PHP510:

Lesson 2: Disaster Response and Preparedness for Emergency Medical Services

Introduction (1 of 11)
Introduction

Introduction

Overview

An Emergency Medical Services (EMS) system is designed to provide pre-hospital emergency medical care in a community. This common definition can be broadened to include the practice of emergency medicine outside a hospital as well as in a health care facility.

In the United States, there are two distinguishable EMS systems, civilian and military, which usually operate independent of each other. However, during disasters, both systems work together to provide the necessary emergency medical care to the affected community.

This lesson covers critical incident management, triage, communication and equipment standards, and education and training issues related to EMS in the United States.

Objectives

By the end of this lesson, you should be able to:

Road Map (2 of 11)
Road Map

Road Map

Note: The purpose of the Lesson Road Map is to give you an idea of what will be expected of you for this lesson. You will be directed to specific tasks as you proceed through the lesson. Each activity in the To Do: section will be identified as individual (I), team (T), graded (G), ungraded (U), or pass/fail (P/F).

To Read

To Do

In this lesson you will complete the following activities:

  1. Team Activity (T, P/F)
  2. Lesson Review Worksheet (I, P/F)

Topics

 
Critical Incident Management (3 of 11)
Critical Incident Management

Critical Incident Management

The Incident Action Planning Process

Every emergency incident requires some form of planning to control each aspect of response.  The planning process was designed to expand and shrink as needed.

Initial tasks are accomplished intuitively by the Incident Commander, followed by a more formal and systematic planning process called Management-by-Objectives (Irwin, 1989).

As with all bureaucracies, the planning process includes the filling out of forms.   The two types of forms are 1) “action,” which sets objectives, assigns the organization, and outlines the tasks to be done, and 2) the “support and recording” forms, which assist incident management by providing worksheets for systematic plan development, assuring that data and records are available and that resources are accounted for, integrating communications capabilities, and documenting decisions.

Unified Command

Of those emergencies serious enough to require the response of several agencies, each has its own legal obligation to perform some type of action.  These critical, multiple-agency emergencies call for a Unified Command structure, and are those incidents that affect more than one geographical jurisdiction, incidents that affect more than one functional jurisdiction, and incidents that affect geographical and functional jurisdictions.  The use of Unified Command at terrorist incidents is a must to achieve a successful outcome of the incident with the fewest complications.

Unified Command, comprising eight individuals, is a consistent, systematic means of organizing a variety of autonomous civilian agencies into one concerted emergency response effort (Irwin, 1989).  Uniform procedures enable all involved agencies to perform their roles effectively by overcoming inefficiencies and duplications of effort.

The practical goals of Unified Command are to (Irwin, 1989):

The Incident Command System causes differing response agencies to come together in a major emergency and become “one” organization, with overarching management by Unified Command.  The planning process for Unified Command is the same as it is for the Incident Commander, starting with stated objectives, but from a team perspective of the individual Commanders who have approved their portion of the plan that affects their agencies.

Agencies who assign Commanders must have the authority to order, transport, and maintain the resources necessary to meet Command objectives, which is not based on size or budget level of the agency but dependent upon the legitimate capability of fiscal authority.

Two alternatives to participation in the Unified Command group are having Deputy Incident Commanders or by placing a senior officer of an agency in charge.  Agencies with limited involvement may choose to fill their commitment to the incident with a Deputy, rather than a “full” Commander (Irwin, 1989).  For smaller jurisdictions involved in a major emergency, it may be appropriate to designate that agency’s area or function as a Branch, Division, or Group, and place a senior office of the agency in charge.  That office will be an integral part of the unified effort and take part in the planning process, while at the same time fulfilling “at home” responsibilities and serving its own jurisdiction.

Medical Resources

The Medical Unit’s role is to take care of incident personnel only.  A public health officer or other M.D. can be the Incident Commander under some circumstances, or might be a member of a Unified Command Group.  Groups of ambulance and paramedic personnel can be designated as Teams or Task Forces for just about any incident involving injuries.  During a major medical emergency, a Medical Communications Leader position is assigned to coordinate scene-to-hospital(s) communications.

Integrating Volunteer Efforts

Volunteer efforts can both help and hinder emergency response agencies, with their immediate energies and work accomplishments being a valuable help.  The hindrance comes from unmanageable numbers of volunteers, poorly directed work, and a general lack of control. Lack of control can be reduced or eliminated by appropriate use of ICS.

The supervision and integration of these resources into disaster response requires Command attention to recognize the situation, set reasonable objectives for volunteers, and provide supervision and clear direction from Planning, Logistics, and Finance (where approved and appropriate).

A real world situation where techniques were used to manage this effectively was in the aftermath to the 2010 Haitian earthquake.  It was well known that people with medical skills were interested in volunteering to assist the victims so the American Medical Association and National Disaster Life Support Foundation quickly established an online registry where physicians could volunteer. In addition to the registry that captured information including specialty, availability, language skills, and previous disaster medicine experience, they also posted a webinar to prepare volunteers for working in Haiti (Kerr, 2010).

