Other disasters are typically natural in nature. Many of these are already handled by federal authorities; hurricanes, floods, earthquakes all are handled by FEMA. But there are smaller disasters that will require that the local community handle the response. These are addressed in the following sections.
INITIAL INCIDENT PLANNING / PLANNING PRIOR TO INCIDENTS
(A) Command and control is dependent on trust, leadership and confidence. The command team had exercised, worked, and trained together many times, often in environments that posed an immediate threat to team health and safety such as oxygen-deprived environments, and environments filled with asbestos, lead, and other known hazardous substances. Each member of the leadership team knows the capabilities, personalities, strengths and weaknesses of each other and it is understood that task assignments need only be articulated once and then the task must be achieved safely and precisely.
Future teams should be pre-configured and remain on-call and immediately deployable. These teams should train together often, have a complete understanding of all of the equipment that they will be working with and be trained to operate both independently or to integrate seamlessly into a larger National Incident Management System.
(B) All team members, when faced with a mission or task that is going to be beneficial to others, will rise to the challenge even if it means making a significant personal sacrifice or putting themselves in harm's way. Therefore, the incident commander and safety officer must remain diligent in their duties to ensure that all personnel continue to observe all safety rules and procedures at all times.
(C) Incident Commanders must be trained and experienced to manage the RSO&I functions to ensure that the team maintains mission effectiveness under all conditions. Equipment inspections, safety briefings, team assignments and operational/mission parameters must all be defined and articulated to all team members.
(D) Incident Commanders must require that written documentation and notes be taken regarding all safety meetings, tasks and assignments, as should include any noted equipment malfunctions, field repairs, or deviations from the standard operational procedures.
SAFETY AND SECURITY LESSONS TO REVIEW DURING INCIDENT HANDLING
(A) Safety officer(s) are imperative to the mission. This can be measured directly by the number of OSHA recordable injuries (goal is 0) and the number of lost work days (goal is 0).
(B) Safety plans can be pre-designed for a medical facility but need to be reviewed with local fire departments, fire inspectors and building inspectors.
(C) Security cannot be understated. While no violent crimes took place at the Nevada Hospital Association facility, almost 30% of all patients arriving at the hospital had firearms in their possession.
Be prepared for this experience.
(D) While not included as part of our set-up operation, it should be noted that a high percentage of “drug seekers” will report to any temporary hospitals and staff must be prepared to deal with this inevitability.
(E) All Federal OSHA rules should be followed; efforts to cut set-up times or to appease extrinsic agencies by ignoring, side-stepping or “looking the other way” on safety practices is a really bad plan. All set-up times should be estimated based on following the letter of the OSHA regulations 29 CFR 1910.
(F) Safety Officers should have knowledge/ experience with aircraft safety, particularly rotary aircraft that will be prevalent in any domestic disaster situation.
(G) Because the Nevada One medical facility was being hooked-up to the power grid and contained multiple electrical devices spread over a large land area, OSHA lock-out/tag-out procedures needed to be in place.
(H) Ladder safety rules and fork lift operator rules need to be stressed every day. These are the two elements during the construction phase that lend themselves to major employee injuries.
(I) Evacuation plans must be in place before the first patient arrives. The Nevada Hospital Association facility was evacuated as Hurricane Rita struck, and at one point a building adjacent to the Nevada Hospital Association facility caught fire, putting the Nevada Hospital Association facility at risk of exposure.
Public Information Officer (PIO)
The Nevada One facility did not deploy with or officially name a public information officer. This function should be included within any future deployment assignment. A public information officer would have been beneficial in the daily, and often even more frequently, responses to inquiries from various EOCs, (Local, State, Federal, FEMA, DHS, etc.) as well as from the press. In future missions the PIO should liaison with the local hospitals and hospital association(s) to foster faster and easier assimilation into the community. This partnership would afford the disaster medical facility to Incident Command.
