Article - Medical Response Capabilities to a Catastrophic Disaster - Journal HSEM (Vol 9 Issue 2) 2012

Volume 9, Issue 2 2012 Article 1
Journal of Homeland Security and
Emergency Management
Medical Response Capabilities to a
Catastrophic Disaster: “House” or House of
Cards?
Donald A. Donahue, University of Maryland University
College, American Academy of Disaster Medicine, Diogenec
Group
Evelyn A. Godwin, Diogenec Group
Stephen O. Cunnion, Diogenec Group
Recommended Citation:
Donahue, Donald A.; Godwin, Evelyn A.; and Cunnion, Stephen O. (2012) "Medical Response
Capabilities to a Catastrophic Disaster: “House” or House of Cards?," Journal of Homeland
Security and Emergency Management: Vol. 9: Iss. 2, Article 1.
DOI: 10.1515/1547-7355.2029
©2012 De Gruyter. All rights reserved.
Brought to you by | De Gruyter / TCS
Authenticated | 173.9.48.25
Download Date | 10/9/12 8:05 PM

Medical Response Capabilities to a
Catastrophic Disaster: “House” or House of
Cards?
Donald A. Donahue, Evelyn A. Godwin, and Stephen O. Cunnion
Abstract
Planning for a disaster is often influenced by the dual factors of perception of probabilities
and current technology. Response design is built upon assumptions on the size, scope, and severity
of the catastrophe. Yet, history documents myriad disasters that far surpassed even the direst
predictions. Similarly, response mechanisms build upon what is in use at the time in terms of
equipment, transportation, and employment. Current planning factors may prove inadequate to
address a disaster of historical proportion. The authors offer a review of significant disasters as a
measure of the potential scope of needed medical response and the inherent shortcomings therein.
They call for a more comprehensive approach to medical response planning.
KEYWORDS: disaster response, surge capacity, medical care

Background
There is a natural predisposition to not prepare for disaster (Redlener 2006). What
can be termed “disaster denial” permeates our culture. Preparedness malaise can
be passive: coastal residents often fail to heed evacuation orders in the face of a
hurricane (Dash and Hearn Morrow 2001); and despite robust recommendations
by the Centers for Disease Control and Prevention (CDC) and the World Health
Organization, less than a quarter of the U.S. population sought and received
vaccination against the H1N1 pandemic—well short of even regular influenza
season target rates (CDC 2010). Preparedness malaise can also take the form of
active opposition that can be misinformed and, in the extreme, deadly. One of the
many objections voiced against the anthrax vaccination program launched by the
Department of Defense (DoD) was that it was unnecessary because no one had
previously employed anthrax as a weapon. That assertion was proven tragically
misguided in October and November of 2001 (U.S. General Accounting Office
[GAO] 2003).
The reality is that the unthinkable can happen. Contingency planners have
been called “professional pessimists” (B. Maliner, personal communication,
2003). This outwardly dour perspective is born from recognition of the vast
variety and scale of potential disasters. “I am often asked, ‘When will we be
prepared for all the threats we face?’ My answer is—not in my lifetime”
(Carmona 2004) This pragmatic portrayal of preparedness by Dr. Richard H.
Carmona, the 17th surgeon general of the United States, highlights a looming
crisis within a shrinking U.S. health system, an infrastructure that saw 19% of all
hospitals close between 1975 and 2008 (American Hospital Association [AHA]
2010). As levels of preparedness have increased over the past two decades in
terms of the broad spectrum of disaster response, capabilities in the areas of
patient evacuation and treatment have arguably diminished or been found to be
based on faulty planning assumptions (Franco et al. 2007). Evacuation of
casualties can, to a certain degree, remediate immediate health care crises but may
be neither possible nor sustainable because of logistical challenges or the limits of
receiving locations (Franco et al. 2007). Moreover, the wholesale removal of sick
or injured victims works counter to the goal of a rapid recovery within the
community as it means dislocating residents to disparate locations (Donahue et al.
2012). In the face of a large-scale catastrophic disaster, the nation’s medical
response edifice may prove to be a Potemkin village.
Myriad potential contingencies are confirmed by recent history. The 1989
Loma Prieta earthquake caused extensive damage throughout California. In 2005,
massive hurricanes destroyed vast swaths of the Gulf Coast. Epic floods
inundated Saint Louis, Missouri, in 1993 and Iowa in 2009. Some natural events
are almost beyond comprehension. Although occurring more than a century ago,
1Donahue et al.: Medical Response Capabilities to a Catastrophic Disaster
Published by De Gruyter, 2012