The World Health Organization also enacted measures to mitigate the unregulated flow of donations to the earthquake site, as they outlined medical supplies most needed in the response. This list, which included things such as “bandaging and adhesive tape, intravenous equipment, plaster of Paris for casting, suction tubing, suture silk, X-ray film, Foley catheters, aminophylline, atenolol, ibuprofen, paracetamol, bupivacaine, and ketamine” (Kerr, 2010) was accompanied by specific instructions about how to donate these supplies.

The Incident Command System (ICS)

The Incident Command System (ICS) was developed after a series of wildland fires that caused death, damage, and destruction in southern California in 1970 (Irwin, 1989).  Hundreds of problems with the response and coordination effort spurred the development of the ICS.  There are five functions in the ICS, designed to improve effectiveness, accountability, and communications.  ICS uses an incident action planning process that is systematic and comprehensive; multiple agencies and emergency response disciplines can be integrated into a common organization using the process (Irwin, 1989).  It is “a set of personnel, policies, procedures, facilities, and equipment, integrated into a common organizational structure designed to improve emergency response operations of all types and complexities” (Irwin, 1989).  The Incident Command System process has gained national acceptance to the point that any form of planning may be thought of as being an “ICS” process, which can be dangerous as the planning may be incomplete or ineffective.  The interrelationship between vulnerabilities and critical functions must be understood and addressed during risk assessment.  The United States Government Accountability Office (GAO) is the investigative arm of Congress and they review and provide reports on risk assessments funded by the federal government on their website. See http://www.gao.gov

In 1970, most of the radios in use were of single-frequency capability; scanners were rare; and federal, state, and local forces were operating in different frequency bands (Irwin, 1989).  Agency dispatch centers could not communicate with each other.  Major strategic events were not reported or logged from agency to agency.

Each agency did its own planning and training without cross-communication.  Knowledge of the capabilities of other agencies was limited.  There was no intelligence gathering, so follow-up was impossible for situational analysis.  Resources were poorly managed.  As a result, responders to a fire looked as if they were responding to a Chinese fire drill.  Crews, engines, bulldozers, and other resources were lost, sometimes for days (Irwin, 1989).  Lack of basic tracking capabilities hindered predicting impending conditions.  There was no way to warn homeowners to evacuate or where they might go once they did leave.  Clearly, this was a case of waiting for the technology to advance to resolve these issues.  Design criteria for critical incident management were stated well before the technology was in place to implement the needed changes.

There are 36 basic positions in the complete ICS organization.  It is unlikely that all 36 positions would be filled during a normal response.  ICS can manage up to 5,200 people and is scalable based on the size/complexity of the incident. This is one of the advantageous features of ICS: regardless of the magnitude of the incident, the same familiar framework can be employed.  The 36 positions are arranged to perform the following five functions:

ICS - Command Function

Command responsibilities are executive in nature.  This position has been designed to develop, direct, and maintain a viable organization and to keep that organization coordinated with other agencies (i.e., FEMA, FBI, ATF, EPA, etc.), elected officials, and the public (Irwin, 1989). Unified Command is a unified team effort that allows all agencies with responsibility for the incident to manage it by establishing a common set of incident objectives and strategies without losing or abdicating agency authority, responsibility, or accountability. Responsibilities include (Irwin, 1989):

Command executive responsibilities cannot be ignored as much attention is required to organizing and managing.  The Incident Commander (IC) is supported by a Public Information Officer (PIO), a Safety Officer (SO), and a Liaison Officer (LO).  These Officers assist the IC in fulfilling the duties of coordination with others and the overall safety of the organization’s members.  Part of this assurance of the safety of responders and command staff can be supplied from the U.S. Army in the form of personal protective equipment (detection equipment, respirators, gloves, hoods, suits) depending on the type of response required.

In addition to focusing on safety, careful attention must be paid to communications with the media covering the incident.  Pertinent and correct information is vital.  Rescinding or correcting false information released to the media can be a difficult process and can erode the public’s confidence in the response effort.  The PIO oversees execution of the plan to deal with the media, defines rules for media personnel, provides protective clothing if necessary, and may help to designate the location for satellite trucks.

When determining the location for the Command Post, careful attention must be paid not only to the location specifically (i.e., the IC posts in the lobbies of the World Trade Centers), but to secondary devices whose purpose is to harm responders.

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ICS - Operations Function

The Operations Section is usually headed by a person from the agency with the greatest jurisdictional involvement and must be agreed upon by all agencies involved in the unified command by utilizing the specific and/or special talents of all individuals involved. Therefore, Operations is the “doer” in the organization where tasks are accomplished as this person has been charged with executing the IC’s directions.  This “doing” of the work can be exhaustive and failure is frequent.  Responsibilities include (Irwin, 1989):

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ICS - Planning Function

Planning Section responsibilities are of a staff nature.  They are support of Command and Operations and designed to provide past, present, and future information about the incident.  This information includes both resource and situation status on a real-time basis.  Responsibilities include (Irwin, 1989):

The Planning Section includes a position for “Technical Specialists.”  This position requires qualified advisors to provide Planning with technical data that are critical to incident management. 

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ICS - Logistics Function

The Logistics Section responsibilities are also of a staff nature and are divided into two sub functions: Service and Support.  Logistics provides all of the personnel, equipment, and services required to manage the incident. 

