Why are Special Medical Needs Patients Political Hot Potatoes?

While great strides have been made to develop large-scale disaster evacuation plans for America’s citizens, our most vulnerable minorities have been left behind asking to be heard. Federal laws require equal and integrated treatment of persons requiring specialized medical assistance. However, our federal evacuation system has resisted development of a national capability, instead deferring responsibilities to the states.

The majority of states simply do not have the resources to implement full-scale evacuation of these populations during statewide disasters. Lacking viable options, many defer to local authorities who either incorrectly assume the federal government meets requirements or that certain populations fall outside the responsibilities of government. This passing of the hot potato between federal, state, and local governments needlessly delays the development of a critically important, national response capability for special medical populations.

While laws such as U.S. Code §753(b)(4) (A)(I) (ii)(iii) require equal federal treatment of these patients, instead of building a federal capability, the federal government has instead attempted to meet legal requirements by authorizing states through grant funding to provide implementable special patient evacuation plans. However, states have not been successful in meeting this requirement for large scale disasters, and federal laws have continued unabided for decades.

States have found that the complexity of the problem requires greater resources than can be obtained at the state or local level. They have cited several reasons for not solving special needs patient evacuations needs including insufficient:

• Transporters to quickly move all special needs patients.
• Specialized equipment to quickly transport all special needs patients.
• Receiving beds for certain special needs patients.
• Coordination for safe, effective and fast evacuation of all special needs patients.

During my discussions with most state agencies and many local ones, they have shared complex examples of special medical needs patients requiring solutions. Examples include:

• A neonate hospital on the Atlantic coast requires the ability to quickly evacuate 150 critical care neonates when a hurricane approaches, but no federal, state, or Emergency Management Assistance Compact capability exists to transport these children or to absorb them into capable receiving hospitals.

• A group of behavioral facilities along the gulf coast houses over 400 physically and mentally disabled patients who must permanently remain in specially made “lounge” chairs. Because of their odd sizes, the chairs cannot be transported by conventional ambulances or paratransit vehicles. No local, state, or federal service has been identified to transport these patients during an emergency.

• A verified burn center in the Midwest noted that because burn facilities run near capacity, no region can absorb a full evacuation of a center. Without a national transportation capability, most large-scale burn incidents continue to rely on lesser care options.

None of the many examples I have examined are insurmountable. All can be accomplished through current communication and logistical technologies. However, they require a collective will of our federal government and states to integrate specialized, rapid-response resources. We no longer have a reason to postpone answering the voices of our special medical populations. We no longer have a reason to leave the requirements of our laws unfulfilled. It is high time we develop a national evacuation capability for patients with special medical needs.

America Needs a National Medical Evacuation Response

In 2011, America is not yet capable of mounting an effective national medical evacuation response to a disaster of the scale of Japan’s tsunami. We are striving to overcome 60 years of EMS, emergency management, and hospital response history within America’s federalist system of government. Our federalist system gives to local and state governments those responsibilities which are not expressly given to the federal government by our constitution. Federalism has served its constitutional purpose, but has made delivery of large-scale, emergency services much more difficult.

During the last six decades, after national emergencies, each of America’s presidents capitalized on America’s temporary disaster urgency to push America through its federalist trenches toward a national capability. Yet 60 years of presidential bully pulpits have still left us short of mounting an effective national response.

Americans want a national capability to protect our citizens in times of emergencies. Well before the next great disaster strikes, America must resolve to overcome the last of our federalist obstacles to create a truly effective force. Below is an abbreviated history of our development thus far. Notice that progress occurs after disasters. Note especially that President Clinton used another Japanese incident as a catalyst. Let us resolve that Japan’s tsunami can be the catalyst to take deliberate steps toward a comprehensive national medical evacuation capability before America’s next great disaster.

•1949 – Soviets successfully detonate a nuclear bomb.

•1950 – Congress passes the Federal Civil Defense Act, the first act that encourages interstate compacts between states to share disaster resources. However, with minimal funding, the program fades.

•1964, Hurricane Betsy floods New Orleans, at the time the costliest hurricane in our history.

•1964, Without federal tools, President Johnson works tirelessly and uses immense political capital to introduce temporary legislation to aid states.

•1964, The United States has no capacity to respond to a major disaster. Ground and rotor ambulance industries are just beginning. The country’s federal emergency response capabilities are spread over 100 disparate agencies that do not cooperate.