the 1908 meteor strike in Tunguska, Siberia, illustrates an enormous event beyond
man’s ability to mitigate. It is estimated to have produced an explosion equivalent
to 500 kilotons of TNT, or approximately 60 times the explosion at Hiroshima
(Hartman, n.d).
Sadly, natural disasters do not represent the full scope of threats. Acts of
human violence have produced significant numbers of casualties with alarming
frequency: New York City in 1993, Oklahoma City in 1995, and New York and
Washington, D.C., in 2001. Oversight or neglect can result in catastrophe or, in
some cases, in a near miss. Consider the case of the Citicorp building, a landmark
New York City skyscraper. A student research project identified a structural flaw
in the 59-floor, 915-foot-tall building in midtown Manhattan. Analysis revealed
that the edifice, built in 1977, would be unable to withstand a 70 mph wind from a
45-degree angle. The approach of the 1978 hurricane season presented an urgent
situation: structural failure would endanger the estimated 300,000 people within a
six-block radius at midday (Morgenstern 1995). An emergency reinforcement
project remedied the deficiency, but not before anxious contemplation of the
potential consequences.
Acts of human violence entail physical injuries to life and property.
Further danger is posed by a panoply of pestilence; severe acute respiratory
syndrome (SARS), H5N1, H1N1, and anthrax—both the postal attacks of 2001
and the 2011, inexplicable rash of deaths among heroin users in Europe—are
among the latent threats faced. The deceptively mild outcome of the 2009–2010
H1N1 outbreak belies the potential for massive casualties from an influenza
pandemic (see Table 1). Modeling by the CDC projects the need for more than ten
times the number of hospital beds currently existing in the United States (CDC
2006; AHA 2009).
HHS Health Outcomes
Characteristic Moderate (1958/68-like) Severe (1918-like)
Illness 90 million (30%) 90 million (30%)
Outpatient medical care 45 million (50%) 45 million (50%)
Hospitalization 865,000 9,900,000
ICU care 128,750 1,485,000
Mechanical ventilation 64,875 742,500
Deaths 209,000 1,903,000
Table 1. Number of Episodes of Illness, Health Care Utilization, and Death
Associated with Moderate and Severe Pandemic Influenza Scenarios (Office of
the Assistant Secretary for Preparedness and Response, 2008)
2 JHSEM: Vol. 9 [2012], No. 2, Article 1

These dire circumstances are exacerbated by waning capacity in the health
delivery system and inherent structural challenges. Emergency department
overcrowding severely limits the ability to respond to a sudden event (Eastman
2006). The number of inpatient beds is shrinking; between 1995 and 2008,
hospitals eliminated 129,556 (12%) of all operational beds (AHA 2010; Cantrill
2007). From 1995 to 2001, 20% of intensive care unit capacity was lost (Cantrill
2007). Most health care is in the private sector, not under state governmental or
municipal authority (Cantrill 2007), thereby limiting the motivation to establish
robust expansion capabilities and precluding opportunities for standardization and
coordination of surge capacity (Franco et al. 2007). The widespread employment
of “just in time” supply processes creates the potential for shortages and single
points of failure. Various preparedness monitoring programs report bed
availability, but the functional extent of this status is far from clear. Is an available
bed simply the piece of equipment or does it include adequate staffing, supplies,
and ancillary support functions?
The lack of surge capacity in American hospitals is such that few, if any,
hospitals could handle a sudden influx of 100 patients needing advanced
life-support care. In most locales, even the combined resources of all
hospitals in a metropolitan area could not handle such a demand. No city
in America, and no contiguous geographic region could handle 1000
patients suddenly needing advanced medical care. (Senate Committee on
Government Affairs, 2001)
Defining the Need
The Microsoft Word thesaurus suggests “unforeseen event” as a synonym for
“contingency.” But are contingencies truly unforeseen (Joint Commission 2003)?
Hospital planning factors have for years emphasized not evacuating in the face of
a disaster but, instead, expanding capacity to “surge in place” to accept greater
numbers of patients. Recent history demonstrates, however, this approach is not
always feasible.
Hurricanes Katrina and Rita have shown us that having plans to “surge in
place,” meaning expanding a functional facility to treat a large number of
patients after a mass casualty incident, is not always sufficient in disasters
because the health care organization itself may be too damaged to operate
(Joint Commission 2006, iv).
Depending on the nature of the disaster, a surging hospital has three
operational alternatives: expand current capabilities, replace extant infrastructure,