The Service Branch is responsible for tasks that “keep the organization going” (Irwin, 1989), such as communications and medical care for the incident personnel.  The Support Branch assures that all parts of the organization can function by providing adequate facilities, supplies, resources, and service equipment.  Once the human, technical, and mechanical resources are obtained by Logistics, the management of those resources are turned over to Planning and Operations.

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ICS - Finance Function

Finance is a staff function.  This Section is responsible for financial management and accountability on the incident (Irwin, 1989).  Finance authorizes expenditures in accordance with agency policies but does not actually purchase or order anything; the Logistics Section obtains identified needs after approval by Finance.

Finance uses the Incident Action Planning process, the resource-status tracking, and the Logistics acquisition records to accomplish its accounting objectives as well as four other critical functions (Irwin, 1989).

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Triage (4 of 11)
Triage

Triage

Definition

Triage is a dynamic system used for categorizing and sorting patients. This is done according to the severity of their injuries and prioritization for evacuation to definitive care, given the limitations of the current situation and available resources (time, equipment, supplies, personnel, and evacuation capabilities) (Auf der Heide, 1989; Szul, Davis, Maston, Wise, & Sparacino, 2004).  The goal is to afford the greatest number of casualties the greatest chance of survival by making the most efficient use of available resources.  There is no single, standard, or universal method of triage (Auf der Heide, 1989).  Various color codes, numbers, and symbols have been used to identify the categories of triage, identified by the use of a triage tag.  Practice with the particular system used by local responders is required to be successfully implemented. 

The START System

If not trained in managing a mass-casualty incident, arriving first responders can be overwhelmed by who to treat first.  The START System (Simple Triage And Rapid Treatment) can be a basic system to teach the triage process.  It is a color-coded system with either four or five triage categories using a commercial triage tag (METTAG) with strips that can be torn off the bottom, leaving the color of triage on the bottom.  The colors and their meanings are as follows (Auf der Heide, 1989; Deatly et al., 2003):

Figure 2-2: START Triage System Flowchart

SMART Triage System Flowchart

© 2006, Community Emergency Response Team (CERT) - Los Angeles. Used with Permission.

One problem associated with the use of this colored tag system has been the lack of availability of the tags at the incident site. Another problem has been responders' lack of familiarity with the tag system. This can be overcome with practice and training.

Categories of Triage

Military Triage

In the military, the ultimate goals of combat medicine are the return of the greatest possible number of soldiers to combat and the preservation of life, limb, and eyesight in those who must be evacuated (Szul et al., 2004).  Triage begins in the field, first with self-aid (placing your hand on your wound); buddy-aid (placing your hand on your buddy’s wound if he/she cannot); and then medical personnel (the medic replacing your hand with a pressure bandage).

Combat/Civilian Stress

Stress casualties are a concern both in the military and the civilian response efforts.  Repeated training builds the “muscle memory” needed to overcome a potentially shocking and overwhelming situation that can cause others to freeze in the response efforts.  If this is recognized, assigning the individual to focus on a specific, accomplishable task that requires a relatively short time frame for results can be the catalyst needed to reset the “muscle memory” of training.  Although individuals may believe themselves prepared for such an incident, until in the actual situation they will know their reaction.  Even seasoned responders have moments when they have to take a break to “reset” in order to resume their duties.

While there are situations when this stressful reaction can be anticipated, it is important to allow for unexpected aspects of a situation that cause extreme stress in individuals. For example, in 2007, a mother and her two young daughters were tortured and murdered in their CT house. The husband was badly beaten but was able to escape. In 2010, one of the two men accused of the atrocities went on trial for his crimes. The jurors heard days of graphic testimony and saw crime scene pictures that greatly affected them. Following the conviction, “Out of concern for the shell-shocked jury, Connecticut's Judicial Branch took the rare step of offering counseling services” (Melia, 2010). In another murder trial in NH, one of the jurors compared themselves to being “almost like we were a military unit that went through a battle. We survived it, and we all had that common traumatic incident to share” (Melia, 2010). These strong reactions reported by the jurors are important for 2 reasons:

  1. Being involved in an emotionally trying situation can be difficult for more than just the people with boots on the ground and it is important to understand and be aware of how all the responders are coping.
  2. For especially trying situations (the CT case was thought to be “exceptional” because it had factors including “multiple victims including children, sexual assault, graphic evidence and — as a capital case — the responsibility of deciding whether a defendant should live or die”), strong emotions can come from simply reliving the event through pictures and others’ testimonies.

EMS/Disaster Triage

Search and rescue (S&R) is often the initial contact with disaster victims.  An uncoordinated and confused operation can result in continued confusion and lack of coordination as those victims enter the EMS system. 

