[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
MITIGATING CATASTROPHIC EVENTS THROUGH EFFECTIVE MEDICAL RESPONSE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON PREVENTION
OF NUCLEAR AND BIOLOGICAL
ATTACK
of the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
OCTOBER 20, 2005
__________
Serial No. 109-48
__________
Printed for the use of the Committee on Homeland Security
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Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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COMMITTEE ON HOMELAND SECURITY
Peter T. King, New York, Chairman
Don Young, Alaska Bennie G. Thompson, Mississippi
Lamar S. Smith, Texas Loretta Sanchez, California
Curt Weldon, Pennsylvania Edward J. Markey, Massachusetts
Christopher Shays, Connecticut Norman D. Dicks, Washington
John Linder, Georgia Jane Harman, California
Mark E. Souder, Indiana Peter A. DeFazio, Oregon
Tom Davis, Virginia Nita M. Lowey, New York
Daniel E. Lungren, California Eleanor Holmes Norton, District of
Jim Gibbons, Nevada Columbia
Rob Simmons, Connecticut Zoe Lofgren, California
Mike Rogers, Alabama Sheila Jackson-Lee, Texas
Stevan Pearce, New Mexico Bill Pascrell, Jr., New Jersey
Katherine Harris, Florida Donna M. Christensen, U.S. Virgin
Bobby Jindal, Louisiana Islands
Dave G. Reichert, Washington Bob Etheridge, North Carolina
Michael McCaul, Texas James R. Langevin, Rhode Island
Charlie Dent, Pennsylvania Kendrick B. Meek, Florida
Ginny Brown-Waite, Florida
______
SUBCOMMITTEE ON PREVENTION OF NUCLEAR AND BIOLOGICAL ATTACK
John Linder, Georgia, Chairman
Don Young, Alaska James R. Langevin, Rhode Island,
Christopher Shays, Connecticut Ranking Member
Daniel E. Lungren, California EdwarD J. Markey, Massachusetts
Jim Gibbons, Nevada Norman D. Dicks, Washington
Rob Simmons, Connecticut Jane Harman, California
Bobby Jindal, Louisiana Eleanor Holmes Norton, District of
Charlie Dent, Pennsylvania Columbia
Peter T. King, New York (Ex Donna M. Christensen, U.S. Virgin
Officio) Islands
Bennie G. Thompson, Mississippi
(Ex Officio)
(II)
C O N T E N T S
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Page
STATEMENTS
The Honorable John Linder, a Representative in Congress From the
State of Georgia and Chairman, Subcommittee on Prevention of
Nuclear and Biological Attack:
Oral Statement................................................. 1
Prepared Statement............................................. 2
The Honorable James R. Langevin, a Representative in Congress
From the State of Rhode Island, and Ranking Member,
Subcommittee on Prevention of Nuclear and Biological Attack.... 3
The Honorable Bennie G. Thompson, a Representative in Congress
From the State of Mississippi, and Ranking Member, Committee on
Committee on Homeland Security................................. 41
WITNESSES
Dr. Roy L. Alson, PhD, MD, FACEP, FAAEM, Associate Professor,
Emergency Medicine, Wake Forest University School of Medicine:
Oral Statement................................................. 9
Prepared Statement............................................. 11
Richard Bradley, MD, Medical Director, Emergency Center--LBJ
General Hospital, University of Texas Health Science Center at
Houston:
Oral Statement................................................. 18
Prepared Statement............................................. 19
Jenny E. Freemen, MD, President and CEO, Hypermed, INC:
Oral Statement................................................. 28
Prepared Statement............................................. 31
Donald F. Thompson, MD, MPH&TM, Senior Research Fellow, Center
for Technology and National Security Policy, National Defense
University:
Oral Statement................................................. 23
Prepared Statement............................................. 24
MITIGATING CATASTROPHIC EVENTS THROUGH EFFECTIVE MEDICAL RESPONSE
----------
Thursday, October 20, 2005
U.S. House of Representatives,
Committee on Homeland Security,
Subcommittee on Prevention of Nuclear and Biological
Attack,
Washington, DC.
The subcommittee met, pursuant to call, at 1:03 p.m., in
Room 1310, Longworth House Office Building, Hon. John Linder
[chairman of the subcommittee] presiding.
Present: Representatives Linder, Dent, Langevin, and
Thompson, ex officio.
Mr. Linder. The hearing will come to order. We are going to
be very short on this end of the bench, because we finished
voting an hour ago and everybody is on airplanes already, I
suspect.
I would like to welcome and thank our witnesses for
appearing before this subcommittee today.
There is an inordinate amount of attention focused on what
went wrong during Hurricane Katrina. Today, instead, we are
here to discuss what we must get right to prevent, mitigate and
respond to a catastrophic biological or nuclear incident.
As tragic as the loss of life was during the Katrina storm,
imagine for a minute the consequence of a nuclear or
bioterrorism event. The Atlantic Storm exercise showed us that
a covert attack on key transportation hubs with smallpox can
result in possibly 660,000 cases worldwide in just 30 days. A
10-kiloton nuclear device detonated near the U.S. Capitol can
result in 15,000 instant deaths and another 15,000 injured.
Can our current medical response capabilities meet this
challenge?
In 1979, President Carter established FEMA to centralize
Federal emergency functions. Five years later, the National
Disaster Medical System was created within HHS to provide
medical and related services in the event that a disaster
overwhelms the local medical emergency capabilities.
In the Homeland Security Act of 2002, NDMS was transferred
to DHS and at present functions under the management of FEMA.
Twenty years since their creation, both of these entities
played a significant and crucial role in response to Hurricane
Katrina.
In December 2004, the Department of Homeland Security
launched its National Response Plan, designed to coordinate the
Federal Government's efforts to prepare for and respond to a
catastrophic event. Under the NRP, DES would take the overall
lead for responding to such events, with HHS tasked with
coordinating the response of the public health and medical
sectors. As the events of Katrina also highlighted, the
Department of Defense played a vital role in providing both
logistical and medical asset support for the victims.
We have rearranged the deck chairs, come up with new plans,
and Congress has committed substantial financial support to
both Federal and local agencies. My question to you is very
simple: Are our medical responders better prepared to mitigate
a truly catastrophic terrorist event?
I can assure you that while Mother Nature often gives us
warning, we will not receive fair warning from terrorists. We
will not have the luxury of ``predeploying'' our medical assets
and personnel.
It is often said we have to use an all-hazards approach to
any catastrophic event. I do not buy into this notion. There
are unique requirements for both mitigating and responding to a
nuclear or biological event. We cannot continue to rely on
lessons learned because terrorists continue to plot and plan
against us. It was my impression that the lessons learned
occurred almost 4 years ago on September 11th.
I look forward to your testimony, because each of you
represents boots on the ground and not the bureaucratic
apparatus. Your insights will be valuable to members of the
subcommittee in constructing legislation to fix problems.
I recognize the ranking member of the subcommittee,
Mr. Langevin of Rhode Island, for the purpose of making an
opening statement.
Prepared Statement of Hon. John Linder
I would like to welcome and thank our witnesses for appearing
before this Subcommittee today.
There is an inordinate amount of attention focused on what went
wrong during hurricane Katrina. Instead, we are here today to discuss
what we must get right to prevent, mitigate and respond to a
catastrophic biological or nuclear incident.
As tragic as the loss of life was during the Katrina storm, imagine
for a minute the consequence of a nuclear or bioterrorism event. The
Atlantic Storm exercise showed us that a covert attack on key
transportation hubs with smallpox can result in possibly 660,000 cases
worldwide in just 30 days. A 10 kiloton nuclear device detonated near
the U.S. Capitol can result in 15,000 instant deaths and another 15,000
injured.
Can our current medical response capabilities meet this challenge?
In 1979, President Carter established FEMA to centralize Federal
emergency functions. Five years later, the National Disaster Medical
System was created within HHS to provide medical and related services
in the event that a disaster overwhelms the local medical emergency
capabilities.
In the Homeland Security Act of 2002, NDMS was transferred to DHS
and at present functions under the management of FEMA. Twenty years
since their creation, both of these entities played a significant and
crucial role in the response to Hurricane Katrina.
In December 2004, the Department of Homeland Security launched its
National Response Plan, designed to coordinate the Federal government's
efforts to prepare for and respond to a catastrophic event. Under the
NRP, DHS would take the overall lead for responding to such events,
with HHS tasked with coordinating the response of the public health and
medical sectors. As the events of Katrina also highlighted, the
Department of Defense played a vital role in providing both logistical
and medical asset support for the victims.
We have rearranged the deck chairs, come up with new plans, and
Congress has committed substantial financial support to both federal
and local agencies. My question to you is very simple: Are our medical
responders better prepared to mitigate a truly catastrophic terrorist
event?
I can assure you that while Mother Nature often gives us warning,
we will not receive fair warning from terrorists. We will not have the
luxury of ``pre-deploying'' our medical assets and personnel.
It is often said that we have to use an all hazards approach to any
catastrophic event. I do not buy into this notion. There are unique
requirements for both mitigating and responding to a nuclear or
biological event. We can not continue to rely on lessons learned,
because terrorists continue to plot and plan against us. It was my
impression that the lessons learned occurred almost four years ago on
September 11th.
I look forward to your testimony, because each of you represent
boots on the ground and not the bureaucratic apparatus. Your insights
will be valuable to members of the subcommittee in constructing
legislation to fix the problems.
I now recognize the Ranking Member of the Subcommittee, Mr.
Langevin of Rhode Island, for the purpose of making an opening
statement.
Mr. Langevin. Thank you, Mr. Chairman.
I would like to thank our witnesses for being here and for
your service to our Nation. We are all truly grateful. You all
have a wealth of experience in providing medical care during
catastrophes, and we welcome your testimony here today.
In our country, medical responders come from all sectors of
society, from local hospitals and public health agencies,
private care facilities, local first responder departments,
State and Federal agencies, the military and volunteer
organizations.
As the recent hurricanes in the gulf coast have shown us,
coordination of all these different entities is very
complicated, but the failure to do so leads to confusion and
ineffectiveness, and in some cases can be the difference
between life and death. One of the responsibilities of this
committee is to provide oversight of programs such as the
National Disaster Medical System to ensure that it functions
correctly.
Members of this committee have heard many accounts from
members of DMAT teams that organization and mission assignments
in various situations have been confused and, in some cases,
nearly absent. Dr. Freeman's testimony tells the story of her
colleague and fellow Massachusetts DMAT member, Dr. Tim
Crowley, who was so frustrated and disturbed by the failure of
the leadership of his team while deployed to Louisiana for
Hurricane Katrina, he resigned upon returning to Massachusetts.
Dr. Freeman recounts her own experience with a similar lack
of leadership, sense of mission and logistical support during a
DMAT deployment when she volunteered to provide medical
response capabilities to the G8 Summit last year.
I have also been asked by my colleague, Representative
DeFazio of Oregon, to submit for the record a letter that he
received from the team leader of the Oregon disaster medical
team. The letter details many problems the team faced during
its deployment after Hurricane Katrina.
Mr. Chairman, I would ask unanimous consent that it be
placed in the record.
Mr. Linder. Without objection.
[The information follows:]
NDMS AFTER ACTION REPORT
Team: Mission: Mission Dates:
IMSURT E Hurricane Katrina 9/3/05--9/18/05
Submitted by: E-mail: [email protected] Phone: 978-443-0808
Timothy Crowley
Date Submitted: 10/5/05...................... Reviewed by: Date Reviewed:
Instructions:
Please include both constructive criticism and positive feedback where appropriate. Do not include security-sensitive issues or personal
comments.
``Impact'' refers to ``how did this impact your mission'': 1-none, 2-minor, 3-moderate, 4-significant, 5-critical.
``Effect'' refers to ``how effectively was this topic/issue handled'': 1-very well, 2-good, 3-acceptable, 4-poor, 5-failure.
Under ``Discussion/Description'', please include any meaningful comments for the corresponding topic or issue. What worked well, what didn't,
etc. Recommendations are strongly encouraged but not required.
If you have additional feedback, feel free to duplicate the form or attach additional pages or documents as required; refer to the number of
the Topic/Issue (e.g., 2a) in your attached documents.
Using the ``Save As'' command, title the document with the mission name and team identifier (e.g., IVAN-CA1, Katrina-VMAT2, etc.). Secondary
deployments to the same mission should also be identified (e.g., IVAN-CA1b).
Once completed, please email copies to:
Team Program Manager
Team Regional EC
[email protected]
----------------------------------------------------------------------------------------------------------------
Recommendation/
Topic/Issue Impact Effect Discussion/Description Action FWG
----------------------------------------------------------------------------------------------------------------
1. Situation Deployed as: 0 0 We were supposedly deployed as ...............
a. Full team of 37 a specialty team to set up a
b. Strike/Augmentation team field hospital similar to our
of 11 mission in Bam, Iran. It
c. Individual turned out much different. We
d. Describe mission ended up either sitting in
assignment Baton rouge waiting for a
mission for several days
(while teams in the field, we
later learned were begging MST
for help) We were then finally
deplyoed to the Airport and
ultimately divided into strike
teams to assist the DMORTs,
cruise ship and West Jeff.
Hospital sites. Some were left
at the airport (after all
evacuations were shut down and
there was NO BUSINESS for us
to be there.
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2. Alert & Notification 5 5 We were notified ONE WEEK after ...............
a. Initial alert or the hurricane and after the
organization most critical events where we
b. Notification Process could have made an impact, had
already transpired-(the
disasters at the convention
center and the airport and the
Superdome.
----------------------------------------------------------------------------------------------------------------
3. Deployment 5 5 We were sent to Houston in ...............
a. Timeliness several groups over an
b. Method extended period of time which,
c. Preparedness by the time everyone was there
and accounted for, required an
overnight in a hotel, thus
wasting another day and money.
We then had to travel 250
miles in a convoy which took
up the next day.
----------------------------------------------------------------------------------------------------------------
4. Response 5 5 As noted above, when we got to ...............
a. Mission execution Baton Rouge there was no
b. Local staging execution organization and no mission
for the multiple teams waiting
there despite what we learned
later, that teams in the field
such as the teams at the
Airport and West Jeff were
pleading for help. I confirmed
this myself when I was tasked
to demobilze 190 DMAT
personell myself at the
ariport on 9/8/05.
Everyone told the same story.
This was repeated when we
arrived at our strike team
missions and repeated again
when we called for help and
were told by MST that there
were no assets to send us.
When out relief finally came
we learned, again, not to our
surprise, that the teams
relieving us had been sitting
on their butts for days
wiating and asking for
missions. This was a TOTAL
FAILURE in the MST system and
NDMS to deliver the assets and
resources to the areas of need.
----------------------------------------------------------------------------------------------------------------
5. Incident Command 5 5 This is a complicated question ...............
a. Unified command (JMT) to answer since we had so many
b. Group Supervisor (a.k.a. locations and interactions
DMAT liaison or LNO) with leadership personell at
c. Local interface (e.g., various levels. The best
local govt or hospital experience I had was at West
command & control) Jeff. where Tom Lowe (?sp) the
d. Your team/unit command) team commander of NY-
e. Establishment of Minnesota, also performed at
priorities the highest level. The other
outstanding performance to be
commended was the JIOC under
the command of Col. Petrenko
which I was privileged to be
part of when I was made
Medical Director of the
Airport. (I previously had
been made Supervising Medical
Officer for Imsurt East when
Dr. Briggs was brought up to
the MST due to illness of that
director. I ultimately was
made Acting Medical Director
for the whole 3 state region
when Briggs returned to
Boston, although I remained at
West Jeff due to lack of
coverage for the night shift.
I mention this not to blow my
own horn but to explain that I
may have had a unique exposure
to the deployment because of
all the various posts held and
the demobilization of several
of the DMAT teams who were
able to relay their stories to
me. The rest is pretty ugly.
As Medical Director at the
Airport, I had the unfortunate
experience to be under the
command of H. James Young. His
judgement, knowledge and
overall command decisions wre
nothing short of abysmal.
Example--As anyone whoever
worked in such a deployment
knows, different teams members
have different skills, Some do
logistics, some commo, etc.
Rather than ASKING the staff
at the airport who did what,
he just named people randomly
to positions with the expected
results. He also kept several
people on our team manning a
medical clinic long after the
airport had any need and while
the military had set up a full
medical facility and despite
pleas from myself and our team
commander to release the team
members to where the need was.
Finally, there was a mission
at the cruise ship which was
also closed and despite this,
MST in Baton Rouge refused to
release the docs there to help
at West Jeff where the teams
were getting slammed and
asking for help. I never
learned what sort of politcal
agenda or just plain
incompetance or stupidity was
behind these decisions, but
they were disgraceful.
----------------------------------------------------------------------------------------------------------------
6. Communications 4 4 First, our intra-team commo. ...............
a. Within your response unit was excellent. Commo to MST
b. Within the incident scene (for whatever good it did) was
c. Interagency poor. The communications under
d. Standardization & the auspices of the JIOC at
compatibility with local the airport was superb. The
resources morning briefings were crisp,
to the point and very
efficient. The JIOC was the
quintessential example of
Interagency cooperation and
effectiveness and should serve
as the ``model'' for future
national responses to
disasters, in my opinion.
----------------------------------------------------------------------------------------------------------------
7. Logistics 31 1 Supply and housing all were ...............
a. Identifying logistics quite acceptable. The U.S.
needs Forest Service did a fantastic
b. Resupply process job at the airport with their
c. Staff housing, feeding, meal and shower units.
etc.