Additional job assignments that we would recommend for the PIO during future missions are: tracking patient census data and numbers of patients processed, seen and types of injuries/illnesses; maintaining records such as fuel status, critical supply status, personnel requirements, physical plant status, etc. These types of statistics are what were required by logistics planners, area commanders, health departments, paramedics and first responders as well as the local and national press corps. In summary, the PIO position could help alleviate a lot of extra work and stress from the incident commander and could/should function as the role of a scribe throughout the entire event or deployment.
PIO Lessons Learned:
(A) Designating a PIO will free-up a substantial amount of time for the Incident Commander as many easy to predict questions and appropriate responses could be handled without the need to keep interrupting the IC.
(B) Liaison with the existing EOCs, public health and health care associations early to gain a better situational awareness of the patient population.
(C) Do not assume that the various federal EOCs and various local EOCs are routinely sharing information.
(D) Produce standardized situation reports that track critical resource inventories and patient census type data points. Fax, email or otherwise communicate these to all local EOCs and partners at regular intervals (i.e. every 8 hours, etc.).
INCIDENT DEPLOYMENT STAFFING
(A) Having a trained set-up team that exercises together frequently, under different conditions and circumstances created a cohesive group that together can overcome most deployment obstacles.
(B) The set-up crew should be large enough so that it can be sub-divided to work as two or more workgroups. This will facilitate a faster set-up if required.
(C) The set-up crew should contain the following disciplines within the make-up of personnel:
heavy equipment operators
general machine repair personnel
(D) The physical structure should be engineered based on the 21-point integrity standards developed by NHA. Standards must address fire safety, snow load, wind ratings and levels of redundancy. All certifications and inspections should be completed by an outside, third party or government agency.
(E) All equipment and supplies must be planned for including not only their functionality but their bulk and weight.
(F) Plans should address locally acquiring heavy, hazardous or bulky items.
(G) Hospital beds, commodes, walkers or other durable medical equipment should be rented on an as needed basis to minimize storage requirements as well as onward movement logistical concerns.
(H) Renting non-essential items affords the team more flexibility in regards to onward movement and mission capability.
(I) Standardize all equipment and supplies within any DMF system so that a “pull” supply exists for immediate re-supply and items like vent circuits or other device specific supplies can be easily requested.
(J) Personnel need to understand the indications for use of each piece of equipment as well as the strengths, weaknesses, limitations, life cycles, maintenance schedules and terminal cleaning needs.
(K) Do not assume that USPHS personnel have any understanding of various aspects of the federal response system or national incident management system. Many of the personnel that are dispatched to help are regular doctors and nurses within federal hospitals and are not intimately involved in preparedness or response activities.
(L) Develop a training plan for all personnel that encompass all equipment, supplies, capabilities, emergency procedures, contact numbers, etc.
(M) Develop a plan to conduct follow-up training as the personnel will rotate out and be replaced approximately every 2 weeks.
(N) Develop robust inventory control system for all equipment that tracks each machine individually and that can be linked directly to the equipment’s maintenance and life-cycle records.
(O) Deploy with an IT component that at a minimum provides a local area network (LAN), printer and scanner and copier capabilities throughout the DMF system.
(P) Develop model staffing packages that include staffing minimums and optimal levels. These model staffing packages shall be based on both 12 hour a day and 24 hour a day operational periods as well as be based on the likely mission assignments.
(A) “Wrap-around logistics” is much more efficient then waiting for an EOC or other agency to place a request for goods and services on your behalf. This is particularly true if the other agency doesn’t have authority to enter into contracts.
(B) The team logistics person should verify all items that are to be shipped before loading them on to aircraft or trucks for deployment. This could prevent the wrong equipment from being shipped.
(C) Consider establishing a listserver that all parties can post to for such things as informational updates, request for clarification of facts, concepts of operations, etc. This could also be used throughout the response with the additional benefit of creating a record of all requests and situation reports.
(D) Trucking should be the primary method of forward movement for the equipment and supplies. Forward teams and crew could be expedited by being flown in small chartered aircraft.
(E) USFS Overhead Teams are great! The use of these teams should be encouraged and/or their training and compositions mimicked within FEMA, HHS and State response systems.
(F) Personnel who are working the logistics desk at any/all EOCs should have the authority to purchase needed items.