In traditional EMS, routine triage is directed more towards temporarily by-passing those with minor wounds (the “walking wounded,” or “green” casualties) and focusing more on stabilization of immediate life-threatening (“red” casualties) wounds for transport before attention is turned to those with less severe injuries (“yellow” casualties).  Therefore, triage establishes the order of treatment, not whether treatment is given, and is usually the responsibility of the most senior medical person on site.  In instances when medical treatment facilities have been damaged in a disaster incident, further triage may be necessary once evacuees arrive and resources or personnel are limited. This was the situation faced by the medical personnel in New Orleans after Hurricane Katrina struck, resulting in moral, medical utility, and ethical dilemmas that can haunt future planning efforts. (Triage During a Mass Disaster, 2005).  In a large-scale disaster, a person who would otherwise survive their injuries might—justifiably—not be treated and may even die as a result, since diverting the resources, manpower, and time necessary to treat the one might cost the lives of several patients who would otherwise be helped or are more likely to survive.  Withholding care is contrary to the fundamentals of medical training and can be quite stressful for medical personnel to implement if this ethical framework has not been included as part of a hospital’s disaster plan.

In the disaster incident, field care is limited to “simple” procedures, such as opening the casualty’s mouth/airway or placing an oral airway if one is available.  The responder can move from victim to victim in rapid succession, not taking more than 30 seconds to a minute per casualty rendering simple care and a triage status.  “Complicated” care would involve the use of artificial ventilation or CPR, requiring a more prolonged effort of life-saving and personnel involved on a single victim.  Field surgical or invasive procedures would be limited to placing intravenous access for fluids or emergency cricothyrotomies for those victims making spontaneous breathing efforts but who cannot support their upper airway even with an oral airway. Triage is not static; patients must be reassessed at short intervals to confirm that their original triage category has not deteriorated.

At this point, the victim may be placed in the “Expectant” or “black” category—those who are expected to die without further extensive interventions, such as surgical repair of ruptured organs requiring specialized hospital-based (civilian) surgeons, who may be located in facilities far from the incident site.  This triage category exists in some triage systems to guide responders to devote the time and resources necessary to save those who have less severe injuries.  Keep in mind these are situations potentially faced in the field disaster theater, and hopefully not in the hospital (if sufficient infrastructure exists) where it is generally agreed that all living casualties may be considered potentially salvageable.

Special Categories of Triage

Patients who do not easily fit into the above categories and casualties who pose a risk to other casualties, the medical personnel, and the treatment facility, may require special consideration.  These patients would be those who are contaminated by a biological and/or chemical agent, those who have unexploded ordnance contained within their body, or those who pose the threat of a secondary device on their bodies (such as a suicide bomber) or hostile intent, such as a desperate drug addict who has been cut off from his/her source (the snipers in New Orleans after Hurricane Katrina).

Problems Found in the Triage Process

Even those who teach mass triage can find shortcomings in their own self-confidence when faced with the desperate circumstances of a true disaster (Triage During a Mass Disaster, 2005). The presence of on-scene uniformed personnel can lead secondary responders to falsely assume that triage of victims has been done. Furthermore, lack of scene control allows those who are the “walking wounded” to walk or drive themselves to the nearest treatment facilities they know and trust, thereby bypassing the EMS system of triage and potentially overwhelming that facility. As a result, that facility may be unable to accept those more serious injuries remaining at the incident unless an effective hospital disaster plan exists to control such situations.  Keep in mind the difficulties of performing adequate triage when casualty distribution is dispersed over wide areas by natural disasters such as tornadoes and hurricanes.  

Adding to the problem is the natural tendency to load as many injured as possible into one vehicle and send them on their way, the belief being that this is a great way to quickly clear the incident scene of victims.  For these reasons, some disaster plans call for a delay in evacuation of victims from the scene, the intent on achieving an orderly and rational field stabilization and transport.  Also, the use of field first-aid stations needs to be widely broadcast as these can relieve the burden faced by receiving facilities and can address the desire of the “walking wounded” for prompt care.  As a result, the public will view positively the medical management of the incident, a benefit since public perception of “good emergency care” usually means the most rapid transportation possible to the hospital, not what is best for those needing medical care.

The triage process is one that takes practice, both internally and with other agencies comprising the response effort.  In this manner, participating agencies learn the shortcomings and capabilities of the partner response agencies, as well as confirming who is responsible for the identified tasks.  These practice sessions can assist with the needs assessment crucial in uncovering assumed responsibilities and non-available equipment.  A properly executed needs assessment can broaden limited perspectives and highlight those resources actually available during the disaster response as well as the funding or training needed to accomplish stated objectives. 

Non-local Responders

Control of well-meaning non-local responders is a difficult task to be handled with thought and advance preparation. These non-local organizations do not fall under the control of the local EMS system and can contribute to the lack of organized triage, especially those medical centers with helicopters located within aeromedical range (Auf der Heide, 1989).

Improving the Triage Process

Effective triage requires coordination and communication among medical and non-medical organizations at the disaster site and between the site and local hospitals (Auf der Heide, 1989).  Using common terminology, reducing the use of acronyms, joint planning, joint training, and testing all contribute to an improved response effort.  Jointly reviewing and approving procedures for cooperative communications, situation assessment, resource management, and integration of unexpected or unfamiliar responders are all applicable to organized triage (as well as decontamination) efforts.

Casualty Distribution Procedures

Disaster casualty distribution can be based on what is most practical depending on the size of the community, the number of area hospitals, and the difference in the capabilities of these institutions (Auf der Heide, 1989). 