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8. Personnel 1 1 My team experience on this ...............
a. Staffing and shift account was excellent. I will
procedures relate that accountability on
b. Personnel accountability some of the demobilizing teams
c. Stress management I interviewed at the airport
d. Life safety was, in some cases,
nonexistant. I can't recall
which teams were lacking in
this regard unfortunately--
they all kind of ran together.
----------------------------------------------------------------------------------------------------------------
9. Plans/Training/ 5 5 Strong feeling about this area. ...............
Preparedness In my view all teams should
a. Adequacy of plans have their caches and
b. Execution of plans equipment loaded on trucks or
c. Adequacy of training pallatized in a form that
program for the mission allows for roll-on deplyoment
d. Adequacy of pre-planned to a military aircraft- C-130,
equipment (e.g., basic load) C-17 or C-5, if necessary and
for the mission be flown point to point ASAP
when the need arises. They
sould have a small contingent
of military units deployed
along side for security. Sites
for DMAT units and field
hospitals should be
preselected across the country
as part of national
contingency planning OR the
local field commanders should
be given the authority to set
up shop at sites selected in
conjunction with local
authorities. Disaster teams,
in that scenario could deploy
within 6 hours and be anywhere
in the country in 12 hours and
be up and running within 24
hours, at most, from the time
of activation.
----------------------------------------------------------------------------------------------------------------
10. Demobilization 5 5 This was one of the most ...............
a. Notice annoying parts of the
b. Team member travel deplyoment. At the end, our
c. Transportation of cache whole teams was AT AN AIRPORT.
d. Cache inspection/resupply We were in New Orleans and
e. Financial concerns were made to go to Baton
including reimbursements Rouge, in a convoy, to HAND IN
payroll, etc. PAPERS. Nothing else was done
there. The physcial exams and
mental health checks were
DONE. We were then sent to
Houston to stay over night at
the expense of the taxpayer
and had flights arranged to
Ohio and then on to Boston to
arrive on the 15th day of the
deployment at midnight.
There were 27 openings on the
flight to Boston from New
Orleans Airport hat Saturday
at 9 AM and 40 opening on the
flight at 12:30. The whole
National Travel service scam
should be abandoned and the
teams should be allowed to
book their own flights and
send the damn paperwork in
later. The main problemn with
this agency is that it is too
concerned with politics and
bureaucracy and too little
with getting the medical
resources to the areas of need
expeditiously.
----------------------------------------------------------------------------------------------------------------
Conclusion: The whole NDMS concept needs to be rethought. The current management team and
disaster response, as I stated above, is completely dysfunctional. What is more
worrisome is that this was a response to a disaster that we had fair warning of.
I believe it has exposed a significant vulnerability to a sudden mass casualty
event such as an earthquake or terrorist attack with NBC agents. Competant
contingency planning and refocusing the efforts of the agency on getting the
resources to the areas of need are essential to success of its overall mission
and to the security of the nation.
----------------------------------------------------------------------------------------------------------------
Mr. Langevin. I feel strongly that the National Disaster
Medical System can and should be an important asset to help
treat injuries and provide aid in times of crisis. We must
ensure that this incredible resource is not squandered. The
members of the medical community who volunteer to be a part of
this effort are highly motivated and highly skilled. We must
ensure that those skills and that motivation are harnessed to
the maximum possible effect.
Now, I am disturbed by the numerous reports of botched
leadership, lack of a defined mission and an emphasis on
bureaucratic functions, such as filling out paperwork when
citizens are in distress and time is of the essence.
I am further concerned that in close analogy to the stories
we heard about our troops in Iraq not being properly equipped,
the members of these teams were not provided with the equipment
that they needed to do their jobs.
Now we have a lot of ground to cover here, and I am anxious
to explore these issues with our witnesses. I do want to thank
you all for being here, and I certainly look forward to your
testimony.
Thank you, Mr. Chairman, and I yield back.
Mr. Linder. We will now turn to our witnesses. Dr. Alson is
Associate Professor of Emergency Medicine at Wake Forest
University School of Medicine. He was also the commanding
officer of North Carolina's DMAT team that was deployed during
Hurricane Katrina.
Dr. Richard Bradley is Medical Director of the Emergency
Center at Lyndon B. Johnson General Hospital in Houston and is
a member of the Texas Urban Search and Rescue Team. He was
deployed during both Hurricanes Katrina and Rita.
Dr. Donald Thompson is a colonel in the U.S. Air Force and
is a Senior Research Fellow at the National Defense University.
Dr. Jenny Freeman is President and CEO of Hypermed, Inc.,
and a member of the Massachusetts DMAT team.
Thank you all for being here.
Mr. Linder. Dr. Alson.
I would ask you to keep your comments as close to 5 minutes
as you can.
STATEMENT OF ROY L. ALSON, PhD, MD, FACEP
Dr. Alson. Thank you, Chairman Linder and members of the
committee. Good afternoon, and I appreciate the opportunity to
speak.
My name is Dr. Roy Alson. I am an Associate Professor of
Emergency Medicine at Wake Forest University School of
Medicine, and I am here representing the American College of
Emergency Physicians, the specialty of emergency medicine and
the personnel disaster medical assistance teams of the National
Disaster Medical System.
I currently serve as the commander of DMAT NC-1. I have
been in the NDMS since 1989. I have had the privilege of
leading an extraordinary group of people on multiple responses,
including, recently, Hurricane Katrina.
We have been extremely lucky in this country. We have yet
to face a truly catastrophic medical event. This is not to
diminish 9/11, Rita or Katrina to those who were involved
victims; they are catastrophes. But compared to the casualties
suffered in the recent earthquake in Pakistan, the 1976
Tangshan earthquake or the tsunami, we have not had the number
of victims. Our events that we have had have taxed our medical
systems because of disruptions of infrastructure, but our
response systems at the local, State and national level have
eventually met those needs.
Was our response perfect? No, it may never be. Can we do
better? Yes. And many lessons have been learned.
It remains only a matter of time before we face a truly
catastrophic event in this Nation. It may come in the form of a
terrorist attack, using biologic or radiologic weapons; it may
be a natural disaster or even the looming pandemic from avian
flu that now faces us.
To deal with the consequences of a medical disaster, there
are certain requirements that need to be in place. There must
be facilities to give care, there must be personnel to provide
that care, and there must be supplies for those personnel to
use. All of these items can be greatly affected by the event
that has taken place, and it may take additional time to bring
in replacements.
Also, we have to have the ability to move injured and other
victims from the impact area to other portions of our country,
where they can receive definitive care.
Consequently, at a time when a community has increased
demands for medical care, the ability of that community to
provide care is compromised by the very event that caused it.
Complicating this picture is the current nature of medical care
in our country.
All of us practice in competitive environments. Emphasis is
on cost containment and efficiency. Many facilities operate
near capacity. Supplies depend on just-in-time delivery. Thus
our ability to surge in the presence of large numbers of
casualties is compromised.
We have, in the past, since September 11th, funded heavily
the decontamination capabilities, the first responders. We may
have saturated that market in funding. We need to look at where
we are going to send the people they have deconned. Do we have
that surge capacity? Currently, it is limited. Options for
providing that definitive care remain bringing in more beds,
such as portable field hospitals, setting up alternate care
facilities or evacuation of victims. These are not mutually
exclusive, but are part of a coordinated approach.
Catastrophic events rapidly overwhelm the local system and
produce casualties that exceed their capacity. We have to
harden the locals to handle the first period of time after that
disaster. This is something that was apparent in most recent
disasters. We have to give them the capability, as it will hold
the fort until outside support comes.
The other thing we have to realize is that the mission of
bringing these facilities in and distributing patients around
the country has been the very mission that the NDMS was created
for in the 1980s. Katrina was the first time we tested the
evacuation piece; we have learned a lot of lessons. That
portion needs additional support. It needs to be more robust,
because such evacuations are resource-intensive.
We also, as I said, have to have the ability to bring in
medical support. We currently have the DMATs and the NDMS; HHS
has other assets, and there are many other local and other
agencies that have come in. We need to look at the continued
development of things such as the Federal Medical Contingency
Stations originally proposed by NDMS and DHS. We have to expand
the capabilities of recruiting volunteers when they offer their
services. We saw large numbers in this event with many people
complaining about the red tape.
ESAR-VHP, the Emergency System for Advance Registration of
Volunteer Health Care Personnel, is there to handle the
registration. We need to also train them in responding.
In my summary then, our catastrophic medical response must
include hardening the local infrastructure, a coordinated
Federal response, ideally under a single agency with committed
medical logistic support. We also have to make the process of
bringing the Federal assets in easier. We depend now, through
the National Response Plan and the Stafford Act, on the request
of the State to bring the assets. For certain types of
catastrophic events, the Federal Government needs the ability
to launch those assets and put them in place before we get the
request from the State.
Lastly, the programs must be sustained. Equipment and
personnel have been gathered and put in place, but it takes
time, and we must maintain them, and that takes additional
funding.
It is not ``if'' we have a catastrophic event, but
``when.'' I again thank you for the opportunity to speak. I
want to assure the American people and this committee that when
such an event happens, the medical and response communities
will do our best for our fellow citizens.
Thank you very much.
Mr. Linder. Thank you, Dr. Alson.
[The statement of Dr. Alson follows:]
Prepared Statement of Roy L. Alson, PhD, MD FACEP
Chairman King and Members of the Committee; good afternoon and
thank you for inviting me to speak before the committee. My name is Dr.
Roy Alson. I am an Associate Professor of Emergency Medicine at Wake
Forest University School of Medicine. I am very pleased to be here
representing the American College of Emergency Physicians, the
specialty of Emergency Medicine and the response personnel of the
Disaster Medical Assistance Teams (DMATs) of the National Disaster
Medical System (NDMS) which is part of FEMA. I currently serve as the
Commander of DMAT NC-1 and have been active in the NDMS since NC-1 was
formed from our local team Special Operations Response Team, in 1989. I
have also previously served as the executive officer of the NMRT-E
which is a chem-bio response team for the NDMS. I have had the
privilege of leading the DMAT on numerous responses beginning with
Hurricane Andrew and most recently with Hurricane Katrina.
Background
We have been extremely lucky in this country. We have yet to face,
in recent memory, a truly catastrophic event, from a medical point of
view. This is not to diminish events such as 9/11 or even Katrina and
Rita. For those who suffered from these, they are catastrophes.
Thousands died and hundreds more injured. But when compared to events
such as the 2004 Tsunami or the recent Pakistani earthquake or the
Tangshan earthquake of 1976 which killed 240,000 and left another
200,000+ injured in just one city, our recent major disasters have not
generated the massive numbers of victims needing acute and long term
medical care. Our events have taxed our medical systems because of the
disruptions to infrastructure, but our response systems at the local,
state and national level have met those needs. Was our response
perfect? No, but it never will be. Can we do it better? Yes and many
lessons have been learned and continue to be studied from both this
year's storms, the 2004 season in Florida and Hurricane Allison in
2001.
The fact remains that it is only a matter of time until we face a
truly catastrophic medical event in this nation. It may come in the
form of a terrorist attack, using biological or radiological weapons;
it may be a natural disaster such as a massive earthquake in the
central US or Pacific Coast or it may be the threat now looming in
front of us of a pandemic such as Avian Flu.
To deal with the medical consequences of a disaster, certain things
are needed. Some are common to all events and some are specific and
determined by the type of event. These needs are identified and
categorized as the Emergency Support Functions (ESF's) as listed in the
National Response Plan. ESF 8 is the Health and Medical Component of
the Plan, but it does not stand alone, as appropriate shelter, and food
and water all have significant impact upon the public health following
a disaster.
In order to provide this medical care after a disaster there are
certain absolute requirements:
There must be facilities to give care. However during
a disaster these sites may be damaged or destroyed, as we saw
after Katrina and Allison, where flooding shut many hospitals.
Much of day to day medical care is provided in physician's
offices and clinics. These too are often rendered inoperable
after disasters.
There must be personnel to provide the care. In the
affected community, medical and response personnel can become
victims themselves. They may not be able to reach the
facilities that remain operational or they may have chosen to
evacuate the area.
There must be supplies and medications for the care
givers to treat patients with. These may be destroyed by the
event and after the event; it can take time to bring them in.
The ability to move victims from the impact area to
other non affected areas of the country, thus reducing the
burden on the medical infrastructure also needs to be a
consideration.
Consequently, at a time when a community has increased demands for
medical care, the ability of that community to provide care is
compromised by the event that created the demand. Complicating this
picture is the nature of medical care in the US today. All of us
practice in a highly competitive environment, with an emphasis on cost
containment and ``efficiency''. As a result many medical facilities
operate at near capacity and supply inventories are kept as low as
practical, depending on ``just in time delivery systems''. Our ability
to ``surge'' in response to disasters or epidemics is thus further
hampered.
Furthermore, cooperation between hospitals and other components of
the healthcare system is needed for locally based disaster response to
work. Such groups are often reluctant to share information, such as bed
availability, for fear of providing competitors with key information.
We hear over and over in disasters about the importance of information
exchange and cooperation. We have begun the process of addressing the
need for Surge Capacity and Capability through various initiatives such
as grants from the Health Resources and Services Administration. This
support is essential if we are to be successful. It is also primarily a
local and regional responsibility to develop and operate these
``surge'' programs.
WMD versus Natural Disasters
September 11 provided us as a nation with the impetus to begin to
address many disaster medical issues. We have committed large amounts
of funds to train and equip local communities and ``First Responders''
and more recently the hospitals as ``First Receivers''. A condition of
receiving these funds the adoption of Incident Command, which places
all responders at the same table and we have supported the acquisition
of interoperable communications. The emphasis has been on equipping
Fire and other responders to deal with WMD events and we have purchased
large quantities of decon supplies and stockpiled necessary medications
to treat exposures to WMD agents. As an aside, portions of the
Strategic National Stockpile were activated for Hurricane Katrina and
were a valuable asset in supporting both Federal and State Response
assets in the impact area. The SNS lacks many of the day to day
medications and supplies needed by healthcare facilities and this needs
to be rectified.
While we have heavily funded decon and rescue I do wonder whether
we have ``saturated the market'' regarding the ``decon'' portions of
our response. Once we have decontaminated or rescued victims, we still
need to move them to medical facilities, yet last year only 4% of the
Homeland Security funds went to ready EMS agencies (per the Advocates
for EMS group sponsored by NAEMSP and NASEMSD). We need to be certain
we have the assets in place to move the patients. Additionally, as
mentioned above, we need to put in place the ability to provide
definitive medical care for the victims of an attack. After victims
have been decontaminated following a nuclear attack, where do they go?
As previously stated, the ability of most medical systems to surge
is limited by the existing economic pressures of medicine. Options for
definitive care are thus to bring in more ``beds'', such as field
hospitals (equipped with negative pressure capability for pandemics or
biologics), establish alternate care and outpatient facilities for
those whose conditions allow and arrange for evacuation of those
victims who can travel. These are not mutually exclusive, but rather
are part of a coordinated abpproach. The evacuation of victims with
medical issues from Katrina was the first time we have really tested
this portion of the system. It was challenging, but it did id give us
the opportunity to see the strengths and weaknesses of the concept
which will help guide improvements in the system.
Hospitals and other medical facilities need support to be able to
expand capacity on short notice. Retrofitting facilities to increase
the available number of negative pressure rooms, which decreases the
risk of spread of biologic agents is an expensive proposition and one
which the medical facility is not able to recoup from patient charges.
Hospitals will also need increased staff to care for these additional
patients as well as staff to man ``alternate care facilities'' in the
community. Medical personnel from outside the impact area will be
needed and plans for credentialing and moving these personnel must be
in place and coordinated between the various Federal, State and Local
agencies. Recent events to which we have responded show that there is a
need for better coordination of many types of response assets.
We need to take an ``All Hazards'', approach to disasters and as we
identify needs, fund the necessary programs to correct those needs. For
example funding needs to be directed to ``hardening'' the local
responses. This works for both natural and WMD events, as Federal and
other outside help still require time to arrive after a major disaster.
In fact, it can take several days for certain types of assets to be
setup and running. This is not because of ineptitude, but simply that
it takes time to move assets, identify needs and get the personnel and
equipment in place, often in an environment were movement is restricted
due to damaged or blocked roads and limited helicopter and other
resources. Lastly under current rules, Federal assets, for the most
part, can only be committed upon request of the local or state
authorities. Maybe it is time to review how we commit these assets.
It is crucial that local medical assets to have the capability to
begin caring for the immediate victims and to have the necessary
supplies in storage to support operations for the first several days.
This includes medical supplies, equipment to expand the number of
available beds, establish alternate care facilities and maintain
existing medical care. This concept has long been advocated by Dr. Carl
Schultz, at U Cal Irvine, as part of the local planning for the ``big''
earthquake, based upon the experiences with earthquakes along the San
Andreas.
We must also remember that a response to a Catastrophic event is a
long term response. For natural disasters, many of the injuries happen
during or in the immediate post event period. Long term medical needs
are the result of the regularly occurring problems in the community,
often exacerbated by lack of access to care. In a Biological or Nuclear
event, the medical demands arising from the event can actually grow
with time, given the time course of radiation illness or the continuing
spread of the biologic agent. Thus Catastrophic medical response must
also be scaleable and flexible in design.
In addition, we must also look to the psychological aspects of a
nuclear or biological attack. Natural disasters produce many such
issues, primarily in the immediate victims and responders. A terrorist
attack can impact not only those in the immediate area but also at
great distances. All across our nation, people were affected by the
events of 9/11. Another such event will have the same or perhaps
greater effects. Response capability for this issue exists within
present day response systems, but the needs after such an attack must
be estimated and the assets developed to meet that need.
