article - medical response capabilities to a catastrophic disaster - journal hsem (vol 9 issue 2)...

Volume 9, Issue 2 2012 Article 1

Journal of Homeland Security andEmergency Management

Medical Response Capabilities to aCatastrophic Disaster: “House” or House of

Cards?

Donald A. Donahue, University of Maryland UniversityCollege, American Academy of Disaster Medicine, Diogenec

GroupEvelyn A. Godwin, Diogenec Group

Stephen O. Cunnion, Diogenec Group

Recommended Citation:Donahue, Donald A.; Godwin, Evelyn A.; and Cunnion, Stephen O. (2012) "Medical ResponseCapabilities to a Catastrophic Disaster: “House” or House of Cards?," Journal of HomelandSecurity and Emergency Management: Vol. 9: Iss. 2, Article 1.

DOI: 10.1515/1547-7355.2029

©2012 De Gruyter. All rights reserved.

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Medical Response Capabilities to aCatastrophic Disaster: “House” or House of

Cards?Donald A. Donahue, Evelyn A. Godwin, and Stephen O. Cunnion

AbstractPlanning 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 severityof the catastrophe. Yet, history documents myriad disasters that far surpassed even the direstpredictions. Similarly, response mechanisms build upon what is in use at the time in terms ofequipment, transportation, and employment. Current planning factors may prove inadequate toaddress a disaster of historical proportion. The authors offer a review of significant disasters as ameasure 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



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,

1Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster

Published by De Gruyter, 2012



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) Severe (1918-like)

Illness 90 million (30%) 90 million (30%)

Outpatient medical care 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

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)

2 JHSEM: Vol. 9 [2012], No. 2, Article 1



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,





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)




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





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.




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.





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,




modular in configuration, and mobile for maximum geographic distribution, an

FMS is designed to be q

this assumes a degree of predictability of available resources, the absence of

which can seriously hinder operational capabilities

operational in three days from the reques

travel and another 48 hour

encompasses 250 beds (in 50

of care (Franco et al. 2007

While the design

most significant shortcoming

a sports arena, hangar, or armory

control, infection control,

management, space management, and a homeless shelter atmosphere

demoralizing baseline hardly conducive to the psychos

victims (Cantrill 2007). Moreover, as Franco and colleagues note

Medical Stations (FMSs) would take even longer to deploy [than DMATs] and

are limited by the equipment and staffing available”

Figure 3. Federal Medica

The FMS has significant logistical support requirements, many of which

may be unavailable following a catastrophic disaster

building of opportunity must offer

beds. An electrical power source and

communications support

include perimeter security, waste removal, medical waste disposal, laundry,

potable water, ice, refrigeration, food service for patients and staff,

showers, local transportation, and billeting for 150 personnel p

2006; Cantrill 2007). There are also significant operational concerns


FMS is designed to be quickly integrated with on-site resources. By definition,


which can seriously hinder operational capabilities. The FMS is designed to be

operational in three days from the request for deployment—requiring 24 h

ours for set up—and to use buildings of opportunity

in 50-bed units) and can deliver quarantine or lower level

2007).

design of the FMS is its greatest strength, it is also the station’s

most significant shortcoming. An FMS is typically set up in a large space

r, or armory (see Figure 3). This results in issues of

control, infection control, communicable disease spread, patient property

management, space management, and a homeless shelter atmosphere

hardly conducive to the psychosocial recovery of disaster

Moreover, as Franco and colleagues note, “The Federal


are limited by the equipment and staffing available” (322).

Federal Medical Station in an Aircraft Hangar (Cantrill 2007)

significant logistical support requirements, many of which

may be unavailable following a catastrophic disaster. To provide utility, the

must offer 40,000 square feet of enclosed space

ectrical power source and distribution are required, as is

ommunications support. Additional support functions that must be furnished


potable water, ice, refrigeration, food service for patients and staff,

showers, local transportation, and billeting for 150 personnel per FMS

There are also significant operational concerns,


By definition,


The FMS is designed to be

24 hours for

buildings of opportunity. It

uarantine or lower levels

the station’s

in a large space, such as

ssues of crowd

communicable disease spread, patient property

management, space management, and a homeless shelter atmosphere—a

cial recovery of disaster

“The Federal


significant logistical support requirements, many of which

To provide utility, the

enclosed space per 250

are required, as is

dditional support functions that must be furnished


potable water, ice, refrigeration, food service for patients and staff, latrines,

er FMS (Trabert

including





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 F5-

strength 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.




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, last-

chance 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





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




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





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




• Standardized and interoperable

• Highly mobile and multimodal

• Self-sustainable

• Focused on the needs of the population served.

As an adept mechanic includes a wide array of tools in his repair shop, a

proficient response system must include various tools to address myriad

potentialities. In the aggregate, current options offer many capabilities, but not

without altering original design configurations or combining disparate equipment

systems. Perhaps more significantly, the aggregate capabilities of all deployable

hospital assets are likely to be insufficient to address—and are not designed for

indefinite use in—the aftermath of a catastrophic disaster. We suggest that rather

than attempt to build a response contemporaneously based on the specifics of the

disaster, a better approach would be to create a robust, overarching capability

from which a customized response package can be drawn.

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