In the simplest case, only one local hospital may be available to receive casualties.  The hospital may act as the triaging facility, stabilizing patients and then evacuating them to more distant facilities.  When there is more than one hospital available to receive patients, all with similar capabilities, ambulances may rotate dropping off their patient load in an effort to avoid over-burdening one particular facility (Auf der Heide, 1989).

Recovery

Recovery is a process of standing-down those resources no longer needed. This can be a phased process.  After-action reviews of the incident response can highlight the good, the bad, and the ugly, in preparation for the next time a response is mustered.

 

Personal Protective Equipment Standards (5 of 11)
Personal Protective Equipment Standards

Personal Protective Equipment Standards

The type of personal protective equipment (PPE) required for a disaster response depends on the nature of the incident and other factors such as environmental conditions (Deatley, Allan, Hauda, Dehaven, & Stangby, 2003). For all emergency responses, the minimum level of PPE must include gloves, goggles/safety glasses, and the appropriate clothing for the conditions and weather faced by the responder. Responses related to situations that include potential exposure to hazardous materials (e.g., chemical, biological, radiological) require additional protection. This level of protection requires training specific to the equipment to be used. Only those who are properly trained, fitted, and authorized to don the level of PPE should do so. Also, it is important that responders realistically train and plan for patient assessment while wearing the PPE as this can be a hindrance to normal assessment techniques. 

PPE is characterized by escalating levels of protection, with Level A as the highest level and Level D as the lowest (EPA Levels of Protection).

Level A

Level A protection should be worn when the highest level of respiratory, skin, eye, and mucous membrane protection is needed.

Level B

Level B protection should be selected when the highest level of respiratory protection is needed, but a lesser level of skin and eye protection. Level B protection is the minimum level recommended on initial site entries until the hazards have been further identified and defined by monitoring, sampling, and other reliable methods of analysis, and equipment corresponding with those findings utilized.

Level C

Level C protection should be selected when the type of airborne substance is known, concentration measured, criteria for using air-purifying respirators met, and skin and eye exposure is unlikely. Periodic monitoring of the air must be performed.

Level D

Level D is primarily a work uniform and is used for nuisance contamination only. It requires only coveralls and safety shoes/boots. Other PPE is based upon the situation (types of gloves, etc.). It should not be worn on any site where respiratory or skin hazards exist."

Once the level of appropriate PPE is determined, it can be adjusted based on the needs to the dynamic situation.

Reasons to upgrade to a higher level

Reasons to downgrade:

Communication and Equipment Standards (6 of 11)
Communication and Equipment Standards

Communication and Equipment Standards

Communication Technology Standards

Communication technology standards are technical specifications that enable technological components from different suppliers to work together within a given communication system. Some standards refer to the physical interfaces between network and terminal equipment. Others refer to logical elements expressed in algorithms and embodied in software.

Mesh Networks

Mesh networks offer higher bandwidth, improved reliability and greater coverage than Wi-Fi, and could allow first responders to create interoperable networks on the spot (McKay, 2005).  Standard point-to-point or point-to-multipoint technologies, such as 802.11, are short range, wireless networks where bandwidth decreases as additional users join the network, but mesh networks are stronger with more users.  The multiple nodes in a mesh network provide reliability because if one node fails, many more are available.  Mesh networks can also be used for areas where Wi-Fi would not work, such as in concrete buildings.  Functionality begins to decline when a large-scale network is needed, such as a statewide system.

Real World Case

Please see this story which is an example of Wi-Fi technology at http://www.news.com/Citywide-Wi-Fi-network-put-to-test-in-Minneapolis/2100-7351 _3-6201561.html

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WiMAX

WiMAX is an extension of Wi-Fi, which can deliver high-speed wireless connectivity but at a far greater distance, as far as 30 miles, and this ability to blanket a large area is of benefit to public safety operations.  WiMAX may have the potential to provide an open standard nationwide that will allow for true interoperability between agencies in different areas and could revolutionize wireless public safety systems.  It offers flexible radio performance in both licensed and unlicensed radio spectrum.

Fixed wireless, or “pre-WiMAX” networks are already being deployed for police, hospitals, and ambulances to transmit data and images in real time. More WiMAX wireless products that support mobility are expected to become available.

A challenge to overcome is the matter of interference, which is likely in unlicensed spectrum.  The FCC has freed spectrum in the 800 MHz band for public safety so interference can be avoided (McKay, 2005).

Real World Case
The District of Columbia Public Safety Office was the first in the nation to implement a high-speed wireless broadband data network which was first used operationally in January 2005 (Wireless Accelerated Responder Network, n.d.). The broadband network is secure, spectrally-efficient and affordable. The capabilities of the system include linking hospitals and ambulances with real-time video or conveying detection of a chemical weapons attack. Not all areas can support such an ambitious endeavor due to the limited radio spectrum allocated to public safety. The District Government formed the Spectrum Coalition for Public Safety, a national coalition of state and local governments formed to secure nationwide spectrum in the 700 MHz band.

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VoIP

VoIP refers to the transmission of voice over a data network.  VoIP digitizes voice audio, sends it in the form of data packets over an IP network, then converts the data back to an audible voice.  This would be valuable where efficient or enhanced voice communications, advanced calling, or messaging features are needed, such as those in emergency operations centers during simultaneous multiple communications (Amber Alerts, tornado warnings).