Federal Medical Disaster Response
Let us now turn to the Federal Medical Response to disasters. While
many agencies play roles in this and Health and Human Services is the
Lead Agency for ESF-8 under the NRP, the National Disaster Medical
System has been and remains the Federal Government's primary rapid
civilian medical response to disasters. Begun in the mid-80 the mission
of the agency is (taken from the web site) . .''to design, develop, and
maintain a national capability to deliver quality medical care to the
victims of--and responders to--a domestic disaster. NDMS provides state
of the art medical care under any conditions at a disaster site, in
transit from the impacted area, and into participating definitive care
facilities.''
The teams are composed of medical and support personnel who on
notice as short as 6 hours, leave their primary jobs or close their
medical practices and respond to provide medical care in disasters. We
at the NDMS are the ``tip of the spear'' for Federal Medical Response.
There are approximately 9000 of these responders all over the US (A
list of teams and assets is Attachment 3) and while there are many
issues and problems with how the system works, it is important to note
that it does work. 19 NDMS DMAT's and other NDMS teams were pre-staged
for Katrina, and as the storm passed, they along with the USAR Task
Forces, began moving, into the impact areas. By the day after the
storm, teams were providing medical care and continue to do so today.
The mission is still ongoing, with personnel staffing hospitals and
clinics destroyed or rendered inoperable by the storms as we speak.
(Attachment 2 lists patient services by NDMS personnel as of As of 10/
13/05).
Like many issues in response, much of the NDMS problems are related
to funding and support. Full time NDMS staff numbers about 50. They are
stretched thin on a daily basis and during a disaster deployment; I am
amazed they do not snap. Much of the problems in the field, for us as
teams, stems from agency's lack of an intrinsic medical logistics
support system. FEMA logistics has shown on the last 3 deployments a
great inability to deliver medical supplies in a timely manner.
The emphasis and design of the team equipment and operations is
heavily geared towards acute care, yet many of the missions, including
those ongoing, have a strong primary care component. Often what is
needed after the acute phase (often handled by local and state
response) is to back fill and replace local medical assets destroyed by
the disaster. Many of the physicians involved in this program,
including myself, feel that a stronger medical presence in the
operation of the agency will help correct some of these issues and
balance the current emphasis on ``rescue'' type activities with the
provision of ``medical care''.
I believe the public and much of Congress thinks of dramatic
rescues and surgery taking place in ``MASH'' like tents, when they
think of Disaster Medicine. That is but one component of the entire
picture. This early phase acute care is an important one and I must
again stress the importance of having local communities and regional
assets trained and equipped to deal with this in the first few days
post event as well as the importance of having rapidly deployable
medical elements to get onsite and begin care. This must be followed by
a rapid response of outside help to relieve the locals and expand the
capabilities. The other portion of the Disaster Medicine equation is
the replacement of the community's medical infrastructure to handle the
``day to day'' needs that are no longer met. People still have heart
attacks and babies still get born. Not perhaps as exciting as the other
aspect, but just as important.
CATASTROPHIC EVENTS
These are events that rapidly overwhelm the system and in terms of
medical issues produce casualties that exceed the ability of local and
state resources to provide care. When local and state assets cannot
handle the demands, the role of the Federal Government's response is to
provide them the support and personnel to manage the problem. The
mechanism by which this happens either after the event or in
anticipation of certain high risk types of events is outlined in the
NRP and I will not review these in detail. There is also a Catastrophic
Incident Annex to the Plan, which further defines assets and Federal
Capabilities involved in the response.
To deal with the medical needs, as was said earlier, one needs to
have facilities, personnel and equipment, all of which can be adversely
impacted by the event. In addition, once stabilized, patients will
likely need to be moved from the impact are to definitive care at
medical facilities elsewhere. This mission: of bringing in medical
facilities and personnel and distributing injured to medical facilities
around the country is the mission which the NDMS was created in the
1980's. Besides developing medical response teams, the NDMS recruited
hospitals around the nation, who would make beds available to care for
victims of disasters or soldiers returning stateside for further care.
As was said above, ``excess'' bed capacity in the US is low. For
most of our disasters, the number of victims was relatively low and the
transfer of patients to open more bed space or provide definitive care
has not been needed. It was however needed during Katrina. The movement
of patients requires the support of NDMS partners including DOD and VA
and does require time to ramp up. Katrina showed that it can and does
work and this program requires continued support.
During a true catastrophic event the number of patients to be moved
can easily number in the thousands, since one way to increase surge
capacity in a community is to move existing patients out of the area
for continued care. But moving or evacuating patients may be much more
difficulty than it first appears. Such evacuations are resource
intensive and the air frames available for such activities are limited
and may be committed to military operations. Similar limitations on
availability of ambulances may result from the response demands to the
disaster. Funding for additional transport assets must be included in
catastrophic medic planning.
The other arm of post catastrophic event care is to bring in
additional, portable medical facilities. I have been serving as one of
many subject matter experts on a working group that is developing this
type of facility, the ``Federal Medical Contingency Station-Type I''.
This project has been designed by Dr. Lew Stringer and Capt Gary
Sermones, USPHS (ret), at NDMS. As proposed, the:
``FMCS (I) provides hospital care capability during an emergency
response by augmenting the local or community health care system with
additional or replacement hospital facilities. In addition to declared
national emergencies, FMCS (I) can support a continuum of state public
health missions. One such mission would be to replace a local hospital
if it becomes non functional due to contamination or destruction. Based
on this scenario the hospital unit can be deployed to support the
community hospital needs by providing up to 250 patient ED visits/24
hours, 12 ICU and 252 medical/surgical inpatients as well as up to 25
operative procedures/24 hours. The units will be fully staffed with
NDMS healthcare professionals.''
The prototype and project development for this unit was funded in
FY 2005. The funding of $10 M to receive, equip the facility and carry
out training, evaluation and design revision, as well as maintain the
units was removed from the FY 2006 budget by the Senate. While I have a
bias as to the importance of the project, since I volunteer my time to
help with it, I believe that it is important for this to go forward. It
allows us to rapidly bring into the affected those 3 key things I
mentioned as essential to disaster medical care: Facilities, Personnel
and Supplies.
Personnel issues must also be addressed. We have about 9000
personnel in the NDMS and in the ongoing response to Katrina; this
resource was taxed to the maximum. Our day to day employers have been
supportive and USERRA status for the NDMS has helped greatly, but it
does become hard on the personnel's primary agency or hospital or
private practice to be without them for long periods. During major
disasters large numbers of medical professionals of all levels step
forward to help, as we saw in the recent Hurricanes. It will be the
same with any other catastrophic event. We will need these personnel
and must find a way to effectively tap this resource should we have a
true catastrophic, Biologic or Nuclear event.
Licensure and liability concerns have always been an issue with
these volunteers and these hurricanes were no exception. There was much
complaining about the ``red tape''. Emergency System for Advance
Registration of Volunteer Health Care Personnel (ESAR-VHP) will help
reduce some of this. However, ESAR-VHP only credentials personnel. . .
it does not train them. Just because someone has a license or
credential as a medical provider does not mean they are able to
function in an environment they have never been in and which is very
different from their day to day practice. I believe that ESAR-VHP needs
additional funding to provide some basic disaster medical response
training to those participants, especially to deal with infectious and
communicable disease issues seen with biological agents. We will need
the manpower.
This same type of training needs to be made available to Medical
Reserve Corp volunteers as well. An excellent opportunity to provide
this type of training in a realistic setting is to use these Medical
Volunteers to assist with patient care in the continuing portions of a
response to natural disasters such as NDMS has ongoing now in Jefferson
and St. Bernard's Parishes in Louisiana. In a pandemic event, the
demands for primary care, health screenings and similar services will
rise dramatically. The ability to feed in additional medical personnel
is important to maintain quality of care. The process must be worked
out in advance.
This brings up the topic of coordination of medical response
efforts at the Federal level, as MRC and ESAR-VHP are under the
umbrella of HHS. Many agencies are involved in preparing for and
responding to disasters and their medical consequences. FEMA and the
NDMS have such programs, as does HHS and Public Health, to name a few.
In order to reduce wastage and duplication of effort, as well as
improve coordination before the event and in the field, I believe that
all of these should reside under a ``single roof''. To be honest, I do
not know whose roof that should be but I do feel that the purpose of
this agency is to coordinate and provide the Federal Medical Response
to disasters. I also believe that as we are talking about the provision
of medical care, there must be active medical oversight and input as a
key component of the process.
Furthermore, the agency that oversees these programs must have some
flexibility to deal with response and other issues. Many of us in the
medical community find the inflexibility and slavish devotion to rules
and regulations we encounter with FEMA to be counterproductive to
disaster response. Personnel tasked with specific responsibilities
should not have to worry whether their decisions made during events
will be second guessed afterwards, in the comfort and safety of
headquarters by accounting and legal personnel. In addition, the
response must have a dedicated medical logistical group, solely tasked
with supporting the medical assets, both in the field and during the
planning and preparation phase. Under current FEMA and NDMS operations,
support of team medical needs has been less than stellar.
Lastly I must ask this body and the American public to be realistic
in their expectations of what will happen after a major disaster.
Federal medical assets will be coming. We are not going to be there as
soon as the smoke clears. Personnel must be mobilized and they and
equipment moved. Assessments of needs must be done to determine what is
needed and where and then those assets sent in and setup. That is not
going to happen in just a few hours, but realistically may take several
days.
To summarize my remarks, recent natural disasters, which are as
close to a catastrophic event as our system has faced, severely taxed
our capabilities. Our existing disaster medical response assets at
Federal, State and Local levels did meet the challenge. We have learned
much from these events and can apply those lessons to dealing with the
medical aspects of a future Biological or Nuclear related attacks or a
catastrophic natural disaster.
Our catastrophic medical response plan must include:
1. Equipping, training and hardening local medical
infrastructure and rescue assets so that they remain functional
after the event, with adequate supplies to operate in the
immediate post event period.
a. Provide the funding and support to enable surge
capacity at the local level to deal with the influx of
victims following such catastrophic events.
b. Provide adequate decontamination capability
c. Provide adequate medical supplies and
pharmaceuticals in storage to support the initial
``local'' phase.
2. The Federal Catastrophic Medical Response must be scaleable,
flexible and rapidly deployable, with trained personnel. This
response must have its own dedicated supply chain that can
support the operation consistently.
a. The Federal response must be coordinated such that
multiple agencies are not duplicating the efforts in
advance and during the event and the there is
consistency in how the program and response is run.
b. While a number of options exist to accomplish this,
the NDMS is currently the best positioned of the
Federal medical response agencies to carry out this
mission and needs to be supported.
c. The Federal Response to an event must be ``long
term'' as Biological and Nuclear events have long term
medical consequences
3. During a Catastrophic Event such as a terrorist attack with
an IND or, if we have advance warning, such as in a Category 5
Hurricane, the Federal Government must have the authority to
mobilize and engage assets, without waiting for the request
from the local officials.
a. Eliminate the requirement, during Catastrophic
Events, which under the Stafford Act, has the states
paying for up to 25% of the response cost for Federal
Assets. The question of how the state can come up with
the funds may serve as an impediment to asking for
Federal help.
b. Federal Response assets of all types need the
authority to engage and carry out their respective
missions during a Catastrophic Event, without waiting
for local or state requests. This will shorten Federal
Response times and bring more assets to bear on the
event. This is a major change from the current National
Response Plan and Stafford Act.
4. Federal Disaster Medical Response for all types of events
needs to be under a single agency umbrella, to eliminate
duplication of effort and improve communication
5. Lastly, our response programs MUST be sustained. We have
bought large amounts of equipment and supplies and distributed
them or stockpiled them. These items require maintenance and
even periodic replacement. Personnel must be trained and
retrained. Otherwise they and the equipment lose their
effectiveness. The Civil Defense Packaged Disaster Hospitals of
the 1950'-60's all rotted in storage, for lack of support
money. Congress must continue to support these efforts, not
only today, but in the future.
It is not if we will have a catastrophic event, but when. I again
thank you for the opportunity to speak and I assure you and the
American people that when such an event happens, and we pray it does
not, the Medical and Response communities will be there and will do our
best for our fellow Citizens. Thank you
Attachment 1: Summary of Federal Medical Contingency Station
Department of Homeland Security/Federal Emergency Management Agency
(DHS/FEMA) is developing two Prototype Field hospitals which will be
called Federal Medical Contingency Stations (FMCS) type I in
2005.Sec. ne will have its own sheltering and support system and the
second will require a building to be placed in. Both will have a one
hundred forty (140) bed capacity, Emergency room, Lab, X-ray, Pharmacy,
Central Supply/Processing, Operating rooms, Post Operative Unit, Labor
and delivery and intensive care units. The two Split field hospitals
could be combined as a single fixed or mobile 270 bed facility.
These two facilities will be staffed by the National Disaster
Medical System (NDMS), now under DHS/FEMA. These Medical response teams
will begin training and exercising with the FMCS Type I units in 2006
after the units are packaged. . .The exact locations that the two
medical units will be stored and maintained have not been determined at
this time. Funding to maintain, train and evaluate the units is in the
requested FEMA 06 budget under Medical Surge Capacity.
DHS and HHS have been collaborating closely for many months on the
design and operational issues for the Type I units.
Attachment 2: Listing Patient contacts since start of operations and
current personnel deployed by NDMS, based upon FEMA Region
HURRICANE KATRINA
NDMS RESOURCE STATUS REPORT
Updated: 10/14/05-0700
REGION IV: Through Reported Operational Period: 10/13/05: 0700-1900
--Total Patients Treated = 16,477
--Total Number of Personnel in the Field = 75
REGION VI: Through Reported Operational Period: 10/13/05: 0700-1900
--Total Patients Treated = 40,995
--Total Individuals Immunized = 59,917Total Number of Personnel
in the Field = 383
HURRICANE RITA
NDMS RESOURCE STATUS REPORT
Updated: 10/14/05--0700
REGION VI: Through Reported Operational Period: 10/13/05: 0700-1900
--Total Patients Treated = 9,074
Total Number of Personnel in the Field = 49
Attachment 3:
National Disaster Medical System Response Teams
22 Disaster Medical Assistance Teams
(Fully Operational/Operational)
33 Disaster Medical Assistance Teams
(Augmentation/Developmental)
4 National Medical Response Teams / WMD
5 Burn Teams
2 Pediatric Teams
1 Crush Medicine Team
3 International Medical / Surgical Teams *
3 Mental Health Teams
3 Veterinary Medical Assistance Teams
11 Disaster Mortuary Operational Response Teams (1 WMD)
10 National Pharmacist Response Teams
10 National Nurse Response Teams
1 Joint Management Team
* Includes 1 under development
Dr. Bradley.
STATEMENT OF RICHARD N. BRADLEY, MD
Dr. Bradley. Chairman Linder, Ranking Member Langevin, Mr.
Thompson, thank you very much for the opportunity to address
you today.
I do represent the University of Texas Health Science
Center at Houston, and through a contract with FEMA, I serve as
the medical team manager on the Texas Task Force One Urban
Search and Rescue team. I did deploy to Hurricane Katrina and
several other incidents with them. However, the testimony I am
providing today is my own, and I am not testifying on behalf of
FEMA or the Urban Search and Rescue program or Texas Task Force
One.
The primary mission of an urban search and rescue team is
to rescue people from collapsed buildings. Thus, urban search
and rescue teams would be useful in the medical response to
mitigate catastrophic events. Specifically, they would have a
specific role in the medical response to a nuclear attack.
Since building collapse would be likely, urban search and
rescue personnel would search for trapped victims and provide
lifesaving care until the medical team extricated them and
turned them over to other medical care providers. The teams are
trained in the medical care of radiation victims, and the
medical members on the team know how to limit their radiation
exposure and deal with contamination.
A terrorist attack involving biological weapons would
present an entirely different scenario. While it is reasonable
to consider that such an incident may involve thousands of
people needing medical care, we would not expect there to be
any collapsed buildings or anyone in need of rescue.
While an urban search and rescue task force does have 70
highly trained members, the general level of medical training
is that of the emergency medical technician. A full task force
has only two physicians and four paramedics. Now, while the
National Disaster Medical System does credential these
providers as Federal health care providers, the Urban Search
and Rescue system has neither designed nor equipped their teams
for handling large numbers of casualties.
The treatment priorities for Urban Search and Rescue
medical personnel are, first, injured or ill Urban Search and
Rescue members; second, trapped victims; third are search dogs;
and finally other disaster victims at the incident scene. The
six people on our team are not equipped to operate
independently. We depend on the rest of our team for command,
logistical and support functions. Thus, while total activation
of the Federal Urban Search and Rescue system would provide
approximately 6,000 highly trained personnel to FEMA, they
would be of minimal benefit in the medical response to a
terrorist attack using biological weapons.
In addition to direct medical care, the impacted community
would need services such as laboratory detection, quarantine,
isolation, disease control, disease tracking and mass
vaccination. It is really hospitals and health departments that
are the best providers of these services.
So, Mr. Chairman, to answer your question, we are better
prepared, the FEMA Urban Search and Rescue team, for handling
the medical aspects of a biological and nuclear attack,
specifically a nuclear attack, as long as it is within the
program that we were designed for, which is rescue and medical
care of trapped people.
Beyond the Urban Search and Rescue aspects, there are some
other things that we could do to improve our preparedness to
deal with the medical impacts of a catastrophe.