or create extended isolation capacity. Augmenting current capacity is typically
well considered in institutional disaster plans. Often less developed are plans for
using buildings of opportunity (i.e., existing structures) and temporary structures,
and for replacing damaged or destroyed infrastructure (Barbisch and Koenig
2006). Perhaps most vexing—operationally and ethically—are the challenges in
addressing highly communicable diseases such as SARS. Few hospital
administrators would be willing to functionally rebrand their institution as “St.
Smallpox.”
While the partial or total loss of a hospital may seem incomprehensible to
health care leadership, such a potentiality must be considered. It is likely a major
disaster will strike. Consider the New Madrid fault and its known history. This
fault traverses and directly threatens parts of seven American states: Arkansas,
Illinois, Indiana, Kentucky, Mississippi, Missouri, and Tennessee. Impact of a
major quake can be expected to extend far beyond these states, however.
Beginning with an initial pair of very large earthquakes on December 16, 1811,
the 1811 and 1812 New Madrid earthquakes are the most intense intraplate
earthquake series to have occurred in the contiguous United States. According to
some estimates, the earthquakes were felt strongly over roughly 130,000 square
kilometers (50,000 square miles) and moderately across nearly 3 million square
kilometers (1 million square miles). The historic 1906 San Francisco earthquake,
by comparison, was felt moderately over roughly 16,000 square kilometers (6,000
square miles) (Applegate 2007; Atkinson 1989).
These were not isolated instances. Comparison of the geographic impact
of earthquakes of similar intensity—the 1895 Midwest and 1994 Los Angeles
basin earthquakes—reveals that the former event had a significantly larger
footprint (see Figure 1) (Hildenbrand et al. 1996). As the footprint is significant,
so too would be the consequences.
Figure 1. Comparative Scope of Earthquakes (Hildenbrand et al. 1996)

Critical infrastructure and lifelines will also be heavily damaged and most
likely out of service for a considerable period of time after the earthquake. Such
mass outages are likely to affect a region much larger than the eight states cited
above. Many hospitals nearest to the rupture zone will not be able to care for
patients, indicating that, absent a rapid expansion of local capabilities, those
injured during the event as well as pre-earthquake patients will have to be
transported outside of the region to fully functioning hospitals. It is doubtful that
the transportation system will be functioning to a level that allows such mass
evacuation. Police and fire services will be severely impaired because of damage
to stations throughout the affected region. Many schools that serve as public
shelter will also be damaged and likely unusable after the earthquake.
Transportation into and out of the areas near the fault rupture will be difficult, if
not impossible: airports will be damaged; bridges will be damaged and not
passable or their stability suspect; and some ferry facilities and ports will be out of
service. The massive loss of functionality of transportation systems and facilities
will prevent displaced residents from leaving the region and also make it difficult
for ground-transported aid workers and relief supplies to access the most heavily
damaged areas (Elnashai et al. 2008).
As will be discussed later in this analysis, existing incremental surge
capabilities would prove insufficient to meet post-disaster health care needs
following a major event. It has been estimated that 60% of Memphis, Tennessee,
will be devastated, with 6,000 fatalities in that city alone (Elnashai et al. 2008a,
2008b).
A Recurring Theme
Recent natural disasters have highlighted shortfall areas in current hospital
disaster preparedness. These areas include (1) insufficient coordination between
hospitals and civil/governmental response agencies, (2) insufficient on-site critical
care capability, (3) a lack of portability of acute care processes (i.e., transporting
patients and/or bringing care to them), (4) education shortfalls, and (5) the
inability of hospitals to align disaster medical requirements with other competing
priorities (Farmer and Carlton 2006).
We suggest that a significant disaster will eventually strike the United
States, causing overwhelming patient load, physical destruction, or both. While
many, if not most, post-disaster needs can be met by state and local assets, this
would not be the case should the regional health system fail, the very occurrence
of which would negate local surge capability. One of a governor’s primary
disaster response resources is the National Guard. Despite significant capabilities
and capacity in terms of transportation, law enforcement, civil engineering, and
myriad other functions needed in the wake of disaster, however, the Guard