Challenges still exist in securing the system, but the technology is showing promise—the Commerce Department turned to a VoIP network after the agency’s emergency system failed after the September 11th attacks (McKay, 2005).

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Software Defined Radio (SDR)

SDR is a major breakthrough in interoperability, especially for major incident response where many public safety agencies are mobilized on little or no notice and have incompatible radio systems.  SDR allows the different agencies to plug into a base station and download software that connects with everyone.  Since response for a disaster can result in many teams from different areas of the country converging, this technology solves a major communications block. Costly, not well understood, and lacking stardards or guidance, this technology thus far has not been widely adopted (McKay, 2005).

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Supply Management System (SUMA)

One of the best-known applications of IT during the emergency phase of disaster is the Supply Management System (SUMA), a computerized information management tool created by the Pan-American Health Organization. SUMA helps national authorities track donated supplies in disasters until they are effectively distributed to the affected population.  Another example is the use of commercial software packages (e.g., EIS or Softrisk) by emergency operations centers in support of emergency management functions, such as incident or resource tracking or mapping, or real-time communication (Arnold, 2004).

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Internet and Social Media

If accessible, the Internet can be a valuable tool for information sharing and news gathering during the emergency phase of a disaster. Social media allows for another channel of broadcasting messages to the public, but also allows for two way communication between emergency managers and major stakeholder groups. Recent emergencies have shown that the public is turning to social media technologies to obtain up to date information during emergencies and to share data about the disaster in the form of geo data, text, pictures, video, or a combination of these media. Social media also can allow for greater situational awareness for emergency responders. While social media allows for many opportunities to engage in an effective conversation with stakeholders, it also holds many challenges for emergency managers.

FEMA utilizes numerous social media accounts as part of their mission to provide information to the public before, during, and after a disaster. This includes YouTube, Facebook, Twitter and IdeaScale, and for a list of their official social media accounts see http://www.fema.gov/social-media

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Security/HIPAA and Wireless Peer Networks

In areas of total devastation, OOH responders may need to bring their own communication infrastructure.  This type of communications may be too sparse to cover the entire geographic area affected.  One way to overcome this is wireless peer networks.  These are created by mobile devices brought to the scene by emergency responders, where each device produces, receives, and relays information.  Two key innovations are ad hoc wireless routing networks and peer-to-peer (P2P) architectures (Arnold, 2004).

Ad hoc wireless routing networks make use of the ad hoc location of mobile peers and discover the shortest route between arbitrary peers when other peers are used as intermediaries.  Two peers out of radio range are enabled to communicate via an intermediary peer who is within communication range of both.  This allows network routing independent of pre-existing network infrastructure, fixed peer locations, or network partitions (Arnold, 2004).  No single device or peer is crucial, allowing all information to be widely available and is redundant in distribution.  This makes P2P architecture resistant to disruption.  As more peers enter the network, the P2P architecture becomes more robust.

Immediately after a disaster event, once-secure networks may no longer exist, so care must be taken when transmitting data that could be used adversely.  Policy must be defined for information sharing and a risk assessment performed.  Security requirements include ensuring the following:

Event logging and subsequent forensic investigations may require that records created by workers are nonrepudiable (Arnold, 2004).

Authentication of the user can be achieved in a variety of ways, with the most common being a password.  Most secure wireless devices can support a 128-bit encryption password or more to help protect patient confidentiality. Protecting such confidentiality is federal law, according to the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA), and an organization must make reasonable efforts to comply.

Real World Case

Please see the Capital Wireless Information Net (CapWIN), an example of a Wireless Peer Network at http://www.capwin.org/

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Wireless Technology Overview

IT communications infrastructures are wireless or tethered (wired).  Wireless infrastructures include satellites, cell towers, Wi-Fi (IEEE 802.11), or Bluetooth.  Tethered communications infrastructures include ethernet over coax cables or optical fibers.  Most disasters require wireless communications with tethered communications being a less reliable necessity (Arnold et al., 2004).  After a disaster, replacing a cell tower that only needs a cleared footprint with its own generator is much easier than running new fiberoptic cable requiring debris removal over a much larger area with extensive excavation.  Alternate sites for wireless relay devices include the tops of traffic light fixtures, rooftops, or other existing fixed sites, so equipment that can withstand extremes of weather is paramount.

Unidirectional wireless systems support the transmission of data from out-of-hospital emergency responders to hospitals in a number of communities.  One example is the use of a fax “notepad” linked to cell phones, which can then transmit information (e.g., a heart rhythm analysis, electrocardiogram, etc.) by fax to hospitals (Arnold et al., 2004).