We know that everything begins locally. It is the local
emergency manager who is responsible for coordinating the
disaster response. There are a lot of resources that he or she
will need and has direct control over, such as fire, police or
EMS, but there are other resources that he does not have
correct control over, such as hospitals and doctors. This is a
significant challenge for him. He is responsible for ensuring
that hospital care is capable, but has no authority over the
hospitals to compel them to respond.
I suggest that we consider developing a template for a
memorandum of agreement between the emergency manager and the
hospital, and this agreement could address a number of things,
including specific response options for each hospital, who
would have the authority to initiate those response options,
and then how those response options would be paid for. Then, of
course, once all the local community assets have been deployed,
the emergency manager is going to look for help from the State
and Federal Government.
We know that the Federal government, the State government
is not going to respond until the local emergency manager calls
for it. But I would like to consider the possibility of sending
in an advisor right away, even before the resources were
requested, someone who can help the local emergency manager
understand what Federal resources are available and help him
tailor his request, because often the emergency manager may not
know exactly what the details are of each Federal asset that
could come.
So we are better prepared now in the Urban Search and
Rescue realm, but I look at how we can support hospitals and
support the local emergency manager more fully in terms of
tailoring his or her requests.
Mr. Linder. Thank you, Dr. Bradley.
[The statement of Dr. Bradley follows:]
Prepared Statement of Dr. Richard N. Bradley
Chairman Linder, Ranking Member Langevin, and other distinguished
Subcommittee Members, thank you very much for the opportunity to
address you today. My name is Dr. Richard Bradley. I am the Medical
Director of the Emergency Center at Lyndon Baines Johnson General
Hospital in Houston, Texas, and an Associate Professor of Emergency
Medicine at The University of Texas Health Science Center at Houston.
The UT Health Science Center at Houston is the most comprehensive
academic health science center in the Southwestern United States. We
are educators, students, physicians, researchers, dreamers, explorers,
and inventors. We have six schools, several institutes, a psychiatric
hospital and a multi-specialty group practice--all focused on improving
health and preventing disease through education, research and clinical
service. We work for our patients, our community and for humanity. Our
institution, its faculty, health professionals and staff were heavily
involved in Katrina recovery and relief efforts both in Louisiana and
in Houston. We provided health care for evacuees; advised elected and
appointed officials in all jurisdictions about public health and
recovery efforts; and assisted people in need in many other areas. I am
proud to be a member of the faculty because our leadership and my
colleagues responded quickly and with enormous compassion.
I also serve the University as the Associate Director for Emergency
Medical Services Preparedness at our Center for Biosecurity and Public
Health Preparedness. The center educates the frontline public health
workforce, medical and emergency responders, key leaders, and other
professionals to respond to threats such as bioterrorism, emerging
infectious diseases, and other emergencies affecting our communities.
Through a contractual relationship between the university and the
Federal Emergency Management Agency (FEMA), I serve as a Medical Team
Manager with Texas Task Force One, a FEMA Urban Search and Rescue
(US&R) team. I have deployed to several incidents with this team, most
recently to Hurricane Katrina, where our team performed hundreds of
rescues in New Orleans. Based on my first-hand experience as an
emergency physician working with the US&R team, along with experience
from participation in other disaster responses, I have formed several
opinions regarding the importance of effective medical response in
mitigating catastrophic events. However, the testimony I am providing
today is my own--I am not testifying on behalf of the FEMA US&R program
or Texas Task Force 1.
FEMA US&R Teams are Prepared to Respond to Nuclear Attacks
US&R involves the location, rescue, and initial medical
stabilization of victims trapped in confined spaces. Structural
collapse is the most common cause of victim entrapment. Additionally,
transportation accidents, mines and collapsed trenches may entrap
people. US&R is considered a ``multi-hazard'' discipline, as it may be
needed for a variety of emergencies or disasters, including
earthquakes, hurricanes, typhoons, storms and tornadoes, floods, dam
failures, technological accidents, terrorist activities, and hazardous
materials releases. The events may be slow in developing, as in the
case of hurricanes, or sudden, as in the case of a nuclear attack.\1\
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\1\ FEMA. About US&R. [Online]. 2004 [cited 2005 Oct 13];[1 page].
Available from: URL:http://www.fema.gov/usr/about.shtm
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There are currently twenty-eight US&R teams in the United States.
Each team can deploy in either a `heavy' or a `light' configuration. In
the heavy configuration, the team deploys with seventy people, all
trained to at least the technician level in their area of specialty.
These specialties include high angle rope rescue, confined space
rescue, technical search, weapons of mass destruction (WMD) and
hazardous materials operations, defensive water rescue, medical care
and communications. Each task force is capable of operating round-the-
clock, is completely self-sufficient for the first 72 hours, and can
sustain operations for up to ten days.\2\
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\2\ FEMA. Typed resource definitions: search and rescue resources.
[Online]. 2005 [cited 2005 Oct 13];[41 pages]. Available from:
URL:http://www.fema.gov/pdf/nims/508-8_search_and_rescue_resources.pdf
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A terrorist attack involving nuclear weapons would likely create a
situation with multiple casualties. Damage to structures may trap
numbers of people. Responding personnel would need to monitor and
control exposure to radiation and control contamination.
The US&R system could be part of the medical response to this
scenario. In the past few years, all of the members of the system have
completed training in WMD and hazardous material operations. In
particular, the medical personnel on the team have training and
certification in handling these types of casualties. The teams carry
equipment to detect radiation and monitor personal exposure. They are
also prepared for contamination avoidance and control.
US&R Teams are Not Appropriate for Response to Biological Attacks
A terrorist attack involving biological weapons would present an
entirely different scenario. While it is reasonable to consider that
there may be thousands of people needing medical care, and a complete
overload of local medical resources, there would be no collapsed
buildings and no one in need of rescue.
While a US&R Task Force does have seventy highly trained members,
the general level of medical training is that of emergency medical
technician. A heavy task force has only two physicians and four
paramedics. While the National Disaster Medical System does credential
these individuals as federal health care providers, the US&R system has
neither designed nor equipped these teams for handling large numbers of
casualties.
The treatment priorities for US&R medical personnel are first,
injured or ill US&R team members, second, entrapped victims, third, the
team's search dogs, and finally, other disaster victims. The six
medical personnel are not equipped to operate completely independently
of the remainder of the task force--they depend on other task force
personnel for support in the logistical, planning and command areas.
Thus, while total activation of the federal US&R system would
provide approximately 6,000 highly trained personnel to FEMA, they
would be of minimal benefit in the medical response to a terrorist
attack using biological weapons. In addition to direct medical care,
the impacted community would need services such as laboratory
detection, quarantine, isolation, disease control, disease tracking and
mass vaccination. Hospitals and health departments are the best
providers of these services. If a community needs federal medical
assistance after a biological attack, Disaster Medical Assistance Teams
(DMAT's), and assets from organizations such as the Veteran's
Administration, The United States Public Health Service, the National
Guard and other Department of Defense medical assets are much more
appropriate.
Command and Control of the Local Medical Response
Effective medical response to a disaster begins locally and the
official ultimately responsible is the emergency manager. This
individual is usually the mayor or city or county manager, who, as the
local chief executive officer, is responsible for public safety and
welfare. He or she directs the response to the disaster by assessing
the needs and assigning resources to meet those needs. The emergency
manager must commit all appropriate local resources and mutual aid
before requesting state, federal or military assistance.3, 4
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\3\ U.S. Dept. of Homeland Security. National response plan.
[Online]. 2004 [cited 2005 Oct 18];[114 pages]. Available from:
URL:http://www.dhs.gov/interweb/assetlibrary/NRPbaseplan.pdf
\4\ While the emergency manager is ultimately responsible for all
disaster response, he or she generally delegates many emergency
response functions. Most jurisdictions will have a health officer or
other individual pre-designated to exercise emergency public health
powers. In many cases, this should be the individual directly
responsible to the emergency manager for medical and hospital issues.
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*ERR13**ERR14*Many of the resources that the emergency manager
needs to deal with the disaster are those that he or she has direct
command over, such as fire, police, EMS, public works, waste
management, etc. There are other resources that he or she needs but
does not have direct authority over, such as hospitals and doctors.
These are critical resources because ultimately, the emergency manager
is responsible to ensure that all victims get the medical care they
need. This is a significant challenge for the emergency manager: he or
she is responsible for ensuring hospital care is available but has no
authority over the hospitals to compel them to respond.
To complicate this further, even though federal law does require
hospitals and emergency departments to treat anyone with a medical
emergency, it does not require them to do anything to augment their
capacity to respond when a disaster strikes. As a result, many
hospitals faced with a nearby disaster will manage the overflow as the
do on any other busy day. This means that when the in-patient beds and
intensive care units are full, patients will backup in the emergency
department.
As local hospitals become overloaded, emergency managers will need
hospitals outside the immediate disaster zone to accept patients in
transfer. These hospitals are only required to accept transfer patients
if they have the capacity to care for them. The issue here is that the
receiving hospital defines its capacity without external validation. It
is under no obligation to call-in extra staff to create surge capacity
during a disaster.
It is clearly in the public interest to address this problem at a
national level. One possible solution would be to encourage local
governments to develop memoranda of agreement (MOA) with the hospitals
in their area. The MOA should specify several things. First, working
collaboratively, each hospital and the local government should develop
a number of specific response options they could invoke in time of
disaster. Some options would be general, such as agreeing to cancel all
staff time off and have all available clinical personnel work twelve-
hour days, seven days per week for up to ten days. Other options would
be specific, such as tasking the hospital to turn its day surgery
center into a ten-bed intensive care unit. The MOA would give the
emergency manager the authority to request hospitals to initiate any or
all of these emergency actions. It should also allow the emergency
manager to send field observers to each hospital to determine the
actual situation and workload during a disaster.
The MOA should also address reimbursement for hospitals and
physicians. During and after a disaster, they should continue to bill
patients for care they provide. This is appropriate, since, in many
cases, third-party payers have financial responsibility for medical
care. However, many individuals who require medical assistance after
the disaster will not be able to pay for it. Furthermore, hospitals and
physicians will experience unusual expenses. Most of these expenses
will be overtime pay, but they may also include the cost of renting or
purchasing extra equipment. Government agencies that request hospitals
and physicians to respond to the disaster should compensate them for a
potion of these unusual expenses. The MOA should specify the
reimbursement rate for each response option that the emergency manager
may request.
There are many advantages to this proposal. Each hospital and its
entire staff will be able to plan for and train to the exact requests
they may receive during a disaster. Emergency managers will gain an
understanding of the extent of the emergency medical resources
available in their community and will know when all of these resources
have been committed. This is a critical step in understanding when it
is time to ask for state or federal assistance. Finally, the MOA will
create a process to track and validate requests for reimbursement.
Government officials will be able to know the cost of the medical
response in real time. I urge our national leaders to consider
requiring the existence of such an MOA as a pre-requisite to full
federal reimbursement for disaster medical expenses.
Defining Health and Medical Resources
As hospitals and communities respond to meet the needs of the
disaster, they may need to request additional medical resources.
Medical response will be more effective when there is consistent use of
standard resource definitions. Whether the need is for a cardiac
monitor or a disease control team, everyone who deals with resource
requests must share the same definition of the resource. The solution
is to include hospitals and other medical personnel and teams into the
national resource typing system. Resource typing is designed to enhance
emergency readiness and response at all levels of government through a
comprehensive and integrated system that allows jurisdictions to
augment their response resources during an incident. Specifically, it
allows emergency management personnel to identify, locate, request,
order, and track outside resources quickly and effectively and
facilitate the response of these resources to the requesting
jurisdiction.\5\ The National Incident Management System (NIMS) has
already developed specific definitions of 120 different types of
resources, covering assets as diverse as `small animal sheltering team'
and `crawler cranes.' The typed resource definitions already include
some health and medical resources, but these are currently limited to
the response teams that have performed so well during past disasters,
such as DMAT's and Disaster Mortuary Assistance Teams.\6\
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\5\ The NIMS Integration Center. Resource typing. [Online]. 2005
[cited 2005 Oct 16];[2 pages]. Available from: URL:http://www.fema.gov/
pdf/nims/resource_typing_qadoc.pdf
\6\ FEMA. Typed resource definitions: health and medical resources.
[Online]. 2005 [cited 2005 Oct 17];[13 pages]. Available from:
URL:http://www.fema.gov/doc/nims/508-5_health_medical_resources.doc
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I would like to commend the leadership at FEMA for their foresight
in establishing these resource definitions. They are continuing to
refine and expand them and are inviting input from the emergency
response community as they proceed. I strongly encourage my health and
medical colleagues from around the country to provide expert
suggestions and comments to FEMA during this process.
Requesting State and Federal Medical Assistance
As the Emergency Manager determines that local and mutual aid
medical resources are fully committed, he or she will begin to request
resources from the next higher political authority, usually the state.
The state, in turn, fills resource requests as best it can, and then
requests assistance from the federal government.
Officials at the state and federal level may face the temptation to
question some resource requests coming from the local emergency
manager. It is clearly possible that some requests may not be
practical, and others might be unreasonable. However, state and federal
officials should not spend an unreasonable amount of time to approve
reasonable requests simply because independent verification of the need
is not available.
I have personally seen what a good job our federal disaster
officials can do with these requests. After Tropical Storm Allison hit
Houston in 2001, I was assigned to the Emergency Medical Services desk
in the City of Houston's Emergency Operations Center. We were beginning
to understand the significant impact that losing six major hospitals
would have on our city. Due to the nature of the storm, the rest of the
country did not yet have any idea of its severity. Our initial request
for medical support was for four DMAT teams and twenty ambulances. Soon
after I submitted this request through channels, I was on a conference
call with the senior leadership of the National Disaster Medical System
(NDMS). I recall one of the federal participants on the call
questioning the severity of the situation in Houston, and suggesting
that it would be a good idea to wait and send a federal representative
to Houston to validate the need before sending assistance. The NDMS
leader on the call responded, ``No. If Houston says they need it, that
is good enough for me. We will send them what they are asking for.''
Any local official who deals with the medical consequences of a
disaster expects and appreciates responses like this.
Under the National Response Plan, federal officials do not send
resources to a disaster until requested by local officials.\3\ However,
this should not prevent federal disaster officials from sending
advisors in to the disaster area immediately after the incident has
occurred. These advisors could work with teams that perform rapid needs
assessments. They could then assist the local and state officials with
determining exactly what the needs are. The advisor could also counsel
the emergency manager and his or her staff to help them determine what
state or federal resources would best meet their needs.
Conclusion
We can mitigate disasters through effective medical response. In
relation to a nuclear attack, US&R teams are clearly a vital part of
the nation's response capability. In contrast with this, the US&R
system would probably not be a key part of our medical response to a
biological attack.
Looking beyond the US&R system, effective medical response will
require efforts to develop new resource definitions in the hospital and
medical area. Using these definitions, each hospital should work with
local government to determine a list of actions that it could take to
expand its ability to care for patients during a disaster. They should
formalize this with a written agreement that has provisions for
assigning activation authority to the emergency manager while
guaranteeing reimbursement for some of the unusual expenses that they
would incur.
As emergency managers are deciding what to request from their
hospitals, they must also decide what to request from state and federal
government. Since, in many cases they may not have a complete picture
of their current medical needs, and they may be unfamiliar with all of
the federal medical resources available, federal advisors should be
available early after a disaster occurs to guide them in making the
correct decisions.
Thank you very much for this opportunity to speak with you
regarding such an important topic.
Mr. Linder. Colonel Thompson.
STATEMENT OF COLONEL DONALD F. THOMPSON, MD, MPH&TM, SENIOR
RESEARCH FELLOW
Colonel Thompson. Mr. Chairman and members of the
committee, thank you for the opportunity to discuss how to
improve our domestic response capabilities.
I am a physician at the Center for Technology and National
Security Policy at the National Defense University, and I am
working on several studies examining terrorism, public health
emergencies such as SARS and pandemic influenza, and natural
disasters such as hurricanes and earthquakes.
Katrina exposed systemic problems in local, State, Federal
and military response coordination. For an effective response,
there must be coordinated planning between these levels of
government that incorporates the private sector, volunteer and
faith-based organizations and academic institutions. Each
agency must understand its roles and responsibilities, its
capabilities and limitations, and from whom it will obtain
additional resources when its capabilities have been
overwhelmed. We are destined to continued haphazard responses
until we get this right.
There are three broad areas that are essential to improved
national preparedness: first, requirements-based mass casualty
planning; second, working across institutional cultures of
response agencies; and third, learning coordinated crisis
management decision-making. A significant deficiency lies in
resolving problems that are too big for or beyond the
jurisdiction of State and local agencies and are beyond clear
Federal control. My written statement describes these areas in
detail.
The Federal Government has a leadership role in developing
preparedness principles, implementation strategies, and
opportunities to test and exercise local plans. Perhaps most
critical, though, is that funds should be provided with strings
attached to cajole local and State agencies to develop
interconnected regional plans. To paraphrase General George
Patton, The best plan is useless if executed too late.
Successful decision-making must be demonstrated in staged
crisis management exercises that proceed to the point of
failure, so all deficiencies can be identified and corrected.
Opportunities for senior leaders to learn about crisis
decision-making in such realistic environments are almost
nonexistent. Some are suggesting that the Defense Department
assume more responsibility in the case of domestic disasters,
but a more appropriate role might be more proactive engagement
in the planning process. As Katrina lessons are analyzed, we
must identify the mechanism by which military medical,
logistics and response planners may engage in planning at the
appropriate Federal, State and local levels. Such a forum
should be cosponsored by the Departments of Homeland Security,
Health and Human Services and Defense. If these agencies work
together to develop effective plans that incorporate public,
private and volunteer resources, the risk of terrorism and the
impact of natural disasters will be reduced and the homeland
security will indeed be more secure.
