The Aftermath of Gustav and Ike

As posted on the The Military Health System Blog

Tuesday, September 30, 2008 - Hurricanes Ike and Gustav
Posted by: Colonel Donald L. Noah

In the wake of hurricanes Gustav and Ike, Air Force Col. Donald L. Noah, chief of staff for Force Health Protection and Readiness, weighs in with lessons learned from the military’s response to these storms.

Hurricanes Ike and Gustav:
Real-Life Application of the Joint Force Health Protection CONOPS

The winds of hurricanes Gustav and Ike have died down but work in the aftermath goes on. Part of that work is assessing what assistance was provided by the Military Health System (MHS), what went right and wrong with that assistance, and how we can do better in the future. One thing is for sure, in addition to all the other missions of the MHS, hurricanes will keep coming and we will keep being requested to assist.

What does hurricane response have to do with the Joint Force Health Protection concept of operations (JFHP CONOPS)? Plenty! Although I’ve only recently studied the JFHP CONOPS, I’ll bet very few of you have—largely due to the fact that it was only recently drafted and published. As a very brief primer, JFHP is organized into six functional focus areas:

1. Human performance enhancement
2. Health surveillance, intelligence, and preventive medicine
3. Command and control
4. Patient movement
5. Casualty management
6. Medical logistics and infrastructure support

Simply put, the JFHP CONOPS examines the future warfighting context and characteristics of the future joint force in order to characterize future required medical capabilities. As I read through the CONOPS document, having recently returned from an on-site visit to the hurricane response area, I saw how effectively the document is organized and how it lays out a process for continual improvement for all types of missions, from the War on Terror to responding to disasters in CONUS.

Alright, enough of the CONOPS lead-in—back to the hurricane situation. Here is a summary of what we did, how well we did it, and how we can do better in the future:

What the MHS provided

· Leadership advice and guidance. Through the NORTHCOM Surgeon’s office, we have a nationwide array of 14 Joint Regional Medical Plans officers (JRMPOs). All available JRMPOs were mobilized to coordinate and synchronize state and Federal ESF-8 capabilities.

· Patient movement. Both within and without the National Disaster Medical System (NDMS), aeromedical evacuation units from Active Duty and Air National Guard units moved approximately 473 non-ambulatory patients out of harm’s way.

· Medical support to general evacuation effort. The Air Force’s San Antonio-based 59th Medical Wing provided medical screening and emergent care to the thousands of people evacuated from the landfall areas.

· Medical logistics. Through the ARNORTH emergency operations center in San Antonio, the right military medical materiel was provided to the right place at the right time.

What went right

· The JRMPOs provided the unique “glue” that bound the interagency effort. During my trip to Texas between the hurricanes, every single agency representative I met requested more of these valuable officers.

· The Texas Military Forces, ably led in the medical context by Joint Surgeon Colonel (Dr.) Connie McNabb, proved capable of augmenting—and in many cases, replacing—Federal response assets.

· Personal initiative at all levels effectively erased policy shortfalls and ensured that patients were moved safely and quickly.

· Operational communication between military medical response experts at all levels (e.g., OSD, NORTHCOM, ARNORTH, and Texas Military Forces) provided effective situational awareness.

What went wrong

· The NDMS does seem adequately user-friendly to state and local medical officials. Additionally, it does not apply to non-ambulatory patients in facilities other than hospitals (e.g., nursing homes and hospice care). Therefore, I believe we dodged a bullet so far in this hurricane season; our success is as much due to the relatively small numbers of patients requiring evacuation rather than to the effectiveness of the system.

· Medical response policies of certain interagency partners (e.g., DoD/TRANSCOM, HHS/NDMS, and DHS/FEMA) are not sufficiently interoperable to ensure seamless operations.

How can we improve?

· First, and perhaps most important, we need to ensure that our DoD response policies are coordinated with all agencies, both internal and external to DoD.

· We also need to lean forward to proactively work with our interagency partners on improving Federal policies. A salient example is patient movement. Whether by air, rail or bus, and whether by NDMS or non-NDMS assets, we need to do a better job of preparing to respond.

As of this writing, we are already taking steps to move out on plans improvement. Dr. Casscells and Ms. Embrey have empowered us to host several meetings to lead this process of policy integration. The first will be an After-Action Review of senior action officers of the MHS to identify issues and workable solutions, whether in the domains of doctrine, policy, operational guidance, or training. The second meeting will include our intergovernmental partners to review, revise, and integrate Federal policies and guidances to operationalize those improvements before the next hurricane season.

To conclude, I must briefly return to the JFHP CONOPS document. Its central theme is Protect the Force, Enhance the Mission. That’s a deceptively simple statement—one that elegantly sums up the strategic objective of all military medical forces. If I’ve been successful in anything during this blog entry, it’s that 1) the MHS provides a unique and vital service to our country—as was demonstrated during our response to the hurricanes, 2) no matter how good we are at providing that service, we can always do better, and 3) the Joint Force Health Protection CONOPS document is an excellent reference in understanding your role in the MHS and how you can contribute to its improvement. I’m attaching the document for those who are (or should be) interested.

