1. Trauma centers are crucial solutions to
mass-casualty aftermath and response
Critically
Conditioned
BY CONNIE POTTER
32 October 2016 | Homeland Security Today Magazine

2. ALTHOUGH IT HAS BEEN REPEATEDLY TESTED, THE US EMERGENCY MANAGEMENT SYSTEM
IS NOT READY. THIS IS NOT A DRILL. MULTIPLE SHOOTINGS OCCUR SO OFTEN THAT WE AND
THE MEDIA ARE NUMB WITH GRIEF AND HELPLESSNESS. SURVIVORS – IF THEY CAN BE
CALLED FORTUNATE – MAY HAVE ACCESS TO A HIGH-LEVEL TRAUMA CENTER. WHETHER
THEY DO DETERMINES THEIR PROBABILITY OF SURVIVAL AND THE EXTENT OF THEIR
ULTIMATE DISABILITY.
his was true in Tucson, when Jared Lee Loughner murdered
six and critically injured Rep. Gabrielle Giffords (D-Ariz.) and
others in a mass shooting in 2011. University Medical Center
Tucson performed heroically, and those who survived did so with lesser
disability than if they were farther away and the trauma center was ill
prepared. So goes Orlando, Fla., and Dallas’ recent mass-casualty inci-
dent (MCI). What does and doesn’t work is often a matter of chance
and too often is determined by proximity to a Level I trauma center, its
skills and depth of resources. Even these are tested and fail without ex-
acting preparation, but fortunately 83 percent of US citizens live within
that “golden hour” – the time to care for blunt trauma – of a Level I or
II trauma center.
Key elements define all types of MCI’s. The type of event determines
the number of survivors and time to treatment. Natural events create
extreme barriers to response, rescue and resuscitation, while mass shoot-
ings and blast attacks create more immediate chaos and overload, to
which hospitals and even trauma centers rarely react to perfectly.
The first element is discovery or communication via 911. Cell and smart
phones have greatly enhanced communication and the ability to pin-
point the MCI’s location through GPS. However, multiple calls to 911
can overload dispatch centers reducing their effectiveness. In addition,
lack of radio interoperability among police, fire and other responders
can add confusion.
Further, the antiquated “surround and contain” active-shooter or crime-
scene response was found at the Columbine, Colo., high school massa-
cre and Newtown Conn., Sandy Hook Elementary School shooting to
cause many preventable deaths. This has led to active-shooter training
nationwide to reduce intervention times and speed victim rescue and
resuscitation efforts. Unlike the golden hour, the crucial time for care of
gunshot wounds is within 27 minutes – the average time from injury
to exsanguination from hemorrhage. Current training places emphasis
on subduing the shooter(s) quickly using robots, SWAT teams, semi-
military tanks, etc., while medically trained law enforcement and fire
department personnel rescue those injured using tourniquets, compres-
sion methods and rapid transport without much, if any, treatment at
the scene. The ideal time for rescue, treatment and transport is 20 to 30
minutes – which is often delayed when a secondary attack on rescuers
occurs.
Rapid transport places a horrendous burden on the receiving trauma
center. Staff must assemble massive numbers of personnel and essential
supplies – from endotracheal and chest tubes to ventilators and blood.
Staff must triage those critical and survivable and leave the morbidly
wounded. Surgery can occur wherever the patient lies: emergency de-
partment, intensive-care unit, hallway or wherever necessary. Nurses
and techs may be left holding clamps on vessels while surgeons move on.
Asepsis is sporadic and may leave most patients candidates for wound
infection well after they survive their injury.
Patient arrival by private vehicle and police car, and walk-ins exaggerate
the chaos, as worried loved ones, families, blood donors and others also
arrive – from the well intentioned to posers. Lockdown must occur
within five minutes of MCI notification to prevent converters from
overwhelming security. Without prior attention to security, the emer-
gency and other hospital entrances will be overrun. Decades of disaster
responses teach that that establishing a secure perimeter and redirecting
well-wishers and others away from care areas is essential, with nones-
sential personnel enhancing security and control. Communication also
is crucial, and serious practice and preparation are necessary – although
this can’t predict the various complications where only leadership,
teamwork and creativity provide optimal outcomes.
Immediate Chaotic Aftermath
When a true natural mass-casualty event occurs, multitudes of survivors
typically are on their own for at least 24 hours. Emergency services and
responders are in the same boat, with personal injuries, family concerns,
impassable roads, lack of transport and ineffective non-interoperative
communication systems. Overall, 911 is overwhelmed, and most 911 fa-
cilities are not “hardened” to survive severe geologic damage. Cell phone
access is random, and without electricity, phones and towers are mostly
useless. Ham radio operators are generally a reliable communication
source, but it’s communication with which many emergency manage-
ment personnel and hospitals have little experience.