Mr. Chairman, I request my complete statement be included
in the record.
Mr. Linder. Without objection.
Colonel Thompson. I thank you for the opportunity to appear
before you, and will be happy to answer your questions.
Mr. Linder. Thank you, Colonel Thompson.
[The statement of Colonel Thompson follows:]
Prepared Statement of Colonel Donald F. Thompson
Mr. Chairman and members of the committee, I thank you for the
opportunity to appear before you and discuss ways to improve domestic
medical response capabilities within the United States. I am a
physician and a Senior Research Fellow in the Center for Technology and
National Security Policy at the National Defense University, and am
working on several studies examining preparedness for and response to
terrorism, public health emergencies such as Severe Acute Respiratory
Syndrome (SARS) and pandemic influenza, and natural disasters such as
hurricanes and earthquakes. I would like to share with you some common
themes I have identified that suggest opportunities for improving our
nation's ability to respond to such catastrophes.
Katrina exposed systemic problems in local, state, federal, and
military response coordination, problems that will be much more severe
and have much more negative outcomes in the event of a terrorist attack
in multiple cities. The strained medical response when there were only
a few dozen serious injuries as a direct result of the hurricane shows
that there is much to be done to prepare for a terrorist incident that
suddenly produces hundreds or thousands of casualties in multiple
locations. This underscores the importance of coordinated preparedness
planning between these levels of government that incorporates the
private sector, volunteer and faith-based organizations, and academic
institutions. It is crucial for response agencies at each level to
understand their roles and responsibilities, their capabilities and
limitations, and from whom they will obtain additional resources when
their capabilities have been overwhelmed. We are destined to continued
haphazard responses until we get this right. While this discussion
focuses on mass casualties, the principles apply in the law
enforcement, logistics, evacuation, recovery, and communications areas
as well.
Difficulties in responding to a catastrophic event are particularly
apparent and challenging in the medical and public health areas, when a
coordinated civil-military response will likely be needed for an
incident that produces significant casualties. There is no health care
``system'' in the United States; there is instead a vast collection of
public and private institutions, agencies, and individuals that deliver
healthcare services, only a small portion of which are provided by
local, state, and Federal authorities. Civilian referral hospitals are
largely unprepared to handle the large patient load from a catastrophic
event. Hospitals are often filled to capacity, have few isolation beds
for contagious infections, and have insufficient staff to handle a
large influx of patients. If an attack involved the real or perceived
threat of biological or chemical weapons, civilian hospitals might
refuse to take contaminated or contagious casualties altogether.
Needs to Improve National Preparedness
There are three broad areas that are essential to improve national
preparedness: requirements-based mass casualty planning, learning to
work across institutional cultures of response agencies, and learning
coordinated crisis management decision-making. In the coming weeks,
analysis of the local, state, and federal response to Katrina will
yield details about--and insights into improving--these elements, so
only a brief description of them is necessary at this point.
T3Requirements: Comprehensive planning for a mass casualty response
must start with defining requirements, identifying capabilities needed
to meet them, and then linking particular units or personnel to
particular needs in specific locations. Policies and procedures must be
developed to task particular resources for an actual mission, reimburse
all associated costs, and backfill the unit or personnel for whatever
it was involved in when tasked.
It is difficult to predict the types and numbers of casualties from
a conventional explosion, a communicable biological weapons attack,
release of a chemical agent, a nuclear weapon detonation, or a
radiological dispersion device where a conventional explosive has been
contaminated with radioactive material. Numbers of casualties would
depend on whether the explosion or release takes place indoors or
outdoors, in a densely populated area, in or near a mass transit
system, or at the busiest time on a weekday. These complexities are the
first order effects of the attack--the victims directly injured,
exposed, or contaminated by the event.
Complexities increase exponentially through second and third order
effects, the unintended consequences of the event. People exposed to
radiological material or anthrax spores will track the material on
their shoes and clothes, endangering more. Those fleeing an incident
area may move into a more hazardous zone. Persons exposed to a covert
release of a communicable biological agent such as smallpox, plague, or
influenza will depart the initial area of exposure and travel to their
homes, school, work, or around the world on commercial air flights
while incubating an infection. They become a risk to others and cause
secondary cases as person-to-person transmission takes place.
These types of complexities, especially those that deal with how
people might respond in a crisis, cause many officials to move such
requirements planning into the ``too hard to do'' box. In actuality,
however, much supportive work has been done in social network analysis
and adaptive response that sheds light on likely human behaviors. Well
worded, timely messages from appropriate opinion leaders often lead to
desired behaviors. The challenge that faces the nation, though, is who
should identify this supportive work, develop and test solutions, and
integrate strategies into response plans at all levels? From the local,
state, federal, and military perspective, this is indeed too hard to
do, because so much complex coordination is required. All-inclusive
answers to these and additional questions must be developed in a
setting that mirrors the likely response to an incident.
Capabilities: Capabilities that are available at each level of
response must be identified and compared with the likely requirements.
Since mass casualty response begins with local emergency medical
response, hospital emergency departments, and emergency management
agencies, the capabilities in each of these local sectors must be
clearly described. Next, response capabilities at the state level must
be identified. These are often limited to National Guard resources
under control of the Governor, as well as state law enforcement
resources. Few states have significant medical response resources,
though public health laboratories are essential in supporting a
response to a natural pandemic or a biological terrorism agent.
Finally, capabilities of various federal agencies must be defined.
Dangerous assumptions are often made that because a particular local,
state, or federal agency has a specific capability in its day-to-day
mission, that agency could provide the same capability in the event of
a national disaster.
Close Capability Gaps: As capability shortfalls are identified,
responsible authorities in response agencies at all levels must develop
plans for closing these gaps. Comprehensive plans include the required
capability, the point in the evolution of the crisis when it is
required, where the resource to meet this capability can be obtained,
who must authorize the request, who must approve its fulfillment, who
will reimburse associated costs, how the capability will be replaced
when it goes to the requesting location, and when it will be released
to return home. The most efficient surge capacity plans consist of
obtaining capabilities from neighboring areas through mutual aid
compacts. These agreements are used every day as police and fire
response units move across jurisdictional boundaries to meet short-term
surge needs.
Coordinated procedures and protocols for closing gaps beyond fire
and emergency medical services are rarely in place for regional and
multistate mass casualty incidents because few jurisdictions have had
to develop them. The hurricane-prone Atlantic and Gulf Coasts and
earthquake-prone California are usually exceptions, but by and large
the United States is not ready for a national mass casualty response to
a major incident.
Planning Deficiencies
National all-hazard mass casualty planning for acts of terrorism,
natural disasters, and public health emergencies includes three primary
components, of which only the first two are being addressed. The first
component is local and state response planning, which varies in quality
according to the local community's experience and resources. For a
terrorist attack such as the 2001 anthrax letters on the East Coast, an
efficient response must consist of integrated, coordinated planning
between all response sectors: public health, emergency medical
services, fire, law enforcement, hospital-based emergency departments,
private sector healthcare delivery, local emergency management
agencies, local elected officials, military installations, public and
private sector businesses who would provide food, water, utilities,
communications, and transportation, local volunteer organizations,
schools, faith-based organizations, and the news media. Such
comprehensive local planning is rare. Furthermore, Katrina showed that
even when plans are in place, they must be promptly executed. Local
leaders cannot afford to wait for the Federal Government to provide an
initial response.
The second component is planning for a Federal response, when
states may approach the Federal Government through the Department of
Homeland Security seeking Federal financial aid and response assets.
Real Federal medical resources are limited, though, and primarily
consist of small deployable medical teams from the National Disaster
Medical System. Planning for Federal alternate hospital facilities is
underway, but integration with actual local and state response
capabilities has yet to be accomplished. These facilities will provide
bed space to care for non-emergency hospitalized patients, so existing
hospital space can be reserved for new, more seriously injured
casualties. Katrina showed that staffing requirements for these
facilities cannot be met from Federal sources. A senior National
Disaster Medical System official underscored this deficiency when he
reported in a 2004 Institute of Medicine workshop that a catastrophic
disaster would require an additional 20,000 healthcare professionals
beyond what could be provided by the Federal government. Catastrophic
mass casualty planning is beginning at the federal level, but more
important is the need to build interoperable state, regional, and
federal response plans for smaller, more likely events.
The third component, not currently being addressed, is planning for
a national response where problems are addressed that are too big for,
or beyond the jurisdiction of, state and local agencies, and beyond
clear Federal control. This type of planning often includes working
with organizations and institutions that operate at the border between
state and society, such as private sector businesses, volunteer
organizations, faith-based organizations, national professional
societies, and academic institutions. Such groups are not part of any
formal governmental structure, but play a crucial role in society,
providing essential support and cohesion. As Katrina demonstrated,
involvement of these groups is essential to disseminate information via
trusted local opinion leaders, to identify volunteers to assist in a
mass casualty response and to maintain trust in local, state, and
Federal authorities.
The Federal Role in Mass Casualty Planning
The Federal Government has a leadership role in all three of these
planning components. Federal agencies must support local and state
agencies by providing principles for preparedness, goals and
objectives, strategies for implementation, and opportunities for
testing and exercising local plans. Perhaps most critical is the
provision of funding with strings attached to cajole local and state
agencies to develop interconnected regional plans.
Federal agencies must identify resources that are likely to make a
difference in a local or regional terrorist or mass casualty incident
response. A chemical, nuclear, radiological, or biological attack may
call for the immediate deployment of capabilities that no local or
state government can afford to maintain. National sources of hospital
beds and medical equipment may be necessary, but identifying sufficient
healthcare professionals and providing them and the hospitals in which
they deliver emergency care with licensure and credentialing standards
and liability protection is a much more crucial federal task. Prompt
response actions are often hindered by built-in delays as requests for
assistance flow from local to state to federal officials, so action
thresholds for requesting additional help should be established in
advance.
The Federal Government must create an environment in which best
practices can be developed and tested. Alternative models for national
solutions should be prototyped and fine tuned in a multistate region,
then provided to state and local governments for adaptation to local
needs. These models should include sources, organization, and
management of healthcare professionals; credentialing, training, and
personal protective equipment; and liability protection and
reimbursement. Tools should be provided to maximize existing hospital
bed space and to create alternate facilities, transport casualties to
regions with excess capacity, and identify funding sources for local
hospital preparedness. National professional medical and legal
societies should be engaged to discuss mechanisms of triage and the
graceful degradation of the quality of emergency care that will take
place in the face of mass casualties.
Organizational Barriers to Coordinated Planning
The rate-limiting step in coordinated planning is the requirement
to work across bureaucratic, organizational, and professional barriers.
Communication and coordination barriers thwart communication
horizontally, with like agencies at the same levels of government, and
vertically, when proceeding up or down the chain of command.
Organizational cultures become barriers when moving across agencies or
business sectors; the resulting bureaucratic obstacles and
inefficiencies seem to be ubiquitous and can be overcome only with
sustained effort.
Crisis Decisionmaking
To paraphrase General George S. Patton, the best plan is useless if
executed too late. The best confirmation that planning and preparedness
efforts are adequate is to demonstrate successful decisionmaking as a
plan is executed in a staged crisis management exercise. Such tests
must intentionally focus on cross-jurisdictional crisis communication.
None of these steps can happen, however, until the basic
coordinated planning described above takes place. For Katrina, a
massive Federal response in less than 72 hours was widely criticized
due to a lack of understanding that the first response is necessarily a
state and local responsibility.
Current Deficiencies
Much positive work has been accomplished in the four years since
September 11 and the subsequent anthrax attacks, but much remains to be
done. For example, planning and training efforts are largely intra-
agency rather than interagency. Federal funding supports this stove-
piped approach rather than requiring cross-sector planning. Exercising
of plans is rare, and the few that are exercises usually stop well
before the point of failure, so true capabilities and limitations are
rarely identified and corrected. Opportunities for senior leaders to
learn about crisis decision-making in a realistic environment are
almost nonexistent. There is little evidence of integration between
local-state planning and federal planning. Catastrophic mass casualty
planning certainly needs to be done at the federal level, but more
important is the need to build interoperable response plans between the
state, regional, and federal levels.
A national target for preparedness for combating terrorism has been
proposed by the Gilmore Commission and applies equally to any domestic
emergency:
Preparedness for combating terrorism requires measurable
demonstrated capacity by communities, states, and private-sector
entities throughout the United States to respond to acute threats with
well-planned, well-coordinated, and effective efforts by all of the
essential participants, including elected officials, police, fire,
medical, public health, emergency managers, intelligence, community
organizations, the media, and the public at large.
The tangible need for the United States is integrated, coordinated,
all-hazard response planning. All requirements, capabilities, and
potential sources must be considered and courses of action developed to
close gaps. Plans need to be developed and realistically exercised,
then improved, and exercised again. Training then must be developed
that supports integration of these plans into day-to-day actions at
every level.
Some are suggesting that the Defense Department should assume a
greater role in responding to such domestic disasters, but a more
realistic role might be proactive engagement in this planning process.
The military possesses several core competencies that directly support
mass casualty planning. These were brought out in the Defense Science
Board 2003 Summer Study on DOD Roles and Missions in Homeland Security
and include training, experimentation, and operational-level planning
and execution. The need persists, though, as Katrina lessons are
analyzed, to identify the mechanism in which military medical,
logistics, and response planners may engage at the appropriate Federal,
state, and local levels. Military planning for civil support will be
ineffective if it is not carried out with all the agencies involved in
a response. Engagement at the Federal interagency level is important
but insufficient. It is incumbent on leadership to create the national
forum in which functional, effective mass casualty preparedness
planning can occur across artificial bureaucratic barriers.
Such a mass casualty planning forum should be cosponsored by the
Departments of Homeland Security, Health and Human Services, and
Defense, but must address local and state needs first. Its charter
should be to support the development by states of local, state, and
regional mass casualty preparedness and response plans, rather than
simply Federal response plans. It must include private sector and
volunteer capabilities, and must engage local and national medical
associations. In the wake of Hurricane Katrina, this forum could
initially focus on the various tasks associated with evacuation of the
Gulf Coast, alternatives available when local resources and
infrastructure are completely overwhelmed, and the preparedness and
response steps necessary to minimize the consequences of a future
natural disaster or terrorist attack in this region. If an earnest
effort is made to develop effective plans that incorporate public,
private, and volunteer resources, the risk of terrorism and the impact
of natural disasters will be reduced and the homeland will indeed
become more secure.
Mr. Chairman, this concludes my prepared statement. With the
Committee's permission, I request my formal statement be submitted for
the record. Mr. Chairman and members of the committee, I thank you for
the opportunity to appear before you and I will be happy to answer any
questions that you may have.
Mr. Linder. Dr. Freeman.
STATEMENT OF JENNY E. FREEMAN, MD
Dr. Freeman. Good afternoon. Thank you, Chairman Linder,
Ranking Member Langevin and members of the committee.
My name is Jenny Freeman. I am here today to discuss an
issue which is important to me and, I believe, affects every
American, that of the ability of the government to respond
appropriately to protect our citizens in a time of disaster.
My comments come today not only as those of a concerned
citizen or as one who has trained and been part of the mission
and preparedness process of the NDMS, but more importantly, as
one who has actually served on a real deployment. I believe
that this provides me with a perspective I could not have
obtained either by listening to the experiences of others or by
participating in a mythical demonstration or a training
exercise.
I am a pediatric cardiac surgeon by original training. In
that process, I was trained by physicians who stress both
medicine and systems analysis. I understand how important it is
to develop a system that is automatic so that in a critical
situation, the system would have a strong foundation for work
and provide the best patient care.
I have started several surgical programs, run a surgical
practice and founded three businesses, two medical device
companies and a Wall Street health care research analysis firm.
I continue today to practice medicine, supporting two
understaffed area hospitals. I have included my biosketch and
CV in the record.
Relevant to my input here, I have provided charity services
in Nigeria and the Philippines, served on the Defense Science
Board Task Force on Defense Against Biological Weapons, chaired
by George Poste and Michael Hopmeier in 2000, and became a
member of the International Medical and Surgical Response Team
East in 2003.
Under the auspices of that team, I was deployed to help
fill out physician requirements for the Georgia-3 DMAT team in
the G8 Summit in June of 2004. My written testimony revolves
around what I personally observed during the G8 deployment. I
have included excerpts from the journal that I kept there, as
well as the after-action report of Tim Crowley, which Mr.
Langevin mentioned in his opening remarks and I don't need to
repeat here.
I remain on the team, unlike Mr. Crowley--Dr. Crowley,
although after this testimony, I may never be chosen to deploy
again. To date, I have trained with the team for 2 years, have
been part of the ready team for missions including Pakistan,
Katrina and Bam, Iran, and actually deployed for support of the
G8 mission in Georgia in 2004. I believe that this direct
experience allows me to draw a number of conclusions based on
real observation, given my previous experiences. This may
provide input different from what you may receive from those
who have merely studied, but never been part of a real event.
I was concerned from the time I received predeployment
briefing materials to the G8 and I began a journal my first
night. The first paragraph reads, June 6, 2004: ``Based on my
first night at the MACC sick call station, it became apparent
that it would be useful if I had a better understanding of the
mission of this particular facility, a specified set of goals
and objectives,'' and it goes on from there. Four days later I
left with no better information or understanding. I believe
that this represents a microcosm of the bigger picture,
unfortunately.