possesses limited comprehensive medical capabilities, there being no hospitals in
the Army National Guard and limited e-Med1
assets in the Air Guard. A
catastrophic failure of a region’s health care infrastructure will inevitably prompt
federal action, with multiple agencies providing substantial response and
deployable assets. DoD and the Department of Veterans Affairs (VA) will play a
prominent role in domestic disaster response (Piggott, n.d.).
The operational assumption here has been that patients would be
transported, via coordination within the National Disaster Medical System
(NDMS), to definitive care via capabilities in regions beyond that affected by the
disaster. This is problematic in terms of both the ability to move large numbers of
patients and where those patients will go.
The military medical transportation system could transport only limited
numbers of patients. Long-haul transportation of patients is a federal
responsibility but is constrained by the limited aeromedical evacuation
capacity of the U.S. military. Although almost all of the more than 1,000
cargo planes in the U.S. Air Force, Air Force Reserve, and Air National
Guard can be reconfigured for medical transportation (GAO 1998), trained
aeromedical personnel needed to transport patients are limited in number.
Most (65%) of the military aeromedical personnel are in the Air Force
Reserve (Air Force Reserve 2007) and would likely take some time to be
called up in a crisis. For critical care patients, not only is there a limited
number of highly trained personnel, but each three-member Critical Care
Air Transport Team can only accommodate three ventilator patients or six
nonventilator critical care patients per flight (Carter 2006). Thus, even if
the CRAF [Civil Reserve Air Fleet] were activated to supplement the
number of airplanes available, the staff limitations would likely preclude a
significant immediate increase in the medical lift capacity (Franco et al.
2007, 322–323).
The reliance on private assets to augment those of the military would also
prove problematic from the perspective of responsiveness. Some 1,400 airframes,
including 45 Boeing 767s identified for aeromedical evacuation, are available to
the federal government on short notice via the CRAF program. It would take 60
hours to reconfigure the first CRAF aircraft, however; others would become
available over a period of weeks, as all the planes must go to one contractor in
Galveston for the conversion (Wilhite 1996). There is also the question of
available crew members, as a percentage of commercial airline pilots hold
1
eMed (Expeditionary Medical) is the Air Force Medical Service’s modular hospital configuration
designed to support forward-deployed Air Force assets and patient evacuation missions.