Tags: Ambulance, Disaster Management Solutions, Disaster Response Team, DMS, EMS, EMT, Gustav, hurricane, Ike, Katrina, Paramedic

Nursing Homes Detail Evac Process

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I found this video to be interesting.

Tags: Ambulance, Communications, disaster, Disaster Management Solutions, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Incident Communication Solutions, LaserBand, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

Why on Earth is Patient Tracking Important, you ask?

 

Because for every injured person, there is someone who cares. A family, a friend, a coworker, a parent, an aunt, a daughter, a Pastor, a teacher, a neighbor, a spouse.

After attending NIMS ICS 100-400 this spring, I found myself wondering why there was no Patient Tracking Officer in the fancy Organizational chart they had…

It occured to me also that the number one person that is asking me for information usually is not the IC, but the PIO, otherwise known as the Public Information Officer. Oh, once in a while an IC will want to know the details of the reds, yellows, and greens. But at the heart of the matter is the patients themselves, and their family members, who seem to show up far quicker than they could have during regular times. And as these families clamor around, seeking answers, will you be able to provide them?

I found some videos today while I was preparing a new training program I am writing that I thought I should share, I will post them here.

Tags: Ambulance, Communications, disaster, Disaster Management Solutions, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Incident Communication Solutions, LaserBand, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

For your FYI

My daughter went through a period where she would say this phrase at the beginning of every sentence. It was very cute and has now caught on in our house as a kind of “catch phrase” as well as an inside joke.

I tend to use it at work a lot to disarm people when they are getting too serious, and luckily, that hasn’t been the case with this deployment.  I do want to take a little time to make a few observations though about Gustav and the ensuing calamity that has occured now that there have been over 10,000 patients moved within a week period, thousands of evacuees moved all over the country, and multiple services, both volunteer, paid, FEMA funded or other that have entered, left, reentered a small and challenging part of our country, or received these people into their communities.

I personally saw at least four different tracking systems being used. All were redundant at least somewhat in nature.

Many EMA officials had no idea what the other tracking systems were, how to access them, or how to share data with them.

Several agencies with their own internal registration and tracking policies refused to work with other agencies, creating a large gap in communication and the ability to information-share among trusted networks. (and I’m referring to PEOPLE networks, not Computer ones).

I think that proper education and training are the keys to ensuring that things go more smoothly next time, and that hopefully, as we continue to learn and grow, so will the systems we use and develop to help us care for those in need more succinctly.

Tags: Ambulance, Communications, disaster, Disaster Management Solutions, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Incident Communication Solutions, LaserBand, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

Back to Louisiana

Here I was, thinking I was getting to go home.  I am headed back down to Louisiana, this time with the ProMed Ambulance crews, one of the finest bunch of people I have gotten to meet in the EMS business, and certainly the hardest working.  Our tech department back home was monitoring all of our servers this week and commented on the lack of downtime these crews were taking for themselves, instead working to get the critical patients to safety as quickly as possible.  LSU certainly is lucky to have them along with the crews from numerous other companies.  I only got to meet a few of them, but those I did I will name here-

ASAP Ambulance, from Mississippi, Eagle, I am pretty sure they are from Memphis, LifeCare, LifeTeam, and of course, ProMed, who sent trucks from Knoxville (another place close to our hearts here at DMS), Nashville area, and Memphis.

We will caravan down (I will get left in the dust as I drive like a grandmother these days…) and set up shop wherever we can find accomodations for the crews. It’s going to be tough.

Tags: Ambulance, ASAP Ambulance, Communications, disaster, Disaster Management Solutions, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Incident Communication Solutions, LaserBand, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, ProMed, readiness, response, Team, Tennessee

Memphis

I thought the evacuees we were able to work with were all in all, pretty nice. For the most part, they were a lot more well-mannered than I would have been after what they were going through. I heard horror stories from all over the country about problems other communities had had, logistically speaking.  Shelters are miserable places for all involved.  First of all, you have to consider that people these days are mostly solitary creatures and value their privacy.  Having to share a bedroom, a bathroom, a kitchen, and living quarters with one hundred other people has got to stink.  Especially when you are worried that everything you know and own about your world is at the mercy of the weather, and is likely about to change again with almost no warning.

Thank you to all the evacuees, who left this time, (and last time), who took ownership of their safety and preserved the lives and well-being of those responders left behind in their communities.

Tags: Ambulance, Communications, Death, disaster, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

Kim’s Blog- Memphis August 31

Still not too much sleep. It’s about 4am and I am on the side of I-55 somewhere.  I am not sure if it is Tennessee yet or not, but I am pretty sure it is not still Louisiana.  After yesterday, I am glad to be out of the city, headed someplace safe and still I am unsure of how long I will be gone from my family.  I am headed to Memphis to track Gustav’s evacuees for our Memphis Area group, and by the sounds of it, I won’t be looking forward to sleep anytime soon.  I don’t really mind, though, all Disaster Response people like to pretend we hate the no sleeping, no eating, up for days, high stress, helping lots of people with minimal resources things, but the truth is, most of us love the challenge.