(G) It should be stressed throughout the SERT trainings, Overhead Team Trainings and NIMS that Operations Centers are a support system/function for the field operations.
(H) DHS, FEMA and HHS should have a unified command as opposed to separate command structures.
(A) Having redundancy in the set-up team could proveextremely important. This extra labor pool will also help when/if forklifts aren’t immediately available.
(B) The mission assignment will change. Disaster situations are very dynamic and the facility must be configured and designed to facilitate changes while in operation. Assume that the mission will change multiple times during the deployment.
(C) Have a “no-equipment available” set-up procedure developed and pre-planned within the field manual. This procedure should be practiced and or drilled to ensure that it can be achieved safely and efficiently during a disaster response when forklifts and other mechanical devices are not immediately available.
(D) If setting-up on private property, get written authorization from both the owner and, if applicable the lease holder as soon as possible. If the state or federal officials are authorizing set-up prior to or without owner authorization, have this order produced in writing from the appropriate governmental authority.
(E) Assume that the disaster medical facility will be in operation for at least 30-45 days when laying-out the traffic patterns and site design. Also, use this as the minimal timeframe for purposes of developing staffing patterns, supply-chain management, and logistical processes.
(F) If the facility is going to impact others with things such as large crowds, ambulances, helicopters, blocked driveways, etc. make an honest effort to discuss these issues with the people or groups that may become affected by these decisions.
(G) Require written stand-down orders before teardown begins. Often state health, area hospitals, or other federal partners have not been fully informed of the demobilization order and they may need additional time to adjust their own concept of operations. Confirm all orders with everyone.
(H) Any order that will (or may) negatively affect mission effectiveness should be received in writing. If you cannot receive faxes or emails at your location, have the written document sent to your home office or other unaffected location and have it confirmed and read to you before commencing.
(A) Whenever possible before a response, confirm that the requesting person has the authority and authorization to enter into contracts and bind the government.
(B) Have a signed agreement prior to deployment when possible. If this is not feasible, then ensure that you do have the written document before any onward movement order is accepted.
(C) Understand that these missions are expensive and that you may incur significant cost without any positive cash-flow for months. Whenever possible, have contracts provide some ability to draw money during the deployment phase.
(D) Maintain accurate financial records and receipts for everything. The federal government will, most likely, audit all invoices completely before payment is made. The better your records are, the faster you can expect payment.
(E) Pre-contracting may save both time and money. This should be done not only between the federal government and possible responders, but also between the responders and possible supply vendors.
(F) Disaster medical facilities could prove to be cost effective when compared on a cost-per-patient basis.
To do's missing from most natural disaster plans that you must consider and implement immediately
V. Mental Health
When a rubber band is stretched beyond its resiliency point, it will not resume its normal shape again. It is the same with a person; if they are stretched beyond their emotional resiliency point, they cannot recover fully.
Counseling for the victims and families must start immediately. At Newtown, counseling started within an hour
Remember to provide counseling for first responders. This will be an event most have never prepared for
Remove the families to a nearby local facility; talking to other victims has shown to be one of the most effective forms of therapy
Remember to engage the faith-based community, they can be of enormous help
It's too late to prepare first responders when the crisis occurs, train early and often
Strongly consider setting up a Community Resilience Center. Victims and their families, first responders, even community leaders will require an emotionally safe location to help them recover. As mentioned above, talking with other survivors has shown to be very effective for recovery.
In the heat of the moment, it is easy to forget the judicial element of a crisis. Almost always, at the end of the crisis, the courts and lawyers get involved in a very expensive manner. For example, when the Oklahoma bombing trial was moved to Denver, almost a thousand people were required each day to simply feed the number of reporters, witnesses and legal counsel. Denver had not budgeted for such an onslaught of on-lookers. We have learned that:
Federal funding will be earmarked almost exclusively for upcoming court costs and legal fees. Do note count on them being available to pay for first responder overtime or victim restitution
Costs for Judicial sector will quickly rise and will frequently exceed the amount provided in funding
In any crisis there will be victims. If there are a large number, the hospitals will be quickly overwhelmed. Even Boston hospitals had difficulty handling so many injured. Medical costs for victims and their families will normally rise to unaffordable levels causing greater hardship. We have learned some harsh lessons.