commissions in the Guard and Reserve and may be mobilized in support of the
state or federal relief effort.
Additionally, the availability of adequately staffed beds may be limited,
owing to both budgetary and manpower constraints and a lack of awareness in the
receiving institutions. In a survey of training needs at NDMS-participating
hospitals, 25% of respondent hospitals were unaware of their designation as an
NDMS hospital (VA 2005). NDMS planning relies on 110,605 precommitted
beds (McCann 2008), 11.6% of the total 951,045 U.S. hospital beds (AHA 2010).
In 2008, the national average for hospital bed occupancy was 68.2% (AHA 2010).
While this would appear to indicate sufficient bed capacity, it must be noted that
hospitals staff for that occupancy. Therefore, a report of an available bed may be
exactly that: an empty bed sans attendant staffing, supplies, and support services
(housekeeping, food services, linens, etc.). Moreover, this availability is spread
across the nation’s 5,815 hospitals, so while some institutions may be operating at
50% occupancy, others—especially urban medical centers—are at near or over
capacity (AHA 2010).
Delivering Surge Capacity
The prospect of transporting several thousand casualties to myriad treatment
facilities poses a tremendous temporal, transportation, and sustainability
challenge. In this scenario, the needs will include deployable facilities, additional
personnel, or a combination of both to establish a meaningful spectrum of care
within the disaster-stricken region and to foster recovery.
Delivering surge capacity entails multiple operational issues, including
physical space, organizational structure, medical staff, ancillary staff, support
(nutrition, mental health, etc.), supply, pharmaceuticals, and other resources
(Texas A&M Health Science Center 2004). The operational paradigm is to focus
on target capabilities that meet current standards of care, as depicted in Figure 2,
moving to alternative delivery venues—assuming they are inherently
substandard—for as little time as possible (Joint Commission 2006). The
implication is that surge capabilities will be necessary for a short duration.
Following a catastrophic disaster, however, this may not be the case.

Figure 2. Alternative Standards of Care Model (Joint Commission 2006)
The NDMS provides effective but limited augmentation resources (Flacks
2007). For example, 55 Disaster Medical Assistance Teams (DMATs) furnish
emergency medical response with civilian medical teams. Each DMAT can keep
30 medical/surgical noncritical inpatients stable pending evacuation, prepare 200
patients for evacuation, and stage (i.e., move to evacuation transport) up to 100
patients. DMATs deliver quality primary and acute care in an austere
environment: triage, emergent, acute life support, laboratory, pharmaceutical
services, medical ward, and evacuation preparation (National Medical Response
Team [NMRT], n.d.; Piggott, n.d.). They can begin limited operations upon
arrival at a disaster site and then take several hours to establish full operations,
typically from tents (Piggott, n.d.). They focus on the movement of casualties to
definitive care in hospitals outside of the affected region (NMRT, n.d.; Piggott,
n.d.), a process that may not be sustainable or even possible following a
catastrophic disaster.
Once set up, DMATs are limited in the amount and type of care they can
provide. If providing only minor treatment preparatory to the release of
ambulatory patients, all the DMATs in the country working together could handle
about 5,000 patients per day. If, however, the teams are providing inpatient-type
care, such as managing continuous intravenous fluids, pain control, or antibiotics,
their capacity would be only about 1,400 patients per day (Piggott, n.d.). Moreover,
many DMATs are not equipped or trained to provide specialized care for patients
in shock or respiratory failure or for burn or pediatric patients (Franco et al.).
Further surge capacity is offered via a Federal Medical Station (FMS), a
facility that evolved from the Federal Medical Contingency Station. An FMS is
modeled for all age populations and is focused on nonhospitalized, ambulatory
patients with medical needs aggravated by disaster. Scalable to the incident,

