NDMS’s 96 Hour Response Time Should Now be Reengineered

In his remarks on June 21, 2011 to the National Press Club, former FEMA head Michael Brown stated that Americans should not expect FEMA to save them. The purpose of his speech was to inform Americans that they must prepare to be without government assistance immediately after disasters. He rightly stated that Americans should prepare to help their neighbors during the 96 hour lag of federal response.

In fact, given our current national capability to respond to national disasters, expectations should go beyond 96 hours. Most Americans have no clue that the planned initial federal response to emergencies is 96 hours. 96 hours is beyond the golden hours of emergency response, those 72 hours when many victims can potentially be saved. 96 hours after the levees broke in New Orleans, the city was under siege. By 96 hours, most Haitians had died under the rubble. After 96 hours, otherwise savable victims of Japan’s tsunami had perished.

While Mr. Brown was correct that FEMA is not the agency that will save Americans during the golden hours after an emergency hits, FEMA is however one of the group of agencies that make up the National Disaster Medical System, NDMS, that does respond to federal emergencies. Current NDMS planning calls for initial response at 96 hours, 24 hours after golden hours of response have expired and NDMS can no longer have a material impact on a community’s golden hour survival. Thus NDMS was designed with a fatal flaw.

NDMS was created in 1984 to respond to cold war mass evacuations, when our emergency medical response systems were just two decades old and at a time when our country expected less from our federal government. Since 1984, America’s emergency medical response capacity has grown significantly, technology has dramatically improved, and Americans’ awareness has accelerated. As a result, the 96 hour NDMS response time is simply no longer acceptable.

While Mr. Brown praised Director Fugate during his speech for “doing a fantastic job lowering America’s expectations “of what FEMA can do, his praise was misplaced. America should instead raise its expectations of what more FEMA can do to significantly improve FEMA’s role within NDMS, and What NDMS can do to significantly reduce its response time to support local agencies who are charged with saving lives during the golden hours.

After interviewing emergency managers of 2,500 hospitals, my company, EPI-Center, found that even America’s hospitals, institutions that are considered critical to our communities’ emergency medical response, are vulnerable to significant loss of life after 24 hours if left unassisted. That is why we built a commercial medical evacuation capability to evacuate an entire hospital in just 24 hours, called HELP (read about HELP at http://www.epi-center.us). The system was successfully tested in 2008 during Hurricanes Gustav and Ike and demonstrated that 96 hours is much too great a response impediment.

The concepts we operationalized can quickly and cost effectively be recreated within NDMS to build a national rapid response capability. Our country’s ambulance companies can double the effective capacity of NDMS and can be organized to much more effectively support local agencies during the golden hours of emergency response. NDMS can be reengineered to respond much more quickly to national disasters.

America has placed an immense responsibility for saving victims of national crises in the hands of agencies such as FEMA. Mr. Brown is correct that more will be done by individuals to help their neighbors in the coming American crises than should be expected from our federal government. Nonetheless, if NDMS will now commit to significantly reducing its 96 hour premise, its mitigation of this federal impediment will directly improve our states’ and local communities’ response capabilities, and will go far in underpinning America’s trust in FEMA.

America Can Protect the Next Dot on the Map

Watching the video of the tornado hitting the St Louis Airport seemed a disconnect for many Americans. We have faith in the power of our civilization and subconsciously hope that mankind’s greatest structures are immune to the ravages of Mother Nature. And yet, these monuments to modern science, like all of our constructions, are just dots on a map with probabilities of enduring a similar fate as the St. Louis Airport.

Directly between St. Louis and Memphis on the Ten Mile Creek and the Cane Creek lies the city of Poplar Bluff, Missouri, a historic community of 17,000 residents. Since its founding in the early 1800s, the town was regularly flooded by the Black River, until in 1948 the Clearwater Dam was built to control the river’s flow. However, just three years after storms flooded the city in 2008, another series of storms inundated the area with 15 inches of rain swelling the Black River and breaking the community’s levee in several locations, causing an evacuation of 1,000 homes in South Poplar Bluff.

Poplar Bluff was the dot on the map in 2011 that took the brunt of record rains. A year ago, it was Nashville that lived through devastation as nature picked this dot on the map to witness a thousand year flood. As you read this, there are several other communities that are praying their dot on the map escapes the deluge that Poplar Bluff and Nashville experienced, knowing that their devastation would be infinitely times worse.

While travelling through America, promoting my ideas for a national rapid response force, I discussed with one state leader the issue of a dam that has too significant a potential to fail, and that has been the subject of Army Corps reconstruction. However, if a rain deluge were to strike the river basin prior to completion of the project, the dam would have a high probability of rupture, endangering tens of thousands of people downstream. Within 24 hours of dam failure the lives of several thousand patients in multiple nursing homes and hospitals would be lost. The potential for loss of life due to this dam exposure is great, but it is not the only dam with such high risks and this is not the only state so exposed. Similar conditions exist in at least a dozen other dots on the map.

The technology and capability to plan for and respond to a dam failure in time to move all of these patients to safety exists. However, the capability does not currently exist within this state or any other. What I learned through bringing together America’s national private ambulance response coalition, HELP, is that to effectively respond to such grave potential disasters, the resources of the nation must be committed and readied well before the storm, and American communities could use such a resource.

America can create a rapid response team capable of moving thousands of patients within a yet unknown 24 hour notice window. We just haven’t been given this task and this requirement thus far. The current national evacuation response paradigm of a 4 day ramp up and arrival sequence of assets that are then given general priorities and assigned specific tasks based on assessments and in the field situational awareness and analysis will not work for these at risk communities. A new paradigm must be envisioned.

To prepare for such a known threat takes the combination of modern technology, logistics, and communications. It also requires the elimination of historical, jurisdictional, operational, and financial impediments that together significantly reduce the effectiveness of national support.

When I was asked to create a capability to evacuate an entire neonate hospital in 24 hours using our HELP program, our team accomplished the goal, but only by circumventing many of the impediments that exist in America’s mass medical evacuation capability today. A high priority for our nation’s emergency industry should be to commit to banding together to identify, prioritize, plan for and mitigate these critical impediments at the local through the federal level. To maximize saving of lives during a 24 hour dam breach event or during the 72 hour golden hours of a large scale disaster requires a commitment to this approach at all levels of government and within all sectors of private industry medical and emergency response.

Saving more lives requires a multi-industry and multi-agency pre-planned and coordinated response that anticipates the reaction of the public within the disaster zone and accelerates actions de-centrally according to those plans. Pre-hospital EMS, frontline hospitals, inter-facility ambulances, regional hospitals, local and state emergency managers all have roles that can be defined and authorized long before an event happens. With common vision, goals, information and communication, they each act independently and interdependently in an accelerated response.

I have discussed a process for reaching this level of capability with a majority of state leaders and while most have been receptive, many have found the idea of embarking on this path a bit overwhelming at this stage in America’s development. One reason is that many of the impediments at the local and state level are derived from impediments at the federal level. To solve the next generation of accelerated response will require federal involvement. To create a national rapid response to meet this rapid mass medical evacuation challenge and other similar emergency vulnerabilities will require the commitment of a broad range of leadership. It is time our federal and state leaders commit to get on with this essential task.

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