First and foremost, from what I have seen, I believe that
there was a nearly complete lack of understanding of the role
of the DMAT in the natural disaster process, and that stems
from an even greater problem at the very highest policy levels
as to the role of the Federal Government in responding to
disaster.
While I admit that my observation comes from one who is not
at the policy level, it has sadly been borne out by the abject
failure of our Nation at almost all levels to effectively
respond to the recent events surrounding Katrina, to the Chiron
influenza vaccine debacle last year, and to what I see as the
obvious lack of preparedness for the possible emergence of
avian flu that we should be addressing now. In my mind, we are
still sorely underprepared for the H5N1 flu strain despite
long-standing predictions and even the Chiron wake-up call.
These flus and hurricanes that I mentioned are examples of
known cyclic events that we could be well prepared for, yet we
have not been able to develop a proactive plan to mitigate the
events of such expected disasters. In my mind, this bodes
extremely poorly for the greater unknowns we might face in a
bioterrorism scenario.
Due to this fundamental lack of clear mission and set of
goals, the medical response system was unable to effectively
plan and execute even a scheduled mission such as the G8. I am
not sure that any NDMS mission has ever been optimally
conducted. I wish to note most strenuously, this is not due to
the failing of dedication or professionalism at the operational
level, but primarily due to a lack of direction and guidance
from the very highest levels of Homeland Security and medical
preparedness. My colleagues and I have dedicated considerable
time and effort, taking tolls on both professional and personal
lives in order to support this truly laudable mission; however,
we have been let down and not supported by these efforts.
I believe, based on my discussion and discussion with
colleagues, that many of the following are fundamental issues
that must be addressed. There is a genuine need and role for
the NDMS in responding to a disaster, and it is the role of the
Federal Government to provide the guidance, support and impetus
for this mission to occur.
Number two, any response to a disaster is not just a
medical response, but is instead a combination of many factors,
including logistics, management, training, transport, security,
many things. To respond effectively, it is necessary that all
of these factors be considered systemically, not as isolated
bits and pieces. In my opinion, such an important system must
be tightly structured and staffed, at least in greater measure
by professionals and not relegated solely to a volunteer-based
organization or volunteer fire department.
Until we have a clear, rational and accurate guidance as to
what we as medical professionals will be required to prepare
and train for, we will all act as individuals doing the best
that we can in an extremely suboptimal manner. The result will
continue to be significant injury and death to the people that,
as a physician, it is my job to treat.
The recent focus on standardization of medical care through
evidence-based medicine has helped physicians transcend the
responses of individuals acting on isolated experiences, and
this has dramatically improved the outcomes. Similar structure
and standardization will be required to improve our track
record at disaster management.
Four, while the political one-upmanship considering the
result of Katrina and past disasters is certainly entertaining
and results in higher viewership on the nightly news, until a
realistic objective and undoubtedly painful review at all
levels of our national response to disaster is done, this is
nothing more than a sideshow, circuses for the masses.
If my last comments seem frustrated, they are, I have
dedicated my life from the time I first took the Hippocratic
Oath until today to saving lives, as has probably everyone here
on this panel. I see here the potential to save very many lives
thwarted by an inadequate and failing system.
I wish to close with a personal note. I have two children.
They will someday, I hope, have the opportunity to start
families and raise children of their own. I hope they never
have to face a disaster such as the poor victims of Katrina or
the people of Pakistan, if they are involved in a disaster.
However, I sincerely hope that our Nation is better prepared to
face it and protect them than it has been to date. I, as a
mother, physician and citizen, charge you with the
responsibility of leading us to a better state of preparedness.
Again, thank you for the opportunity to testify. I am
prepared to take any questions.
Mr. Linder. Thank you, Dr. Freeman.
[The statement of Dr. Freeman follows:]
Prepared Statement of Jenny Freeman, MD, FACS, FACC
Good afternoon. Thank you Chairman Linder, Ranking Member Langevin,
and members of the committee. My name is Jenny Freeman and I am here
today to discuss an issue which is important to me, and affects every
American: that of the ability of the government to respond
appropriately to protect our citizens, in time of disaster. My comments
today come, not just as those of a concerned citizen, or as one who has
trained and been part of the mission and preparedness process of the
National Disaster Medical System, but most importantly, as one who has
actually served as part of a real deployment. I believe this provides
me a perspective I could not have attained either by listening to the
experiences of others or by participating in mythical demonstration or
training exercises.
I am a pediatric cardiac surgeon by original training. In that
process, I was trained by physicians who stressed both medicine and
systems analysis. I understand how important it is to develop a system
that is ``automatic'' so that in a critical situation, the system would
have a strong foundation to work and provide the best patient care. I
have started several surgical programs, run a surgical practice, and
founded three businesses, two medical device companies and a Wall
Street healthcare research analysis firm. I continue today to practice
medicine supporting two understaffed area hospitals. I have included my
biosketch and CV in the record.
Relevant to my input here, I provided services in charity settings
in Nigeria and the Philippines, served on the ``Defense Science Board
Task Force on Defense against Biological Weapons chaired by George
Poste and Michael Hopmeier in 2000 and became a member of the
International Medical and Surgical Response Team East in 2003. Under
the auspices of that team, I was deployed to help fill out physician
requirements associated with the deployment of the Georgia-3 DMAT team
to the G-8 summit in June of 2004.
My testimony revolves around what I personally observed during the
G-8 deployment. I have also included in written testimony excerpts from
a journal that I kept there as well as the after action report of Tim
Crowley, a respected physician colleague, who described his
experiences, during his deployment in the aftermath of hurricane
Katrina. As a thoughtful and competent physician who wound up in a
command position, the disorganization that prevented him from providing
useful patient care was highly problematic. Over and over again he saw
physician and medical resources squandered--his team remained in Baton
Rouge being told there was no mission while the staff at the key West
Jefferson location were crying for help. When they finally got to West
Jeff and in turn asked for assistance the same sad story was repeated
with other teams and team members being held at irrelevant locations
with nothing to do. I should note that, upon Dr. Crowley's return from
the Katrina operation, he resigned from the ImSURT/DMAT team in disgust
at the lack of preparation, organization and mission knowledge
demonstrated by the management structure of the NDMS system.
I remain on the team, although after this testimony I may never be
chosen to deploy again. To date, I have trained with the team for two
years, been part of the ready team for missions including Pakistan,
Katrina and Bam, Iran and actually deployed for support of the G8
meeting in Georgia, June, 2004. I believe that this direct experience
allows me to draw a number of conclusions which are based on real
observation. This may provide input different from that many of you may
receive from those who have merely studied, but never been part of, a
real event.
I was concerned from the time I received briefing materials before
we even left for the G8 and I began a journal my first night. The first
paragraph reads as follows: June 6, 2004: ``Based on my first night at
the MACC sick call station, it became apparent that it would be useful
if I had a better understanding of the mission of this particular
facility, a specified set of goals and objectives, a clearer
understanding of protocols under which to operate, a list containing
primary and secondary contact information, a better understanding of
available resources and as much of a secondary action plan as could be
disclosed. If I had these things, I believe that I would be able to be
a better resource to FEMA/NDMS.'' Four days later I left with no better
information or understanding. I believe that this represents a
microcosm of the bigger picture.
First and foremost, from what I have seen, I believe that there is
a nearly complete lack of understanding of the role of the DMAT in a
national disaster and that this stems from the even greater problem at
the very highest policy levels as to the role of the Federal Government
in responding to disaster. While I admit that my observation comes from
one who is not at the policy level, it has sadly been born out by the
abject failure of our nation, at almost all levels, to effectively
respond to the recent events surrounding Katrina, to the Chiron debacle
surrounding influenza vaccine last year, and what I see as the obvious
lack of preparedness surrounding the possible emergence of avian
influenza that we should be addressing now. In my mind we are still
sorely under-prepared for the H5N1 flue strain despite longstanding
predictions and even the Chiron wake up call. These flues and
hurricanes that I mentioned are examples of known cyclic events that
could be well prepared for yet we have not been able to develop a
proactive plan to mitigate the effects of even such expected disasters.
In my mind this bodes extremely poorly for the greater unknowns we
might face in a bioterrorism scenario.
Due to this fundamental lack of a clear mission and set of goals
the medical response system was unable to effectively plan and execute
even a scheduled mission such as the G8. In my mind, it is unlikely
that ANY NDMS mission has ever been optimally conducted. I wish to
note, most strenuously, that this is not due to a failing of dedication
or professionalism at the operational level, but primarily due to a
lack of direction and guidance from the very highest levels of homeland
security and medical preparedness. My colleagues and I have dedicated
considerable time and effort, taking tolls on both our personal and
professional lives, to volunteer to support this truly laudable
mission; however we have been let down and not supported in these
efforts.
I believe, based on my experience, and discussion with colleagues
that of many that the following are fundamental issues that must be
addressed;
1. There is a genuine need, and role, for NDMS in responding to a
disaster, and it is the role of the Federal Government to provide the
guidance, support & impetus for this mission to occur.
2. Any response to a disaster is not just a medical response, but
is instead a combination of many factors, including logistics,
management, training, transportation, security, etc. To respond
effectively, it is necessary that all of the factors be considered
systemically, not as a variety of isolated bits and pieces. In my
opinion, such an important system must be tightly structured and
staffed at least in greater proportion by professionals and not
relegated solely to a volunteer based organization.
3. Until we have clear, rational and accurate guidance as to what
we, as medical professionals, will be required to train and prepare
for, we will all act as individuals, doing the best we can in an
extremely suboptimal manner, and the result will continue to be
significant injury and death to the people as a physician it is my job
to treat. The recent focus on standardization of medical care through
evidence based medicine has helped physicians transcend the responses
of individuals acting on isolated experiences and this has dramatically
improved outcomes. Similar structure and standardization will be
required to improve our track record at disaster management.
4. While the political one-ups-man-ship concerning the results of
Katrina and past disasters is certainly entertaining and results in
higher viewer ship on the nightly news, until a realistic, objective,
and undoubtedly painful review of all levels of our nation's response
to disaster is done, this is nothing more than a sideshow providing
circuses for the masses.
If my last comments seem frustrated, they are. I have dedicated my
life, from the time I first took the Hippocratic oath, until today to
saving lives. I see here the potential to save very many lives thwarted
by an inadequate and failing system
I wish to close with a personal note; I have two children. They
will, some day I hope, have the opportunity to start families and raise
children of their own. I hope they never have to face a disaster such
as the poor victims of Katrina, or the people of Pakistan, must today.
If they are involved in a disaster, however, I sincerely hope that our
nation is better prepared to face it, and protect them, than it has
been to date. I, as a mother, physician and citizen, charge you with
the responsibility of leading us to a better state of preparedness.
Again, thank you very much for this opportunity to testify and I am
prepared to take any questions you may have.
Memo, June 6
Based on my first night at the MACC sick call station, it became
apparent that it would be useful if I had a better understanding of the
mission of this particular facility, a specified set of goals and
objectives, a clearer understanding of protocols under which to
operate, a list containing primary and secondary contact information, a
better understanding of available resources and as much of a secondary
action plan as could be disclosed. If I had these things, I believe
that I would be able to be a better resource to FEMA/NDMS.
On arriving at the MACC sick call station, we noted that there were
no drugs at all and some discrepancy with supplies. Over the course of
the night we received drugs which were ``left over'' from the Epworth
facility. We initially noted a very significant shortfall between what
was here and what would be necessary to implement effectively the level
of care that we could provide with the other equipment we had, such as
intubation equipment. We had drugs that could be used to paralyze a
patient but no sedation to make it tolerable, we had a lidocaine drip,
but no injectable lidocaine with which to primarily treat an
arrhythmia, etc. We certainly were not fully equipped to perform as a
unit providing ALS level care,.
It soon became apparent, however, that there were deeper issues
relative to understanding what the actual mission of this clinic was
and what level of care that we were expected to be able to provide,
either now or under other potentially adverse circumstances. It also
became clear that we did not have adequate information as to what
protocols we were supposed to follow. We had little contact
information. There were numbers given out in the briefing, but I had
written those on the map that was handed out at the meeting, which I
had left in the car presuming incorrectly that any important numbers
that I needed would be provided in the sick call area or be in our
packets. We had the Brunswick Hospital address and driving instructions
to tell patients how to get there, but no telephone number or protocol
as to how to get patients into the Emergency Room or potentially out--
patient clinic environment.
Some other questions that arose here and in discussions with other
physicians at Epworth included:
Who exactly do I call and for what? Is there a back up number if
the original one is unreachable?
How do I transport out patients that require further or more
extensive care from the clinic?
How hard will it be to get ambulance services? now? later in the
week?
What are the criteria for strike team mobilization?
What are the criteria for the strike team to take care of patients
on site, vs bring back to strike team facilities vs send to hospital?
If the strike teams have supplies to care for one or two people is
that sufficient?
Over night, we did speak with Ron from MST who was helpful in
sending over additional drugs, and asked us to take an inventory and
find out what we needed in terms of drugs or supplies that were not
there. I said we could do that, but really I needed to know what level
of care we were expected to provide first in order to do that
adequately. He deferred the system related questions until the morning.
Shortly thereafter Stanley Krol of NDMS came in to introduce himself
and we discussed this with him as well.
I presume that is the intention for the Medical Strike Teams to
provide ALS level care, but it seems not to be so for the sick call
clinic. Clearly a full list of medications and supplies required for us
to do our job will depend on the expectation set and mission of each
facility or each team. If standard ALS level care is expected, we are
including a list of drugs that should be available. Please excuse the
formatting, but it was copied from an adobe file and I cannot correct
easily tonight. Supplies as found on a standard EMS truck would be
adequate should the mission be to either provide now or have the
capability to provide ALS level services. Such would include emergent
chest decompression equipment, large bore IVs, saline flush materials,
a burn kit, burn medications, trauma dressings, more than the 2 bags of
saline that we have now etc.
After discussion with Mr. Krol, we are going under the interim
guidelines of serving merely as a triage facility and not actually
attempting to treat any patients that require more than what could be
undertaken at a doctors office. Unfortunately, however, we still do not
have prescription pads either, so even though there is a licensed
physician here, unless we have a way to call in prescriptions that has
yet to be described we are unable to provide that function either.
Please understand that I clearly appreciate the complex nature of
this entire event and that this is really only a very tiny part of the
whole picture, but also please understand that I am trying to fulfill
my responsibility to my potential patients and need to ask for further
guidance in order to do so.
Addendum
June 10
On the morning of June 6, I passed this letter on through the
``Chain of Command''. I thought that I would jot down some further
comments from the next few days to describe the follow through and
consolidate my thoughts. Essentially, nothing changed, we never learned
our mission, we got a few random drugs and supplies. I discussed this
with Dr. Stringer on June 8 when he came over to make sure a form was
filled out properly and e-mailed the letter to him at his request that
night. I never heard back from him. On June 9, I met Gary Sirmons who
asked that I forward it to him as well. I also made copies of the
packet of information that was provided in a manila envelope for the
MACC sick call clinic (which included the preliminary materials
furnished to us over the web before we were deployed), a list of what
the Georgia 3 team was told to bring and what they actually did bring
and whatever random papers that were sent to give us instructions and
had been taped on the wall. I also wrote a somewhat rambling set of
journal type observations of the occurrences and my impressions..
Fortunately, we only saw a dozen patients or so the whole time, and
the most complex problems treated were hypertension and headache for a
week which we sent to a local hospital for evaluation and prescription
of antihypertensive medication and helicopter pilot with an infection
around the finger nail that I drained by using an 18 gauge needle to
slice the skin instead of the scalpel that we did not have. We had no
packing material (would have liked 1/4 inch gauze) so made a small wick
from the sterile covering of an eyepad which had approximately the
right dimensions and characteristics). I only did this because given
his demeanor, I did not believe that he would go elsewhere to get this
done.
Throughout this experience I was treated on more that a few
occasions like I was an idiot or like I was being refractory and not
cooperative. Or that I wasn't a real Emergency, EMS, FEMA, NDMS kind of
person, but more like a silly ivory tower surgeon that wanted
everything handed to them on a silver platter or like a stupid blonde
who couldn't figure out what to do or like someone who was just not
trying to be cooperative; or that I was not of ``the right stuff''; or
that I didn't know how to `` ``rough it'' '' and ``just do what has to
be done''. As it turns out, I have quite a bit of experience making do
at Bellevue in NYC in the 70s and 80s, in Nigeria, in the Philippines
and at new cardiac programs that I had started--and I have seen the
deficiencies in patient care and outcome in those environments (see my
attached CV). But it did not seem necessary in this kind of situation
to have to improvise or to settle for a substandard environment, with
months of planning and millions of dollars spent in preparation and in
the United States of America, optimizing the care of the support staff
assembled at a high risk event and also being available for an unlikely
but possible critical situation. I have also seen the benefits of ``
''institutional knowledge as developed by John Kirlkin in the 1960s-
1980s as he built the University of Alabama at Birmingham from scratch
into one of the premier cardiac surgical programs in the world at that
time, or second hand in talking to the Israeli's about the system they
have developed of conducting well orchestrated medical operations and
of training physicians to have the operational and leadership
experience to handle both missions and medical infrastructure
necessities.