modular in configuration, and mobile for maximum geographic distribution, an
FMS is designed to be q
this assumes a degree of predictability of available resources, the absence of
which can seriously hinder operational capabilities
operational in three days from the reques
travel and another 48 hour
encompasses 250 beds (in 50
of care (Franco et al. 2007
While the design
most significant shortcoming
a sports arena, hangar, or armory
control, infection control,
management, space management, and a homeless shelter atmosphere
demoralizing baseline hardly conducive to the psychos
victims (Cantrill 2007). Moreover, as Franco and colleagues note
Medical Stations (FMSs) would take even longer to deploy [than DMATs] and
are limited by the equipment and staffing available”
Figure 3. Federal Medica
The FMS has significant logistical support requirements, many of which
may be unavailable following a catastrophic disaster
building of opportunity must offer
beds. An electrical power source and
communications support
include perimeter security, waste removal, medical waste disposal, laundry,
potable water, ice, refrigeration, food service for patients and staff,
showers, local transportation, and billeting for 150 personnel p
2006; Cantrill 2007). There are also significant operational concerns
FMS is designed to be quickly integrated with on-site resources. By definition,
which can seriously hinder operational capabilities. The FMS is designed to be
operational in three days from the request for deployment—requiring 24 h
ours for set up—and to use buildings of opportunity
in 50-bed units) and can deliver quarantine or lower level
2007).
design of the FMS is its greatest strength, it is also the station’s
most significant shortcoming. An FMS is typically set up in a large space
r, or armory (see Figure 3). This results in issues of
control, infection control, communicable disease spread, patient property
management, space management, and a homeless shelter atmosphere
hardly conducive to the psychosocial recovery of disaster
Moreover, as Franco and colleagues note, “The Federal
are limited by the equipment and staffing available” (322).
Federal Medical Station in an Aircraft Hangar (Cantrill 2007)
significant logistical support requirements, many of which
may be unavailable following a catastrophic disaster. To provide utility, the
must offer 40,000 square feet of enclosed space
ectrical power source and distribution are required, as is
ommunications support. Additional support functions that must be furnished
potable water, ice, refrigeration, food service for patients and staff,
showers, local transportation, and billeting for 150 personnel per FMS
There are also significant operational concerns,
By definition,
The FMS is designed to be
24 hours for
buildings of opportunity. It
uarantine or lower levels
the station’s
in a large space, such as
ssues of crowd
communicable disease spread, patient property
management, space management, and a homeless shelter atmosphere—a
cial recovery of disaster
“The Federal
significant logistical support requirements, many of which
To provide utility, the
enclosed space per 250
are required, as is
dditional support functions that must be furnished
potable water, ice, refrigeration, food service for patients and staff, latrines,
er FMS (Trabert
including

staff flow, supply management, sustainability, communicable disease control, and
privacy.
The extent to which an FMS can respond to a major disaster is likely to be
determined at the time of need. According to the CDC, “When Hurricane Katrina
struck Louisiana on August 28, 2005, only a few prototype Federal Medical
Stations existed. DSNS [Division of Strategic National Stockpile] took the
program from prototype to reality almost overnight. Over the next few weeks,
DSNS sent nine FMS sets with 5,500 beds to hurricane-affected areas” (n.d.).
While a significant response for less acute conditions, the time line of weeks is
problematic in terms of rapid recovery for the amelioration of injuries and illness
directly caused by the disaster.
Depending on the nature of the disaster, structures once considered viable
candidates for surge capacity can become buildings of inopportunity. During the
San Fernando earthquake of February 1971, a portion of Olive View Hospital
collapsed, effectively eliminating a valuable asset and actually increasing the
surge requirement in terms of number of patients to be placed. Similarly, the F5-
strength tornado that struck Joplin, Missouri, on May 22, 2011, effectively
destroyed St. John's Regional Medical Center. The inherent challenges in
planning for dependable surge capacity have led many jurisdictions and health
care provider organizations to experiment with alternative augmentative systems.
One response to the need for capacity that can be deployed at varying
locations is the self-contained mobile hospital. Carolinas MED-1 is a prime
example of this approach (Carolinas Medical Center 2010):
The first and only hospital of its kind in the world, Carolinas MED-1
incorporates an emergency department, surgical suite, critical care beds,
and general treatment and admitting area. Consisting of two 53-foot
tractor-trailers, the unit expands to a workspace of 1000 square feet and
supports an environmentally-controlled awning structure that incorporates
up to 130 beds. It carries its own generators, oxygen, x-ray and ultrasound
capability, and diagnostic lab (American College of Emergency
Physicians 2006).
This modality offers distinct advantages in responding to a disaster; for example,
it takes less than an hour to set up upon arrival. While it can deliver critical
characteristics necessary for comprehensive disaster response, however, it is
hardly a national asset owing solely to its uniqueness. There is also the issue of
return on investment. The price tag for such a system can easily climb into the
millions. Few hospitals or health systems are likely to have the available
resources to dedicate to extensive surge capacity absent a viable or routine
alternative use.