Perform triage in the field and route the victims to hospitals that cater to their injuries. In heat of the moment, it is easy to shove as many victims into an ambulance and get them to the nearest hospital. This is not effective. Critical care cases should be taken to the nearest trauma center and the less critical cases to the nearest hospital. The reason is that most hospitals don't have a trauma center. Taking critically injured victims to a normal hospital reduces their chance for recovery. Alternately, taking less critically injured victims to the trauma center quickly clogs their beds so that they are not able to handle the more critical cases.
Hospitals can and will write off medical expenses for the victims, if you ask. Be persistent. It took three months for the final hospital to donate services after the Aurora Theater shooting. Medical bills after the incident can escalate quickly. In Boston, for example several victims have incurred exhorbitant medical bills. This does not include additional care that will be required for artificial limbs, etc.
The media will gravitate towards horrific and heart-breaking stories. As the adage says, "If it bleeds, it leads". It is best to be up front with the media.
Designate a PIO (Public Information Officer) with the responsibility of keeping the press up-to-date. No other incident team member should be allowed to approach or update the press.
Set fixed times, usually twice per day to communicate with the press, unless there is breaking news.
Call out their mistakes sooner rather than later. If you wait for a board to approve any message, it will be lost in tomorrow's news.
Keep press releases simple and limited to a single page or less. Often, the media will use the release verbatim.
Incident commander should set up a Joint Information System (JIS) to accumulate information and decide on what facts can/should be released. This group must make immediate decisions; if they wait days to respond to erroneous press claims, they will lose the opportunity to do so.
Emotion trumps fact
In social media, meanness trumps facts
In a great many cases, dozens of charities will pop up in the weeks following an incident; some valid some fraudulent. Even if all the funds were valid, the number of funds can be overwhelming. For example, following the Newtown shooting, 66 funds were created with an aggregate value of well over $20 million. Some of the money was earmarked, some was not. Who manages the distribution? Who fights the legal battles? We have found a way to avoid this problem.
Organize and designate a committee to handle funding issues
Limit the number of funds to 2 if at all possible; allocate one for "Victims and Families", and one for "Victims and Victim Services".
Funds for Victims and Families must be dispersed solely to victims and victim's families.
Funds reserved for "Victims and Victim Services" can be spent on mental health care, rehabilitation services and any other service the victims or families may require immediately or over the years.
When possible, steer donations to the "Victims and Victim Services" fund because this will provide you greater flexibility for distribution.
Recommended dispersion is 60/40 or 50/50 for victims/victim services.
Victims will spend the money when it is received; however, victim's services will be needed on an extended basis especially during:
Court proceedings, if applicable
3. Don't distribute all the victim's service funds immediately. Victims and their families will consume resources for years. Every time there is another event,
mental health service use jumps. We recommend distributing no more than 50% of the funds reserved for victims and services initially.
4. It often occurs that family squabbles will interrupt the distribution of funds to victims' families. If these squabbles require court intervention, it will take at least three (3) years before any money is distributed. Additionally, lawyers and court costs will reduce the distribution amount by 40% and the person responsible for fund distribution will need to be paid for an additional three years.
5. Most (75-90%) Federal money allocated for the handling of the incident goes to the Judicial (see below). You CANNOT count on this money being available for victims or services.
6. Find an iconic, non-political spokesperson to explain funding issues to the public
They should handle the publicity
A retired politician is suggested; not a current politician
7. Presenting a plan of distribution is highly recommended, including an explanation of the timeframes involved.
8. Creating prefund plans are highly recommended.
9. To avoid confusion, the name of the fund should not contain the word "Victim".
10. The NRC is in the process of securing 5 fund repositories that can be used at a moments' notice. This is to help deter the creation of fraudulent fund accounts. Contact us for more information.
11. Allocate 2-5% of incoming donations towards the maintenance of a Community Resilience Center
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