The next round of people should be arriving today, hopefully after I get a chance to eat and maybe shower…

Tags: Ambulance, Communications, disaster, Disaster Response Team, DMS, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Louisiana, mass casualty incident, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

Kim’s Blog August 30, 2008

It was hard not to have flashbacks driving on I-10 yesterday morning, as the sun just started to peek into the sky at my back.  I drove past my old stomping grounds of Ocean Springs, MS and the town I lived in during Katrina.  Slidell, Louisiana is just a short bridge trip to New Orleans East, but Saturday I was headed into the city proper.  The drive from Connecticut was awful, and seemed unending.  I have made the same drive over two dozen times in my life, and never had it been such a chore.  I always feel like I am home when I am in Louisiana, and maybe that is the personality of the people here.  They are tenderhearted.

The sight of the city usually gives me a happy flutter in my chest, but not this morning.  This morning I am terrified. Tired, but focused. But still terrified for the city and the entire Gulf Coast.

It is my job to monitor, support, and assist all of my East and Gulf Coast clients.  I take personally when they are under threat of something, and it is usually Mother Nature doling out the licks to these people.

I just wish the Gulf would catch a break already this century.

Tags: Ambulance, Communications, Death, disaster, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

Kim’s Blog August 28th, 2008

I often have to stop and reassess things I do, which is one of the reasons I love being a Paramedic.  Things around us are always changing, morphing, growing, backsliding, etc and it is our job as humans to be aware of the circumstances, surroundings, and people that we are constantly in contact with.

I find myself on the 30 hour drive down to New Orleans going over and over my choice to work in a different realm of Disaster Response, a new role for me that usually includes a lot of emails, talking on the phone, instruction, training, and conference attendance.  Not exactly the same as my 16 hour (no sleep) 911 ALS Ambulance Service in a busy-small sized city, either.  And while I am driving, I stop and think about how my last big Hurricane was spent, and the days immediately following.

The frustration I felt in 2005 was one of an inability to communicate as we had no real 911, no real dispatch, and a patchwork framework of ideas, strung together very loosely with a rule or two.  No infrastructure, back then I didn’t even know what that WAS! My portable radio didn’t work 30 miles away from the base where we were dispatched from, so we basically threw that up on the dashboard for the week.  We treated and released hundreds of patients, gathered information on them to relay back to the hospitals, we brought Docs and APRN’s around in our bus to hand out Cipro and Doxy and Tetanus shots.  We never ate, we rarely slept, and only cried once the whole week.  We both got injuries that we should have reported to our employer, but never did, fearing the 30 pages of paperwork when we got back, we gave money to people we didn’t know, we shared our food and water with strangers and stray dogs, and burnt ourselves out like crazy.

But of all this the hardest thing for me to forget was that one husband and wife at the Second Street Elementary School (which really wasn’t supposed to be used as a shelter, apparently). The had been married for most of the eighty plus years of their lives and had hung on inside their home nearby when the 27 feet of surge came in.  The husband had some of the worst facial and scalp hematomas I have ever seen, yellow and black and blue, all over his face and the side of his head, she was dehydrated and withdrawn.  After three days of driving back to the same school, (we were making it a regular stop on our daily runs) we discovered quite accidentally that the wife had been unable to ambulate down the stairs at the school to use the restrooms, and while she was being carried down by her loving neighbors and caring strangers, she had fallen.  During the fall, her left humerus had been fractured and she had not wanted to add to anyone’s trouble, so she never told a soul. She went almost two days without treatment for an angulated fracture, and then had a helpful paramedic (eek, me!) almost give her compartment syndrome while attempting to rehydrate her!  I thank God everyday that I thought to do a quick-once over on her after I heard about her fall, and pushed up her sleeve and found the injury.

After I rushed her to the hospital (they were only taking reds at that time) they airlifted her somewhere.  I tried and tried to find out where she had been taken, but due to the lack of any efficient tracking system, was unable to tell her sweet husband where his wife went.  That was and is, close to the worst feeling I have ever had, and still to this day, bothers me.  I think about it all the time.  I think about it when I am at work, when I am bored with the redundancy of my desk-job, when I start to feel unmotivated.

The memory of the look on his face is pretty much the only kick in the tail I need to get back to work.

Tags: Ambulance, Communications, disaster, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee

Evan’s Blog August 28th

August 28, 2008  2100

The call came a little while ago.  It’s official. We have a team headed to New Orleans to supervise the Patient Tracking System used by the  LSU Medical Center System contractor for Patient Evacuations. A satellite lent by Incident Communications Solutions  (ICS) out of Annapolis, MD will be picked up in the morning by our Director of Ops. 

Tags: Ambulance, Communications, Death, disaster, Disaster Response Team, DMS, Drills, evacuation, evacuees, Gustav, Hannah, hurricane, Ike, Louisiana, Memphis, New Orleans, Packing, Paramedic, patient, Planning, readiness, response, Team, Tennessee