Current wireless technology designs suffer from three main limitations related to their dependence on centralized architectures (e.g., cell towers) during disaster response:

Communication Technology Applications

Assessment Databases

Wireless peer networks, which can be distributed over a wide area to responders already on-scene or en route,  can enable scene assessment databases to be updated continuously as events unfold or as triage is performed. Such updating acts as a real-time briefing mechanism and can enable incident commanders to re-route incoming responders and/or equipment.  Wireless peer networks may also support continuous input and tabulation of data from victim assessments to provide such real-time information as the number of victims triaged to a specific category or need (e.g., decontamination).  This information can be coupled with GPS to map the locations of victims and rescue personnel and their vehicles in the affected area.  In addition, radio frequency identification (RFID) systems can be utilized.  RF tags (small computer circuits with identifying information) may be attached to victims during triage, to responding personnel, to vehicles, or to supplies (Arnold, 2004).  In 2010 three key factors drove a significant increase in RFID usage: decreased cost of equipment and tags, increased performance to a reliability of 99.9% and a stable international standard around UHF passive RFID.

Radio-frequency tagged persons or objects do not depend on line-of-sight contact between receiver and tag.  Some RF systems enable data stored on RF tags to be updated or expanded.  Also, RF-tagged victims or resources may be located via GIS to produce a real-time map of the affected area.

Automated logging of key on-scene events, such as a decontamination, may alert those Incident Commanders (IC) in charge of response efforts and help plan for developing problems.  Also, RFIDs can "turn on or off" as personnel or vehicles arrive or leave a scene that triggers an automated logging.  This data can be kept in a database for on-going review of events and help to identify problem areas much quicker.  In the case of a decontamination event, such data would notify the IC to provide or replace proper protective equipment.

Incident Command System Support

Probably the most important application of wireless peer networks in emergencies and disasters is in support of the Incident Command Systems (ICS) functions (Arnold, 2004).  Effective coordination and control of emergency response depends on the effective coordination and control of information sharing. 

Real World Case

The essential requirements of effective emergency management and response include pertinent information sharing across various government agencies as well as non-governmental and private organizations to assess the situation, identify the needed resources for emergency response and generate response plans. Interoperability is a key requirement for information sharing from disparate systems and organizations, such as the case in emergency response. In this demo, we present the capabilities and features of application to application level information sharing among different incident management systems via DHS-initiated information sharing platform called UICDS (Unified Incident Command and Decision Support). UICDS is a Trademark of the U.S. Department of Homeland Security.

Visit the UICDS website http://www.uicds.us/ and watch the UICDS in Two Minutes video.

Applications of wireless peer networks, which may facilitate incident management functions, include the following:

(Arnold, 2004)

Communication Technology Challenges

Numerous critical challenges exist for the effective use of Information Technology (IT) in an OOH disaster response.  Among those, two key areas are human challenges and application challenges.

Human Challenges

On the human level, challenges lie in planning joint powers agreements and procedures and in deciding how to use wireless technology in different situations, which can be overwhelming to non-IT experts.  Any IT being considered must meet the following criteria to mitigate the human challenges:

Application Challenges

Application challenges that are further exacerbated during a disaster include:

Factors enabling the application of wireless technology to OOH disaster response include the following (Adams et al., 2004):

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Education and Training (7 of 11)
Education and Training

Education and Training

Programs

Training and exercises for disaster preparedness and response must be realistic. Clear training objectives must be stated and evaluations to assess if the objectives were met. 

Different training types or methods can be used to train EMS personnel in disaster preparedness and response.  Passive learning initiatives include lectures, seminars, reading, and researching sources.  Active learning initiatives include table top exercises, field exercises (limited and full-scale), and hands-on practice.

In addition to various training exercises internal to specific organizations, state emergency management and homeland security offices typically offer a wide variety of training for everything from preparing citizens to assist during a disaster to giving first responders more indepth information about biological agents. Often, this information can be found on the state’s official calendar.

Grant Assistance

Funding for the implementation of disaster preparedness and response initiatives for EMS is widely available, from federal agencies, not-for-profit organizations, and for-profit organizations. The types and amounts of funding varies with each organization. Courses are available for the proposal-writing process required by some grant applications.

Disaster Response and Preparedness for Emergency Medical Services: Summary (8 of 11)
Disaster Response and Preparedness for Emergency Medical Services: Summary

Summary

Critical Incident Management

The Incident Command System (ICS) model was first developed in the 1970s and includes five core functions:

The functions together implement the incident action planning process.

Triage

Triage is a dynamic system used for categorizing and sorting patients according to the severity of their injuries and prioritization for evacuation to definitive care given the limitations of the current situation, and available resources (time, equipment, supplies, personnel, and evacuation capabilities).

The START System (Simple Triage And Rapid Treatment) is a basic approach to teach the triage process, which involves the use of color coded tags to sort casualties. Disaster triage presents unique challenges to even the most seasoned EMS responders.

Communication and Equipment Standards

Communications infrastructure can be divided into wired and wireless. For several reasons, wireless infrastructure is more relevant to disaster response for EMS. Key standards for wireless communication include the following:

Personal protective equipment (PPE) standards are characterized by escalating levels of protection, with Level A as the highest level and Level D as the lowest (basic protection).  Only those who are properly trained, fitted, and authorized to don the level of PPE should do so.

Education and Training

Education and training for disaster preparedness and response is essential. Funding for these activities for EMS is widely available from federal agencies, not-for-profit organizations, and for-profit organizations.