Fire departments also are hampered by lack of available personnel,
blocked roadways and imprecise victim locations. Bystanders, family,
canines or grid searches locate many but occur hours or even days later.
Safety issues abound in these conditions, as unstable structures can en-
trap or injure rescuers as well. Vital utilities – water, lighting, heating
T
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3. and cooling – are unavailable, but initially live electrical lines add serious
obstacles to the rescue and relocation of survivors.
Three-Day Plan for Staff and Material
Shortages
Because MCIs often last days or weeks, the entire staff must never be
called to duty simultaneously. Instead, preplanned staggered shifts can
ensure the disaster response is sustained. Staff, physicians and support
personnel must arrive prepared to be self-sufficient with pre-organized
“disaster packs” containing a three-day supply of nonperishable food,
personal and over-the-counter medications, water, paper towels and toi-
let tissue, flashlights, batteries, cell phone chargers, clothing and hygienic
care items.
Human resources’ essential role is the “family care” plan for each em-
ployee and staff member. These are essential parts of any personnel re-
cord to assure staff will respond to duty without concerns for children,
disabled dependents, the elderly and pets. These plans must exist in hard
copy, as information technology access is likely unavailable. The facility
needs to provide space and staff to support children, disabled dependents
and the elderly who have no alternative caregiver so skilled and essential
staff can report for duty. These additional victims must have their own
supplies as well, particularly infant or adult diapers, nonperishable food
and other necessary supplies. The plan also should list special needs and
include a pre-signed authorization for other responsible parties to pick
up dependents. Drop-offs should be registered, given armbands or other
identification, and have a summary sheet of contacts, pertinent history
and medical information, including their primary physician.
Special Needs Focus
The care and safety of special needs patients, who include the chroni-
cally ill, morbidly obese, dialysis patients, oxygen-dependent pulmonary
cases, diabetics, pregnant and post-partum mothers, and the mentally
ill is rarely planned. Many stable and independent chronically ill per-
sons become unstable from lack of routine medications, which become
increasingly scarce as hospitals vie for supplies and ordinary pharmacy
refills. Heat-sensitive medications that become ineffective include most
insulins, inhalers, steroids, nitroglycerine and many others.
Locating these persons in an infirmary-like setting, such as a tent hospi-
tal with skilled personnel and some physician oversight, can keep them
out of the inpatient setting and improve their survivability.
Storm Surge
Hospitals are rarely, if ever, able to care for a surge of more than 10
percent of their capacity. Mock disaster surveys that contacted trauma
centers regarding bed availability found most already at or near capacity
and many over capacity. Virtually none could absorb the numbers of
casualties expected in a full-scale catastrophe without heroic measures.
Knowing this, surge capacity must be planned and executed rapidly,
24/7. To do so, on-duty caregivers must have the authority to move able
patients to a pre-assigned discharge area staffed by low-skilled personnel
with some capacity for medication administration, handwashing and
toileting, and seating. These patients are discharged by any attending or
qualified resident, nurse practitioner or physician assistant.
Perimeter Personnel and Premises Control
A critical area for rapid control is the vetting of personnel entering the
facility. Good Samaritan nurses and physicians not part of hospital staff
are unfortunately not useful due to their lack of familiarity with the
premises, policies and equipment. From a legal standpoint, good Sa-
maritan acts so common in the United States do not encompass care in
a medical facility where one does not have privileges or credentials. A
simple cure for this is the commonly used “memorandum of agreement
for mutual aid” that covers virtually all emergency medical service agen-
cies in the United States. Hospitals that establish such agreements must
carefully define what outside personnel can do with and without super-
vision and provide them with readily identifiable badges or card readers.
The range of losses
by hospitals providing
post-MCI treatment
and care of displaced
victims is staggering.
Crews work to cleanup parts of Bellevue hospital that were impacted
by Hurricane Sandy.The orange line on the wall indicates how high
the flood waters rose after Hurricane Sandy.
PhotobyJocelynAugustino/FEMA
34 October 2016 | Homeland Security Today Magazine

4. Critically Conditioned
Imposters are known to invade medical areas in disasters, either for vi-
carious thrills or for media scoops, making this issue critical. Another
aspect of perimeter control is the routing of service vehicles carrying
medical supplies, ventilators, drugs and other necessary items. Many, if
not most, hospitals find their usual suppliers unable to assist in an MCI
because of duplicate service agreements with other regional hospitals. In
one notable case, an entire state had a single supplier for ventilators. Ex-
clusive vendor contracts are a precautionary measure that can save lives.
