trauma. Each uniformed service has its own shelter system, which precludes interoperability. Within the services, there are differences in equipment and readiness status between Active and Reserve Component units. Rarely do the separate medical systems train in an integrated fashion for an incomprehensible number of casualties. Some DoD medical assets are highly visible and are currently being used effectively, albeit to a limited extent. The Navy maintains two hospital ships—in effect, two floating medical centers. Each ship provides 12 fully equipped operating rooms, a 1,000-bed hospital facility, digital radiological services, a medical laboratory, a pharmacy, an optometry lab, an intensive care ward, dental services, a CAT-scan, a morgue, and two oxygen producing plants. Each ship is served by a helicopter deck capable of landing large military helicopters and side ports to take on patients at sea. The USNS Mercy and the USNS Comfort are very large medical centers. Surpassed in length among naval vessels by only the nuclear-powered Enterprise- and Nimitz-class super carriers, the two hospital ships were built on the hulls of San Clemente-class super tankers. With a 33-foot draft, the hospital Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 13 ships require a deep-water berth, which limits the number of ports they can enter to 35 in the continental United States and Puerto Rico. The Comfort and the Mercy have served as remarkably positive public relations tools, particularly when used in support of disasters such as Hurricane Katrina, the Banda Aceh tsunami, or the Haitian earthquake. When considered as an asset for rapid response to a domestic disaster, however, these medical platforms suffer from significant operational constraints. Neither ship is routinely staffed beyond a caretaker crew. When a ship has embarked on a medical mission, clinical and support personnel are ferried to it while it is under way. As the requirement for a deep-water berth limits the number of locations that can support direct transfer of patients, patient flow is extremely restricted. The ship is, in effect, a 1,000-bed hospital with one door reached via helicopter. Landing a helicopter on a ship deck poses its own challenges, as the landing surface rolls with the movement of the water. This requires special training and qualification not routinely associated with medical evacuation flight training. But the most significant limiting factor is that there are only two of these ships, one home ported in Baltimore and the other in San Diego. Far more agile and adaptable, “gray hull” naval vessels have the ability to convert space to clinical use. This is particularly true of amphibious assault ships (LHA [landing helicopter assault] and LHD [landing helicopter dock]), especially once the Marine complement disembarks. The USS Iwo Jima (LSD [dock landing ship]-7) saw service in direct support of relief operations in New Orleans after Hurricane Katrina (U.S. Navy, n.d.). Being self-sufficient and capable of sustaining extended flight and clinical support operations, these platforms could provide robust support. They are limited, however, in their ability to travel significantly inland on waterways. In addition, their availability is subject to military operational considerations and is not likely to be maintained for an extended period. A Square Doctrinal Peg in a Round Operational Hole Baseball great Yogi Berra is credited with saying “When you come to a fork in the road, take it.” In many regards, this has been the thinking behind the “all hazards” approach to emergency preparedness (Donahue et al. 2012). The foundational elements of addressing hazardous materials incidents or medical care delivery have been augmented by operational expertise drawn from the military. This has resulted in the common construct of CBRNE: chemical, biological, radiological, nuclear, and high-yield explosives (Eldridge 2006). The clinical commonality of these diverse threats is scant. The majority of the plans we have surveyed reflected the training and experience of the planners (i.e., they have been drawn from military doctrine). This is problematic because the methodology becomes ineffective when the Published by De Gruyter, 2012 Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM 14 JHSEM: Vol. 9 [2012], No. 2, Article 1 beginning premises differ, particularly with regard to the affected population. Soldiers, sailors, airmen, and Marines are trained to recognize and react to CBRNE events; civilians are not. In the face of such events, the military is equipped to take protective measures and—most significantly—continue with the assigned mission. Experience has shown that civilian populations under attack react quite differently (Pangi 2002). Rather than the CBRNE skills of the first responders that will drive the response scenario, it will be the reaction of a largely untrained public. Most of the victims of the Toyko subway sarin attacks who presented for treatment did so outside the emergency medical services (EMS) system, self-ambulating to emergency departments (Pangi 2002). The construct used for military planning includes a degree of advanced warning. Intelligence identifies the movement of aircraft, artillery, or chemical equipment. Forces are placed on alert and work with a degree of anticipation that a particular type of attack is likely. But terrorists and, to some extent, natural disasters rarely give such forewarning to the civil sector. Domestic response cannot rely on advanced warnings generated by the intelligence community. As an example, one of the authors served as the emergency department (ED) administrator for a New York City medical center located at the edge of an industrial area. On one occasion, EMS personnel transported two factory workers in full pulmonary arrest. It was not until these victims were being treated and the accompanying EMS, fire, and police responders were briefing the ED staff that it became obvious that this was an industrial chemical incident and that all who were standing in the center of the ED had been exposed. The decontamination station at the ED entrance was rendered superfluous. While this may point to the need for more extensive training among the responder community, it is unreasonable to expect every such event to be accurately assessed at the point of incident. Conclusion Systematic planning for medical response to a catastrophic disaster has been hampered by what can be termed disjointed incrementalism. Disparate capabilities are created to meet specific needs driven by organizational missions with little consideration of the full continuum of operations. Operational experience and a review of the literature reveal requirements that we suggest should form the common foundation for contingency planning. Disasters vary by cause, locale, and extent of the population involved. It is not the agent of destruction that must be addressed but rather the needs of those affected (Donahue et al. 2012). Therefore, to fully meet the wide range of potential scenarios, robust domestic response should be Customizable Scalable Brought to you by | De Gruyter / TCS Authenticated | 173.9.48.25 Download Date | 10/9/12 8:05 PM Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster 15 Standardized and interoperable Highly mobile and multimodal Self-sustainable Focused on the needs of the population served. 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