In all of this I have no personal interest, no axe to grind, no
program to promote. I am merely a volunteer deployed for the first time
on such a mission with the opportunity to provide some (nearly)
external review. I believe from what I saw, that the system is severely
inadequate to meet even simple challenges adequately let alone
potential WMD scenarios. Despite what I thought to be completely
inadequate oversight and delivery of a functional operational plan by
Dr. Stringer, I believe that the system that permitted this level of
performance to exist without correction is far more worrisome.. As a
single unknown voice, I realize that it is highly likely that my input
will be discarded, but I believe also that it is my obligation and
responsibility to at least express my opinion in case it can provide
insight that might effect positive change. If it would be of any use, I
would be happy to provide further information.
Events recaptured between June 6 and June 10, 2004
On June 6, when I arrived I asked if we had gotten any information
about our mission or any thing else had been provided. I said again
that we really needed what was on a medic truck if we were supposed to
function at that level or that we needed to be told at what level we
were expected to be able to function. The response from the other staff
was that we just needed to make do with what we had and that it was
always like that. . . I was told when I asked about mission and
objectives that we had received some papers which were now taped to the
wall. There was a paper Entitled G8 Medical Coverage with a variety of
names and phone numbers and teams different from those that I was
familiar with, none of which I recognized and no indication of what to
do with this information ( as of June 10 I still have no clue who they
are or what I should do with the information despite asking many
people). On the wall I still could see the MST info I had scribbled on
the sheet of NDMS coordinators that Stan Krol had given me the night
before. There was still no information about who to call if a patient
was to be transferred out emergently and I still had the naive question
that given the security measures outside if 911 would work the same way
in this environment or a more problematic scenario. I continued to go
with my original plan to call 911 if there were any serious problems
(for lack of any better information). Later that night I was called by
MST and told to identify the Fire Response person from somewhere inside
the complex so that if I needed to send someone out I would know how to
get a hold of him because he would in fact be the one to help me do
that and arrange things. On the Georgia side of the complex I asked for
that person and was told that there was no one there in that capacity
that night, but was referred to the EMS representative. The EMS rep had
a colleague of his help me who had come from another facility which had
been evacuated because of a bomb scare. He came back and told me I
should call 911 and that he had spoken with the local EMS and told them
where the medical facility was within the complex so they should be
able to come over. At least I had an answer for that. Later I was told
that those people (fire and EMS response) should be strictly involved
in the large logistical process and in no way should be involved in
individual patient care.
There was another sheet on the wall labeled ``Response Objectives''
I have copied it below verbatim with questions that arose on first
perusal along side in red.
Incident Name: G-8 at Epworth Date Prepared: 6/6/200 Time Prepared
940 what about MACC clinic where I was--
was it the same mission?
4. Operational Period (Date/Time) 0800 thru 2200 June 6, 2004--page
began with 4 no indications of 1-3 were thos important points?
what about times other than 0800--2200 June 6?
5. Overall Incident Objectives
Provide Safe Work Environment for all team members
Treat all patients as per protocol--What protocol?
Observe all HIPAA regulations
Prepare Strike Teams for Immediate response
Obtain needed Shortfalls from Logistics--Shortfalls from what
list and serving what mission?
6. Objectives for specific Operational Period:
Team Safety
Best possible patient care--What is this???
Maintain team morale during entire period
Maintain adequate rest periods for all team members
Maintain inventory--What inventory are we supposed to have?
Promote communication with team and MST
Provide ongoing education
7. Safety Message for Specific Operational Period
Follow all instructions given--all safety briefings
Buddy System at all times
In/Out Board
Standard Precautions during patient treatment
8. Weather: See Attached Weather Sheet
As you might suspect, this is not what I had been hoping for. While
particular immediate incredulous responses to this paper are noted in
red above, the big picture remained that there was no indication of
what level of care we were supposed to provide, expected protocols to
follow or ways to adjust standard care to this slightly (but
potentially significantly) unusual environment. We did get several
other random medications--a vial of morphine, a few doses of injectable
valium and some vicodin. Some pancuronium to paralyze a patient for a
longer period of time and propranalol, no longer the beta blocker of
choice, but better than nothing.
I did not bother calling again or agitating, or going crazy trying
to figure out what I might want. I just went by what I had decided for
myself the first night--to treat this as having no more capacity than
somewhere between a high-school nurses station and a standard doctor's
office and to send anything else out to the hospital by either private
transport or ambulance. So I did not inventory things or try to prepare
for a variety of circumstances that I might envision occurring. I was
disconcerted however to hear the others on days talking about
intubating people if we had to etc, now that we had morphine. I said
one morning (I think it was the 8th) that I wished we had what was on
an EMS truck as a nice model if people expected us to provide ALS level
care. The response from my relief was that we had most of what we
needed and it was ``always like that'' ``you just gotta make do with
what ya got''. I asked if there were any large bore IVs if we needed
them and asked what about anything to decompress the chest if someone
had a pneumothorax--that there was not a pneumo kit or even a large
bore IV. I was told that there was a chest tube--I said but no
pleurivac suction--the response was that there was a chest tube in one
box with a Heimlich valve (which just lets air go out and not suck back
in). It was only two days later that I found out that we had no
scalpels at our place and that there was one at Epworth that they
wanted to keep for themselves. Hard to put in a chest tube with no
scalpel!! To me that also meant that I could not paralyze anyone to
intubate them because I could not perform a tracheotomy if intubation
was impossible. In one way this is all trivial detail, but it is merely
meant to demonstrate the cascade that occurs from inadequacies.
On June 7 I was told that I needed to fill out a full record for
every patient that came through, including those that just wanted two
tyelenol because they had left their bottle in the car or cepacol
throat lozenges because of a sore throat. I said that that was probably
not what was intended, and perhaps OTC meds could just be dispensed and
written in the med distribution log. I was told absolutely not. I asked
if we could question that in the morning and I was told yes, but could
I please just fill out paperwork on everyone. No other word ever came
back. Several people left over the next few days without registering,
saying that they would get meds elsewhere if they had to stay for the
questions.
On the evening of June 8, I was asked if I could fax over the
patient demographic sheet to MST. I said I had never seen such a sheet
and that we had faxed over the patient log for the full 24 hours the
night before along with the medications used so the drugs could be
restocked. I did not collect the information for this new form and it
was not obvious from the forms that I saw that we had been filling out
i.e. the patient and medication logs. I said I really didn't know about
the patients that had been there during the day, but some info was on
the other forms. I asked if I could fax those forms that had been
filled out from the day shift instead and they could take what info
that was needed. That did not seem to be a viable solution. I was told
to find the new form. I could not. I told MST that they would need to
fax it to me and that was done. When I got it, it had several
categories that I did not know how to fill out--one that asked for
state federal or local--I did not know where to put the air national
guard (was it federal or state or some of each) and one patient had no
record of branch of service or any other job description. Also I did
not know the disposition of the patients from the log (whether they
were sent out to go to the hospital or just back to work). Perhaps more
importantly if this was to be used for epidemiological reporting and
surveillance purposes, there were CDC categories. Because I had not
seen the patients, I did not know the CDC designation. There was a
category for cough, but I had URI written down. Did that count or not?
I said I would do what I could but that I doubted it would be complete.
I was speaking at first to the MST on duty and then Steve Allen who
finally said I needed to talk to Dr. Stringer.
Dr. Stringer called me and started to try to be aggressive about my
not wanting to fill out the form--I told him all of the above again and
that I would have no problem doing that for our shift, but for the
previous one, I would do what I could but I continued to have some
confusion as described and it would not be complete because I could not
find some of the data. I also asked if he had gotten my letter and he
said no he had not--and expressed annoyance that it had not been passed
along, blaming those who should have done so and saying he did not
understand why they had not. I told him that there were really some
issues regarding what our mission was supposed to be, what our
objectives were aside from providing best possible care and what we had
to work with. He said he had been struggling all day with the fact that
he had been working on all of this since September but still none of
the drugs that he had ordered for the units had been delivered. He said
that he understood that was a problem but that I should have gotten
most of what I needed by now and I should list what I was missing. I
brought it back to not knowing what I needed until I was told what I
was supposed to be DOING. He said that he had had little rest for a few
days but all that would get sorted out.
I then went about the task of filling out the requested form and
had most of it done except for places where I did not know the actual
answer I wrote in comments (i.e. 3 Air National Guard and 1 Georgia Air
National Guard not knowing whether they were in some way different i.e.
the question of being State or Federal) and URI next to section for
cough. I was surprised about a half an hour later to see Dr. Stringer
walk in. He walked in and sat down. He looked tired. He asked how
everything was. I started again to discuss that we really were kind of
a mish-mosh--with no mission--and that we had some equipment and
supplies, but were we supposed to be working at the level of a high-
school nurses station, a BLS ambulance, an ALS EMS vehicle etc. He
mentioned quite critically, almost angrily, that he had been by during
the day and no one told him there was a problem at all. I could not
figure out weather he was being critical of the day people for not
telling him or me for not just pretending everything was as it should
be.
Instead he was focused on the form and started to complain about
why I had not gotten the form from the day shift. I replied ``You mean
the form that I had never seen before and didn't know about until I was
told to find it? I asked how I was supposed to request something that I
did not know existed and wasn't that a Catch 22. Dr. Stringer
sheepishly agreed that was a problem, but then rebounded quickly, said
it was in our packets, and got more aggressive again. I said quite
firmly that it was not. I handed him the packet. He shuffled through it
and kept commenting that things weren't stapled and no wonder we
couldn't find anything. I said we had to undo some of the staples the
first night to Xerox patient care forms because they were our only
copies, but that a lot of things had not been stapled to start with. He
kept looking for the form of interest, but finally gave up when he
could not find it either. He also said that the designation for all of
the agencies as federal or state were in there in the briefing he had
sent out ahead of time, and didn't I get that since I was supposed to
have gotten that from my POC. I said I had gotten the briefing, but it
did not have information identifying the acronyms of different branches
of the service. He said they did but when I handed him the briefing he
dropped the subject. Again I said they were not--and he could not find
them either. I said there were no contact numbers for MST or for
ambulance service or anything either and he said they were only just
recently available. I said they could have been provided to the clinic
in a binder on site or some such. I bit my tongue in terms of saying
that his packet basically had no really useful operational information,
but rather described things such as how I should not shake hands with
anyone who did not shake hands with me first. He also mentioned that he
had put some information as to mass casualty in there so everyone would
know what to do. I have a copy of the entire packet if anyone is ever
interested. In my mind it is rambling and sorely insufficient.
I then went back to the discrepancy about the equipment supplied
and the drugs provided. I mentioned that really I would have to treat
this environment like a glorified nurses station because of the lack of
a full compliment of equipment and supplies to provide a higher level
of care, and that I was concerned that others might fall into the trap
of administering medications and performing procedures thinking they
had the right equipment and supplies and get into trouble when the full
armamentarium they were used to for that level of care was not present.
I threw out the example that I certainly would not feel comfortable
intubating someone, but would wait for the local EMS to arrive with all
of their equipment, supplies and drugs. In front of me and my co-
worker, Dr. Stringer brought down his voice and said--``Don't tell
anyone, it would be bad if you did, but the EMS here is very weak--and
we have people here--secret service people and all--it costs a lot of
money to train them they are very valuable and I don't want those guys
to get into trouble--just intubate someone if you have to''. I asked
``because the local guys can't intubate and it costs a million bucks to
train a Navy Seal and that kind of thing?'' and he just nodded and said
``You know, just do the right thing.'' I said that we were not fully
equipped to do that and he said to do what I could.
It seemed like his main objective in coming over to our place was
to fill out this form--he actually sat and reviewed it and made sure it
was filled out and filled some of it out himself. I said repeatedly
that more than anything we needed an understanding of the level of care
that we were supposed to be able to provide and under what
circumstances, routine, difficulty in transportation because of traffic
or other similar issues, but that received far less attention. I asked
also about filling forms for every one that came in--even for OTC meds.
He was vague but basically said, just do what's right. I mentioned that
we had been filling out the medication logs faithfully so that we could
feed into the restocking procedure correctly. He appeared puzzled and
didn't know what I was talking about. There was no such mechanism to
restock supplies based on usage. Rather if we ``got low'' or ran out of
something we should call MST. He asked me to fax the form over. Then he
left.
Later that night I was called up by MST and asked if they could fax
me a form to take to Stan Krol. I said sure. It was a similar form to
the one Dr. Stringer was so interested in but a summation of all sites
instead of just ours. I took it to Stan in the main big room on the
federal side and told him that Dr. Stringer had been by. He asked how
that went and I merely shrugged and smiled and told him to come by some
time.
On June 9, Stan Krol and Gary Sirmons came by the MACC clinic. I
was reading on a cot and sat up to talk. Stan asked if anything got
better after Stringer came by. I said no and described Stringer's visit
and the core problem again in moderate detail. Gary asked me to send a
copy of the letter I sent to Stringer.
On June 10 at 8 pm I got called and asked if I had been told by the
day shift what we were doing. I said no I had heard nothing from them,
but earlier in the day I was told that the plans had changed and that
we were going to have to work overnight instead of leaving at 10PM as I
had heard the previous night. She said no, that we were done at 10, and
we should pack up, but that Epworth would be staying open. I said that
I had asked specifically because I had wanted to leave on a 6AM flight
and had been told that the clinics were open until noon. She said she
would check. She called back and said that we should leave up one
station (and leave one of the three cots) but pack up everything else--
once again I ask, one station to do what?
We were told just to pack everything randomly in the containers
that we had because the Ga3 team had unpacked their usual tightly
organized and inventoried boxes to just bring what Dr. Stringer had
required (with strict instructions to bring no more) so there was no
organization coming in and none required going out. When the Ga3 team
came at 3 AM to pick up ``all but one station'', they told us that if
we needed anything we should call them since MST had been gone since
10PM and would not be back until the morning.
Of note, given circumscribed requests, the support people were very
helpful and responsive in attempting to fulfill them. Under proper
direction their efforts would have been more productive.
Mr. Linder. Some provocative comments by each of you.
We had a hearing, I think it was yesterday, of the
governors who pleaded that we not federalize these things. I am
hearing here a stream that we can't have an effective system
unless it is top-down driven.
Dr. Alson, I think you said the Federal Government needs
the ability to launch assets before we even hear from the
State. That is not the way we have operated in the past. Would
you expand on that?
Dr. Alson. Yes, sir.
As was seen in the events in Katrina, often an experience
in several of the other hurricanes--I will speak to my own
State; in North Carolina it was Floyd. The event happens in
your community, and it very quickly overwhelms the
capabilities. Much of the effort is often devoted to the
immediate things of rescue, whether it is pulling people out of
the floods or starting the search and rescue operations before
USAR arrives.
In many areas the State, local and emergency management
officials are not capable of taking the information that comes
in dribs and drabs and processing it. We have to wait, for
example, for the request to send Federal help, at which point
we begin to send in teams to carry out the assessments. We need
the ability to put them in and begin that process--often when
needs are identified, being able to go to the folks and say, We
have these assets here, we are ready to use them for you; or if
the need is there, even begin to use them.
Mr. Linder. When Floyd came to North Carolina, were FEMA
people on the ground in the planning stages of that? Because
they are routinely--Governor Bush--
Dr. Alson. Yes, there were FEMA people out in the area.
There were also State people.
Our team was deployed as a FEMA asset into the staging,
into the immediate area, but I ended up in one particular
county working where, quite frankly, a medical assessment was
nonexistent. They were concentrating on one, rescue, and two,
providing food and shelter, and had yet to conduct a medical
assessment of needs that they had in the community.
Mr. Linder. Dr. Freeman, you said that DHS should do a
better job of providing leadership and guidance. Most of the
medical expertise we have seems to be in HHS rather than DHS.
Would HHS be more competent to guide these teams than DHS? What
is your opinion on that?
Dr. Freeman. I am not at the level to make that decision. I
mean, I can give you reports from the field. I can give you a
potential analysis of a system failure. In terms of
understanding the resources in those difference organizations,
I am not the one.
Mr. Linder. Dr. Bradley, you commented that the local
emergency manager does not have any authority over universities
or hospitals. Should they?
Dr. Bradley. Yes, sir.
I don't think they should have authority over the hospitals
on a routine basis. However, my recommendation is that the
hospitals and the local government enter into this MOA--that
during a time of a locally declared emergency, the emergency
manager would have agreed-upon authority to direct the hospital
to implement specific actions that have already been agreed to
in the MOA.
One of the advantages of that is that would not only tell
the hospital what to do, the hospital could train for those,
knowing exactly what they could ask for. Also, if there was
reimbursement, that would make tracking the reimbursement a
much more simple process because hospitals could say, we are
clearly responding to this task from the local official.
Mr. Linder. Colonel Thompson, you said that we should have
requirements-based mass casualty planning. If you don't know
what kind of casualty is coming, how do you figure out the
requirements for planning it?
Colonel Thompson. Sir, the way the Defense Department tends
to handle these is, they do a worst-case scenario, a best-case
scenario and then a scenario in between, so that you will have
a situation where you will have a number of casualties, but
perhaps not something that is at the catastrophic level. Then
you will take something at that time catastrophic level and
plan for all kinds of contingencies there. Then you will go
down the center and plan for a contingency that is more in
between those two extremes.
Mr. Linder. Dr. Alson, you concerned yourself with the fact
that the evacuation piece needs to be reexamined for getting
people out. Did the evacuation piece work at all for Katrina?
Dr. Alson. I have no direct knowledge or involvement of
that particular portion in my response to Katrina. I was
running a field hospital in the Gulfport area, and any patients
we had to move, we moved into the local hospital. But it is my
understanding, in talking with other individuals, the component
did work; that it is still going to require some additional
effort, because this is the first time it was attempted. It
does involve a partnership of many, many agencies, not just
DHS.
Mr. Linder. Thank you. My time has expired.