Darkness, Scarce Resources
and Written Records
Generated power coverage is generally limited to critical care, emer-
gency and operating areas with only dim lighting in halls, stairwells and
patient rooms, and even that limited power supply is often unreliable.
Routine care is always hindered by lack of power. Electric beds are not
operational and must be cranked or hand hoisted; Portable radiology
devices are restricted to fewer areas; and severe rationing is placed on all
types of testing. Point–of-service testing using material such as Chem-
strips may have to suffice instead of laboratory sampling. Strict frugality
is essential to managing for the long term – usually from three to seven
days’ duration of MCI events. This means rationing, reusing, adapting
and otherwise suspending the routine disposal of supplies and waste
associated with ordinary care. Waste disposal is a critical issue overall,
with little or no means of removing trash and biologic waste.
Loss of electronic medical record keeping further complicates things.
Lacking paper records creates severe delays in patient identification, lab,
radiology, pharmacy and other requests. Written paper requisitions are
needed as well as proper identification of the patient without the con-
venience of armband bar codes.
The Disaster of Financing Disaster
In part, the enormous problem with family reunification is hampered
by the lack of a central registry for displaced persons, so that locations
can be accessed by a variety of caregivers, Red Cross, Federal Emergency
Management Agency, Centers for Medicaid and Medicare Services, pri-
vate insurers, etc. Insurance cards or other routinely required documents
are often unavailable, which places a significant burden on the receiving
facility when seeking reimbursement for their costs.
The range of losses by hospitals providing post-MCI treatment and care
of displaced victims is staggering. Hospitals already operating on thin
margins face tough financial decisions around aiding another region’s
disaster victims without seeing major changes in compensation, pay-
ments and federal fiscal policies.
First, disaster care requires developing new charge codes through the
American Hospital Association’s National Uniform Billing Commit-
tee, because there are no existing charge codes that bill for the cost of
readiness, immediate disaster care, decontamination or resupply. These
new charges must be ranked by severity according to the nationally
recognized disaster acuity system. Additionally, Medicaid, Medicare,
other federally sponsored payors and private insurers need to extend
payments across state lines and waive authorizations and “in-network”
restrictions when states of emergency are declared. All payor sources
must expedite reimbursement, cover out-of-state treatments, expedite
pharmaceutical and treatment payments, and waive pre-authorizations
or other bureaucratic impediments to hospital and provider reimburse-
ment for displaced or newly homeless persons. Only then will the medi-
cal community feel safe to extend assistance without risk of financial
disaster such as suffered by those aiding 9/11 victims and New Orleans
patients after Hurricane Katrina.
Without adequate reimbursement, resupply and preparation for the
next inevitable event is not possible. Preparedness monies for hospitals
are already scarce and administered with little consideration for need.
The last time this issue was studied – in 2006 – trauma center spend-
ing for preparedness averaged more than $54 million, while funding
was calculated at $69 million. There was extreme variation of funding
among regions of the country. The East and Midwest were the hardest
pressed, with cost and reimbursement being either equal or at a large
loss. Even this funding has since eroded, and hospitals – particularly
trauma centers – are in no position to cover shortfalls.
Trauma Center Solutions
Only 10 percent of the more than 5,000 licensed hospitals in the United
States are high-level trauma centers, so there is an ongoing struggle for
preparedness and an extreme divide in the ability, interest and will-
ingness to sustain the costs, commitment and resources necessary to
perform well in a true catastrophe. General hospitals are already strug-
gling with Affordable Care Act (Obamacare) uncertainties and some-
what punitive measures, dwindling Medicare and Medicaid payments,
private insurers’ parsimonious reimbursement tactics, staffing shortages
and often-brutal competition.
Mostly token attention is given to
disaster preparedness. Attempting to
get more than 5,000 hospitals versus
about 500 trauma centers to rem-
edy decades of failed and muddled
responses so that each next inevi-
table event is met with a stronger,
Connie J. Potter is one of the foremost authorities on the nation’s trauma care industry who currently is CEO and owner of TraumaWorks LLC. She
previously served as president and CEO of the Trauma Center Association of American, formerly the National Foundation for Trauma Care. She served
as Assistant Director of Nursing, Emergency Services Administrator, University of California, Irvine Medical Center; Associate Director/Nurse Manager,
Emergency and Trauma Services at Thomason Hospital in El Paso, Texas; and the Oregon Health Division Trauma System Manager.