•1969, Hurricane Camille devastates the Gulf Coast.

•1970, President Nixon signs the Disaster Relief Act, making Johnson’s efforts permanent.

•1971, San Fernando earthquake rocks southern California.

•1971, Nixon submits bill to consolidate federal disaster assistance.

•1974, Tornado “super outbreak” of 148 tornados rips through 13 states.

•1974, Later amended as The Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988, Nixon’s legislation finally passes and gives the President the right to declare a federal emergency upon request from a Governor and to give grants to states to prepare for emergencies.

•1974, The bill leaves unresolved the issue of over 100 federal agencies involved in disparate aspects of disasters and emergencies.

•1979, With support from the National Governor’s Association, President Carter creates the Federal Emergency Management Agency (FEMA) to consolidate federal emergency operations.

•1984, With the goal of strengthening cold war national defense, President Reagan establishes the National Disaster Medical System (NDMS), as a cooperative partnership of the Departments of Health and Human Services (HHS), Veterans Affairs (VA), and Defense (DOD) with a primary emphasis of overseas military operations, but with a secondary goal of providing a civil disaster response.

•1986, NDMS refocuses on domestic response to large-scale civil disasters. Yet, NDMS has shortcomings. DOD cannot cede control of its own operation, adding time. With military emergencies as its primary mission, its assets also may not be available when a civil emergency erupts.

•1992, Hurricane Andrew devastates South Florida.

•1992, States recognize that they need compacts for times of emergencies. Several steps lead to Emergency Management Assistance Compacts (EMAC).

•1995 Terrorists attack Tokyo subway with sarin gas.

•1996 Congress ratifies EMAC.

•1996, In response to the sarin gas attack, President Clinton signs the Weapons of Mass Destruction Act and merges functions of civil defense and emergency management. His new FEMA cabinet position receives authority for counter-terrorism.

•2001, The World Trade Center and Pentagon are attacked.

•2002, President Bush signs the Homeland Security Act creating the Department of Homeland Security (DHS), consolidating 40 federal agencies under DHS, and reducing 2,000 separate Congressional appropriations accounts.

•2003, DHS absorbs FEMA and disperses functions such as preparedness within DHS.

•2003, President Bush issues a series of Homeland Security Presidential Directives that establish DHS as the lead agency responsible for domestic incident management, directs joint operations to use the National Incident Management System (NIMS), and directs DHS to prepare a national plan for incident management.

•2005, America lives through Hurricane Katrina. With losses exceeding $200 billion and over 2,500 lives, Katrina exposes disaster management weaknesses at all levels: federal, state, and local. It also highlights the difficulties of mounting a national emergency response.

•2005, During Hurricane Katrina, 66,000 personnel are deployed under EMAC, straining its capacity to administer resources, and exceeding the receiving states’ abilities to effectively use the personnel that are sent. EMAC begins efforts with FEMA to support larger future missions.

•2005, Then-Senator Obama introduces S.1685 which would have directed DHS to ensure that each state plan for realistic evacuation of individuals with special needs in emergencies.

•2006, President Bush signed the Post-Katrina Reform Act, re-focusing FEMA’s responsibilities within DHS to lead the nation in developing a comprehensive emergency management system.

•2006, FEMA signed an ambulance contract to provide ground transportation to NDMS mobilization centers. DHS entered into a regional ambulance contract later expanding this to a national contract. Yet, with a limited contractual function, our nation’s ambulance services still are not capable of effective national coordination.

•2008, the National Response Framework (NRF) replaced the National Response Plan. It is the core document for the new emergency management structure, and includes annexes that outline emergency support functions. Some key policies and associated plans to implement these policies are yet developed. The NRF represents a significant change in guidance that has helped direct the nation toward a more comprehensive national response capability.

•2011, nationally we have over 15,000 ambulance companies, 800 rotor wing operations, 100 fixed-wing air ambulance companies in the United States, capable of eventually being co-opted into an effective national emergency medical services strategy. America still cannot adequately transport special patients during national emergencies. We have over 5,000 Hospitals and 12,000 nursing homes that must be given realistic options for evacuating during large scale emergencies. And our network of medical facilities, transporters, and emergency management must be tied together into a real time network of emergency receiving facilities. The national task is ahead of us.

Read more at http://www.epi-center.us