Works Cited (9 of 11)
Works Cited

Works Cited

Arnold, J., Levine, B., Manmatha, R., Lee, F., Shenoy, P., Tsai, M., et al. (2004, July-September). "Information-Sharing in Out-of-Hospital Disaster Response: The Future Role of Information Technology." Prehospital and Disaster Medicine, Vol 19, No. 3. Retrieved January, 24, 2006, from http://pdm.medicine.wisc.edu/19-3%20pdfs/Arnold.pdf

Auf der Heide, E. (1989). Chapter 8: Triage. Disaster Response: Principles of Preparation and Coordination. Retrieved January 26, 2006, from http://orgmail2.coe-dmha.org/dr/DisasterResponse.nsf/section/08?opendocument

Bridge Collapse Tests Minneapolis' public Wi-Fi. (2008). Retrieved April 22, 2008, from http://www.news.com/Citywide-Wi-Fi-network-put-to-test-in-Minneapolis/2100-7351 _3-6201561.html

Capital Wireless Information Net. Retrieved April 22, 2008, from http://www.capwin.org/index.cfm

Deatley, C, Allan, S., Hauda, W., Dehaven, P., & Stangby, A. (2003). Jane's Mass Casualty Handbook - Pre-Hospital. Surrey, UK: Jane's Information Group

EPA Levels of Protection. (n.d.). Retrieved April 12, 2006, from http://www.ehso.com/OSHA_PPE_EPA_Levels.htm

Irwin, R. (1989). Chapter 7: The Incident Command System (ICS). Disaster Response: Principles of Preparation and Coordination. Retrieved January 24, 2006, from http://orgmail2.coe-dmha.org/dr/DisasterResponse.nsf/section/07?opendocument

Kerr, M. (2010). “AMA Establishes Physician Volunteer Registry for Haiti”. Retrieved 18 August 2010 from http://www.medscape.com/viewarticle/716157

McKay, J. (2005, February 26). Technology Evolution. Government Technology. Retrieved January 25, 2006, from http://www.govtech.net/magazine/story.php?id=92872

Melia, M. (2010). “Jurors in Conn. Home Invasion Trial Get Counseling”. Retrieved Nov 17, 2010 from http://abcnews.go.com/US/wireStory?id=12173178

Sarkar, D. (2005, December 6). N.C. county installs public safety network. Retrieved March 04, 2008, from http://www.gcn.com/online/vol1_no1/43736-1.html

Szul, A., Davis, L., Maston, B., Wise, D., & Sparacino, L. (Eds.). (2004). Chapter 3: Triage. Emergency War Surgery, Third United States Revision. Retrieved January 26, 2006, from http://www.bordeninstitute.army.mil/emrgncywarsurg/Chp3Triage.pdf

Triage During a Mass Disaster: The Usual Rules Don't Apply. (2005, November 15). Retrieved January 26, 2006, from http://www.emsresponder.com/features/article.jsp?siteSection=4&id=2427

UCSD Researchers Test Wireless Technologies in Simulated Medical Disaster Response Drill. (2005, May 16). Retrieved February 24, 2006, from http://www.jacobsschool.ucsd.edu/news_events/releases/

Wireless Accelerated Responder Network. (n.d.) Retrieved January 25, 2006, from http://octo.dc.gov/octo/cwp/view,a,1304,q,628505,octoNav,|32780|.asp

Activities (10 of 11)
Activities

Activities

Team Activity

Overview

In this activity, you will research cases, current events, and supporting materials that are relevant to the subject matter of this lesson.

To Do
  1. Using your EMS: Team Activity discussion forum, work as a group to research possible candidates for each of the three following tasks:
    • "Real World Case" - Similar to the format in this lesson, identify and describe a historical real world case relevant to this lesson's content.
    • "Current Events" - Identify and describe a current event relevant to this lesson's content. For the purpose of this course, a current event is defined as an occurrence within the last year.
    • "A Picture Is Worth 1000 Words" - Identify and describe a specific figure, table, graph, or picture that underscores an important element of this lesson's content.

  2. Using your EMS: Team Activity discussion forum, work as a group to discuss the background, relevance, and value-add of the three items you select (one for each task).

  3. The team leader should write three separate one-page documents (one for each task) that summarize the team's research and discussion:
    • Indicating the selected task
    • Describing the selected item
    • Citing the source of the item
    • Describing the relevance of the item to the subject matter of this lesson
    Note that all references must be documented using APA style conventions. If you are unfamiliar with APA style conventions, check these resources.

  4. The team leader should submit the three documents to the EMS Team Activity Drop Box. (T, P/F)

Format for Papers

The preferred formatting for papers is Times New Roman, 12 point font size, 1.5 line spacing, and one inch margins. The exception is the Lesson 8 Grant Project in which double-spacing is preferred. APA style is suggested for citing references. Points are not specifically deducted for deviations in these recommendations. However, difficult to read papers tend to detract from the overall quality of the presentation and therefore the grade.

Lesson Review Worksheet

Complete the lesson review worksheet. (I, G)

Optional Survey

Please complete the optional survey at the end of this week to provide feedback on your experience with the course so far. The survey is anonymous, so please be honest!

Lesson Wrap-up (11 of 11)
Lesson Wrap-up

Lesson Wrap-up

An instructor video will be displayed here at the end of the week providing feedback for the lesson.

 

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