Mr. Langevin.
Mr. Langevin. Thank you, Mr. Chairman.
Again, I want to thank our witnesses for their testimony
today.
Let me start, if I could, with Dr. Freeman, as you and I
have both mentioned in our opening statements you have had
members of your team that were deployed to Katrina. At this
point, I would like to give you the chance to elaborate on
that.
Can you give us some examples of what they saw? In
particular, I would like you to establish a time line of the
Massachusetts DMAT team deployment. When were they called, and
what was the sequence of events of their deployment? Put
simply, where did they go, at what time, and what did they do?
I will preface my remarks, too, before I turn it over to
you, Doctor, that I have a good friend who is an emergency room
physician. He is also part of a DMAT team, was deployed down to
Louisiana and found everything, in particularSec. n chaos,
obviously, but they didn't have a place for the docs to go at
least to the hospital, they really weren't wanted, they were
kind of in the way. So it was poor utilization of resources.
That just can't happen. We have to utilize the talents of
these people who are deployed to the greatest degree possible
where they are needed and not, obviously, underutilize them.
I will turn it over to you for your comments.
Dr. Freeman. With the caveat that I was not at Katrina,
understanding that I was going to be here today, I did speak
with some of my colleagues, including Tim Crowley, who is a
family practice guy in Boston, in the Harvard system, another
physician, Neel Sunder, who is an anesthesiologist at Mass
General, and some other folks who did not wish to be
mentioned--Peter Pillitteri, who was not at Katrina but who was
involved in passing out medications after the anthrax scare and
the anthrax exposure for the postal workers in New York.
But in speaking with Dr. Crowley, Dr. Sunder, et cetera,
and the other ones who wish to remain unnamed, I really got a
sense that there was a significant amount of disorganization. I
can give you a few quotes, if you would like.
You know--at least talking to Dr. Crowley, I think that,
you know, his concept was that the physician and medical
resources were squandered. His team remained in Baton Rouge. He
had been promoted through a variety of medical illnesses and
departures, et cetera, higher and higher up the chain, and he
had never had a command position before.
But his team remained in Baton Rouge. They were told there
was no mission, while there was staff at the West Jefferson
location that was crying for help. When they finally got to
West Jefferson and, in turn, asked for assistance, the same
story was repeated with other teams and other team members
being held at irrelevant locations with nothing to do. I think
that was part of the things that made Dr. Crowley leave the
team.
You know, talking to Dr. Sunder, who is a very mild-
mannered and very gentle kind of physician, he was disturbed,
you know. He really felt that--think his quote was, There was a
disconnect at every level. That was one quote. The other was,
He had never seen such a well-trained group of people--I am
sorry, never seen such highly talented personnel used so
poorly.
If you want to go back to a time line, which I believe I
have somewhere here, I think that what was--what happened was
that we were put on alert on the 27th of August and that the
team was deployed on Friday, September the 2nd. These folks
said they watched the news with increasing disturbance
throughout that time period. I knew I couldn't go, so I was in
a different frame of mind.
They traveled on Saturday, the 3rd of September. They got
to Houston on Sunday, the 4th of September. They got to Baton
Rouge on Monday the 5th of September, and then they stayed
there for basically 3 to 4 days, being told there was nothing
to do before they finally deployed out to West Jefferson
Hospital. I think those were the--again, I wasn't there.
I can't speak to that from personal experience, but those
are the conversations I had with my colleagues.
Mr. Langevin. It sounds like that experience reflects the
experience of the emergency room I mentioned, that our DMAT
team and his DMAT team had as well. It is problems that we need
to correct.
I know that my time has expired so I will not ask another
question as yet, but if there is a second round.
Mr. Linder. I would like to follow up on that point.
Dr. Alson, you were actually on the ground. Did you have
the same experience?
Dr. Alson. Mr. Chairman, I was very fortunate. I had a very
different experience. I had been the team commander, as I said,
in NC-1 for several years and before that served as the XO of
that for a number of responses, including the G8.
We were predeployed on the Sunday before the storm. We were
quartered in the Memphis area, along with a number of other
teams, DMATs, VMATs and DMOG. We were actually deployed into
the impact area beginning on Tuesday. We had to wait for the
storm to pass, so we didn't end up with the trucks on the side
of the road. We staged at Hattiesburg that night.
Wednesday we were set up at the Memorial Hospital in
Gulfport, where we operated basically an overflow for their
emergency department. I believe we saw in the range of 1,200
patients before that operation was closed.
In terms of the entire operation, it is my understanding
that as of the 18th, NDMS has had a total of 126,000 patient
contacts throughout the system. That includes approximately
59,000 people that were treated, plus an additional 60,000
immunizations that are given.
As I said before, we could probably have gotten our
responses up faster, and we certainly feel that we need to
improve that. We are certainly talking to many of our friends,
stories about issues where teams are assigned and not assigned.
But part of it is--the term the military uses, ``the fog of
war.'' There is a lot of information flying, much of it is
good, much of it is not good. It is a very frustrating thing
for medical professionals.
My team members will tell you my blood pressure often goes
sky high when I deal with some of these. But the ultimate goal
for all of us is to go out and do the mission.
As I said, I have been very fortunate. I have not had some
of those kinds of horrible experiences that some of my
colleagues have faced.
Mr. Linder. Thank you.
Mr. Thompson.
Mr. Thompson of Mississippi. Thank you very much,
Mr. Chairman and Ranking Member. I appreciate the testimony
of the witnesses, as well as the job that all of you do.
Some have said, rather than having perhaps an all-volunteer
operation, it might be better if we had a paid system of
response. Give me your thoughts on that, individually.
Dr. Alson. Mr. Thompson, thank you.
I believe that in order to achieve a very rapid response,
it may be necessary to have some paid, full-time personnel and
full-time teams prestaged throughout the country so that the
initial wave can be brought in in a very rapid manner. The
other advantage you would have in such a group would be the
ability to maintain the levels of training, as well as
maintenance of equipment, that is often challenging when
dealing with a volunteer, part-time group, as we see.
But I also believe that when faced with a catastrophic
event, we as a nation cannot afford to employ on a full-time
basis the number of personnel necessary to respond to such an
event. We are going to have to utilize our volunteers.
We have a nation whose history is flush with examples of
volunteerism, beginning back in our colonial days, and it is
part of the American character.
Switching to the fire side of the house, we are really the
only nation on the planet were the majority of fire services
are provided by volunteers. This is part of what we do and who
we are.
I believe we have to incorporate both segments, make sure
that they are appropriately equipped with the necessary
equipment and have the appropriate training under a coordinated
response plan.
Mr. Thompson of Mississippi. Dr. Bradley?
Dr. Bradley. Sir, I am not an expert on the entire Urban
Search and Rescue system, but speaking about the medical
component of Urban Search and Rescue, each team deploys with
six medical professionals. So far in my experience, we have
done a very good job with the six people we have. Of course, we
all become paid FEMA employees during the duration of our
deployment.
We have been able to make our 6-hour, out-the-door
deployment every time. I don't know of a single time when our
team has not made their 6-hour deployment window, so we get
moving pretty quickly.
Mr. Thompson of Mississippi. Colonel?
Colonel Thompson. Sir, I believe--like you, I was a
volunteer fireman many, many years ago. Our fire department put
quite a bit of effort into organization and training and
recruitment. Different disasters call for different kinds of
logistics, different kinds of communications expertise.
I think it will be necessary. I think it is appropriate to
consider that you may need to have some people who are paid to
do this full time, but I think even more so the need is to
figure out a system to recruit and train and organize
volunteers who can then come out for 1 to 2 weeks at a time. I
am not sure that the Nation can afford to have a vast number of
people who are paid just to handle this.
Mr. Thompson of Mississippi. Dr. Freeman?
Dr. Freeman. I guess I would take it one level further
back. I think before you start to decide these operational
kinds of issues, you need to understand what the needs are of
the system, you know, what really are the scenarios, what is
the big picture of what the requirements are going to be.
It was the same thing that I faced at that time, G8. There
was no obvious definition of the mission. So if you really
understood or understood the overall requirements, then you
could take that--what you needed. You could look at what the
DMAT provided. You could take out of that DMAT-NDMS system what
was useful. You could discard what was not. You could fill in
the rest.
I think that whether it comes out--in my mind, there should
be a greater infusion of a nonvolunteer staff. But exactly
where that falls in the spectrum needs to fall out of a real
systems analysis of the need, not somebody's opinion.
Mr. Thompson of Mississippi. Thank you.
One of the other comments I would like to talk about is the
notion of how do we have a support system.
Dr. Alson, you made it to Hattiesburg by Tuesday, and down
on the coast on Wednesday. I talked to a lot of friends who
were first responders and other people who, by Wednesday still
could not talk to each other; the communications system was
still downSec. number of things you would assume that first
responders would absolutely have to have in order to do a good
job.
Did you hear any of these comments about the lack of assets
available to first responders?
Dr. Alson. I did not directly hear any of those issues in
terms of assets, other than that, as in many disasters,
communications were indeed a challenge. It has been on most of
them-- I am afraid for the foreseeable future, will continue to
be one of those issues that we struggle with. There are
certainly efforts being made to improve upon it.
But when you are talking about having to develop a
communications plan that crosses so many different agencies in
so many different spectrums, it does present a challenge.
Our immediate interaction, once we got into the Gulfport
area, was directly with the hospital. The other interaction I
had was with the local EMS service, which had been augmented.
There was a private provider that brought in assets from
elsewhere in the country. So the two groups I directly dealt
with did not have major supply issues or asset issues.
There were some issues dealing with some of the special
needs populations in the community, and I think some of that
was related more to the lack of the local EOC being able to
obtain the assets to support the need that they had across the
spectrum. It was recognized they were attempting to do it, but
they did not have them immediately available to them. Those
eventually did arrive.
Mr. Thompson of Mississippi. Thank you, Mr. Chairman.
Mr. Linder. Colonel Thompson, the National Disaster Medical
System was created in the middle of the Cold War, 1984. Is it
still applicable? Do they have different challenges to face?
Colonel Thompson. Sir, I do think that we do indeed have
different challenges. The National Disaster Medical System was
developed for two reasons: at the time. It was to provide teams
that could deploy for natural disasters, and then to provide
casualty care for military casualties who were coming back from
a major war in Europe. That assumes 30 to 60 days' advance
notice, an opportunity to reorganize the--or to build the
support and distribution system for those casualties here in
the United States.
Things have changed significantly in the last 20 years. Not
only are expectations greater that we will respond to these
faster, but the number of hospital beds has decreased
significantly. Just in the last 5 years, I believe in-patient
beds have decreased another 5 percent, and that is after a very
large decrease back in the late 1980s and early 1990s.
So I think that there are certainly components of the
National Disaster Medical System that make sense, but I think
it is necessary to look at how they mesh with the needs of
today.
Mr. Linder. Dr. Alson, you talked about surge in your
opening statement, surge capacity. Do we have surge capacity?
Dr. Alson. It, I think, very much depends on the community
and the country right now, Mr. Chairman. I also think that
there are initiatives being put forth, a component, for
example, of committees receiving funds from HRSA that begin to
work on a plan.
I know that in North Carolina we have put together a
network where we can now track bed availability on a daily
basis across the entire State, using a computerized system.
Mr. Linder. Is that voluntary reporting?
Dr. Alson. It is currently voluntary reporting, but it is
essentially a component of receiving HRSA funding for the other
preparedness issues, for WMD and so forth. We have had
virtually total compliance. It has proved itself very useful in
some of the recent storms and other issues we have.
I also know in my portion of the country, South Carolina
has a similar system. It actually went on line just before G8.
There are other issues that communities are looking at,
availabilities--as I said, alternate care facilities being
established, but it takes assets. The planning is there.
I don't think we are quite where we need to be with our
capacity, given the potential for casualty generation in a
nuclear or major biologic event.
Mr. Linder. How much training do you do with your team?
Dr. Alson. The DMAT that I command has a monthly meeting.
We do several field exercises a year. We also function in a
number of capacities--not as the DMAT, but as the local
agency--so we have our ongoing training for that.
In addition, we function within our State system as what is
called an SMAT, or State Medical Assistance Team, so we train
with that as well.
The other component that is quartered in our community is
the NMRT, or National Medical Response Team, which is one of
four national medical biologic teams within the NDMS systems. I
served actually as the XO of that team up until last year. That
team train trains and drills on a monthly basis as well.
Mr. Linder. Thank you.
Mr. Langevin.
Mr. Langevin. Thank you, Mr. Chairman.
Dr. Alson, the chairman raised an issue that I am concerned
about as well, surge capacity. You said--in your testimony you
mentioned your concern about lack of surge capacity in our
health care system, and I certainly share your concern about
this problem. I also share your analysis that a big part of the
problem is the economic pressures of a just-in-time economy
that views inventory as a waste.
I am concerned not just about beds, but with all kinds of
medical supplies. The problem seemed so fundamental to the
system.
What do you think we can do to build that capacity? You
touched on a little bit of that. Can you elaborate on that a
little more?
Dr. Alson. Thank you, Mr. Langevin. There are a couple of
ways I think this can be addressed, one of which is at the
local level. We have to put some additional supplies in to deal
with the immediate consequences of the event, particularly
because, depending on the nature of the event, the ability to
get those supplies in can be hampered.
I know I was successful at my own institution to get them
to look at what we keep on hand for disasters and without a
major expenditure. Given the current environment, they adjusted
what we maintained, and we have done that as a private agency.
But I also think that communities need to be looking at how
they stockpile. As I say in my written testimony, Dr. Carl
Schultz out on the West Coast for years has advocated the
concept of hardening communities with stockpiling supplies to
address that immediate phase.
I also think that we have to look at the ability to put
together additional care space, whether it is in fixed
structures or tents to handle that expansion. This could be a
role of the DMAT, it could be the role of a State or local
resource within our State Medical Assistance Teams.
Each of the trauma systems has put together a SMAT-2 or
two-level team. Besides doing decon, their major function is
begin to develop additional surge capacity with the supplies. I
also think a similar approach has to happen at the Federal
level that we can bring in these additional materials. Whether
these supplies are stockpiled in high-risk communities or
whether they are regionalized, we have to have the assets to
get into the hands of the response personnel.
I also believe that one of the issues we have to have is
that the logistics system that handles it has to be a dedicated
medical logistics system. Experience from disasters has taught
us that often medical supplies, being a small portion of what
is shipped, may get lost in the entire FEMA logistics system.
Dr. Freeman. Am I allowed to add something to that?
Mr. Linder. Yes.
Dr. Freeman. I guess it depends--coming again a little bit
from the outside, it depends on what you mean by surge
capacity. If you are talking about a totally different
scenario, you have 100,000 people or 1 million people having a
surge capacity that is two- or threefold in your hospital is
not going to help.
Mr. Langevin. That is a valid point. On that point, do you
want to expand on that a little further since you raised it?
Dr. Freeman. Again, it depends on--it goes back to a
systems analysis, what do you need to prepare for. You know,
are we preparing for 1 million people with a really bad flu?
Are we preparing for 100,000 people with smallpox that we think
we can keep in one particular part of the country? You know,
what are we preparing for?
The analysis needs to be done first, before you decide what
surge capacity is.
I mean, everybody gets tied up in these little operational
details, yes, we need surge capacity, give us more money. But
the point is, I don't think anybody is looking at it from--I am
sure people are-- it appears that people are not looking at it
with a global enough view to really come up with an overarching
strategy.
Mr. Linder. Does anybody else care to comment on
Dr. Freeman's comments?
Colonel Thompson. Yes, sir. I will echo that completely.
The need is really to determine the requirements, what you
need if you have a communicable or biological event; what you
would need if you have contaminated casualties from a
radiological or nuclear event, and then where would the
resources come from to meet those needs; what is the first
level of resources in the particular geographic area, and then
what can you surge in. That needs to be developed.
It needs to be developed with the local, State, regional
perspective in mind. It needs to be--in my personal opinion, it
needs to be resourced from the Federal level to figure that
out, but then it needs to be gamed so you can test the plan,
see where the deficiencies are, because there will be
deficiencies; game it again and then prototype it in some
regional area so that you can get the solution as close to
fixed as possible before an event happens.
Mr. Langevin. Dr. Alson, just very quickly, because I know
my time is about to expire, why was your experienceSec. n your
estimation, why is your experience with respect to the
deployment in response to Katrina and the DMAT team in
Massachusetts and the experience that the DMAT team in Rhode
Island different? Can you speculate?
Dr. Alson. I didn't. I am sorry, sir, I didn't hear the
last part of your question.
Mr. Langevin. Was it your experience as part of the
deployment that the response to Katrina was different from the
experience of the DMAT team from Massachusetts or the DMAT team
from Rhode Island? Can you speculate as to why that was the
case?
Dr. Alson. I really cannot. You know, we were obviously
working very different environments. It is my understanding
that there was a lot more--or somewhat--confusion happening in
the Louisiana area than there was in portions of Mississippi
where I was working. But I really had no plans.
We got a mission assignment, and as soon as we got the
assignment, we deployed into the area, made our contact and
carried out our mission. But while we may have had some supply
and support issues, like most of the time, we are adaptable and
managed to make it through.
But I have no idea why they ended up in the situation they
did. I guess we happened to be lucky this trip.
Mr. Langevin. Thank you.
Mr. Linder. Thank you. That ends our questioning of these
four witnesses. We are grateful for your time and your
expertise, and we thank you for coming.
The hearing is adjourned.
[Whereupon, at 2:03 p.m., the subcommittee was adjourned.]