Continued
on Page 46
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5. In recent years, there have been oc-
casions in which groups of armed
Islamic extremists have attacked and
gained access to supposedly secure
Pakistani military installations. A
year ago, a team of Taliban operatives
in police uniforms passed unchal-
lenged through checkpoints and en-
tered a Pakistani air force base. Before
they were neutralized, they killed 30 Pakistani military personnel. Three
similar attacks have been made on a base near Islamabad believed to
house Pakistani nuclear weapons.
The possibility of a Pakistani weapon being taken by force by terrorists
or handed over to them by sympathetic insiders may be remote, but
it can’t be discounted. Given the consequences, focus on border secu-
rity and preventing such a weapon being moved into the United States
ought to be intense.
Unfortunately, it seems the threat is dismissed as distant and largely the-
oretical. Land border security is virtually nonexistent. Tons of narcotics
are moved across the border unimpeded every year. Tens of thousands
of migrants with meager resources succeed in defeating our efforts to
prevent their entry. In this environment, it cannot plausibly be claimed
that a dangerous terrorist group would be incapable of bringing in a
single weapon that could be carried in a large crate.
Analysis
Efforts to secure ports and put in place a system to detect radioactive
materials have been at best partially successful. After initial missteps,
radiation detection capability is significantly improved and screening
procedures exist not only here at home, but at many ports abroad. The
fact remains, however, that with existing methods and technology, the
task of identifying a nuclear weapon – especially if shielded – in a single
container among tens of thousands is daunting. We remain far too vul-
nerable.
For too long, we have looked at all terrorist “weapons of mass destruc-
tion” threats as something to worry about in some distant future. They
have seemed to us the stuff of science fiction. We have run out of time
to indulge that fantasy.
Nuclear terrorism is an immediate, concrete threat worldwide. That in-
cludes here at home. In Belgium, they are issuing iodine tablets to the
entire population; such is their fear of an attack on a nuclear reactor. In
London, they are running drills simulating a dirty bomb attack. In Ger-
many, authorities are directing the populace to be prepared to shelter in
place and to stockpile food, water and medical supplies for a minimum
of 10 days.
The Europeans have seen the future and found it terrifying. They are
acting accordingly. It is time we moved with the same urgency.
better organized, collaborative
response is a critically needed
change to the nation’s emergency
preparedness.
Trauma centers have much to gain
by embracing the role of the “medi-
cal disaster command center,” as it can
be called. They are already regionalized
and cooperate across state lines. They
are linked by necessity to all levels of emergency medical response. They
are the most involved in disaster management and care, are the recipi-
ents of the most injured patients and have longstanding and personal
relationships with neighboring regional and out-of-state trauma cen-
ters. This makes them uniquely positioned to be the hubs, command
and control centers, and test sites for innovation and standardization
of MCI event response. Trauma centers lead in their ability to surge to
excess capacity because most never go on diversion or bypass. They are
required by their accreditation processes to continuously innovate and
improve care, plan and practice for disasters of all types, and conduct or
participate in research. They excel beyond any other clinical specialty in
the evaluation of their systems of care, from communication through
rehabilitation. All trauma centers have a strict disaster response compo-
nent of their designation/verification review.
Analysis
Giving trauma centers and the systems that encompass them the role
and resources to fully embrace disaster response from all hazards is sen-
sible and cost effective. This is the best investment this nation can make,
as trauma centers can already expand care from the single critical crash
or gunshot wound victim to hundreds and even thousands of victims.
Given the resources and the authority to overcome well-known and
longstanding obstacles through innovation and research, they can be
models for disaster response and care. Trauma centers have already ad-
opted and organized effective regional stroke programs atop the existing
trauma system infrastructure for a paltry $20 million incentive. Their
performance as medical disaster command centers – with realistic fiscal
support – can be extraordinary and resolve many, if not most, of the
vulnerabilities facing citizens and emergency responders when the next
disaster strikes.
The simple solution is to appropriate the $224 million authorized in
2010 in the Affordable Care Act section 3505 Trauma Care Centers and
Service Availability. This funding would quickly solve the problem of
financial instability and lack of access to trauma centers nationwide. As
a result, a trauma center disaster command infrastructure would be built
to resolve known weaknesses and vulnerabilities to the public’s health
and safety as well as daily saving 20 percent of trauma deaths, which is
attributed to lack of proximity to a Level I, and II trauma center.
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46 October 2016 | Homeland Security Today Magazine