One such alternative utility has been suggested by Paul K. Carlton, MD,
the former surgeon general of the Air Force and current member of the faculty at
Texas A&M University. Dr. Carlton envisions dual-use mobile facilities where
clinical platforms, such as the semitrailers of the Carolinas MED-1, are designed
as inserts to a fixed structure (Carlton 2007). The incorporation of mobile clinical
assets within a physical plant would represent a significant capital investment and
require coordination with facilities management staff, architects, and certificate of
need issuing authorities. But by nesting the movable asset within a building that
has a daily clinical mission, organizations can mitigate issues that arise with
dedicated surge equipment, such as nonemergency use, supply maintenance, and
defraying the cost of acquisition. Even given the “fly-away” configuration of the
nested clinical platforms, however, significant logistical support requirements
inhibit the effectiveness of this approach. Each mobile platform requires a prime
mover (i.e., a tractor for the trailer). To be effective, a large number of these units
must be available. Plus, the owning institution must plan for replacement of the
deployed clinical assets for continuing operations.
The ongoing scenario, therefore, entails the availability of limited
augmentation assets for a discrete period of time. In virtually every contemplated
disaster scenario with an overwhelming number of casualties, the default, last-
chance option is to draw upon the largest pool of equipment and expertise in
establishing comprehensive medical treatment facilities in austere
environments—in short, the military. The problem with this as a safety valve is
that available resources fall far short of the perceived capabilities. Although DoD
does boast considerable deployable medical assets, when it comes to rapid
response to an immediate domestic crisis, the proverbial admonition of the Maine
farmer applies: “you can’t get there from here.”
Gold Standard or Rube Goldberg?
The abundant capabilities and significant achievements of the DoD medical
system are beyond the scope of this analysis. They are generally acknowledged
for advances in trauma care, an ability to respond globally, and success in
establishing effective operations in the most hostile of environments.
As a movable capability, DoD deployable hospitals and medical support
units demonstrate characteristics that make them ideal for their intended military
support mission but less ideal for domestic disaster response. The configuration,
modularity, and mobility of the separate services’ deployable hospitals necessarily
vary in accordance with each service’s operational mission. Army assets are
designed to support sustained land warfare, the Navy employs a combination of
land and shipboard clinical configurations, and the Air Force leverages its

mobility via a series of accumulative modules that address the various phases of
area medical support.
Despite their considerable differences in focus, shelter systems, and
transportability, deployable military hospitals have several characteristics in
common. Most have a large footprint, needing tens of acres of level ground at full
operational capacity. Recent use (combat, stability, and humanitarian relief
operations) has seen partial, mission-configured deployments that rely on robust
evacuation capabilities, an approach that may not be possible in a disaster
scenario (Franco et al. 2007).
Most mobile military hospitals require utilities support (e.g., water, waste
disposal), which necessitates additional staff or external support to install and
maintain these functionalities. Movement of land-based systems also demands
considerable transportation support. An Army combat support hospital needs 43
C-141 sorties to move, plus the attendant ground transportation for reaching the
final destination. Given the sustained buildup that typically precedes major
combat operations, this support requirement is an acceptable burden that is
factored into the force deployment plan. Applied to the need for rapid response to
a domestic disaster, however, this model proves to be woefully slow. Continuing
with the Army example, most of that service’s mobile hospital sets are in depot
storage, and each would require several months to unpack, configure, update, and
move. The belief that deployable military hospitals will arrive in the nick of time
like the cavalry in Western movies is dangerously misplaced.
Organizational disparities further degrade the rapid response capacity of
DoD. Deployable military hospitals are designed for war casualties, with
capabilities focused predominantly on trauma. Each uniformed service has its
own shelter system, which precludes interoperability. Within the services, there
are differences in equipment and readiness status between Active and Reserve
Component units. Rarely do the separate medical systems train in an integrated
fashion for an incomprehensible number of casualties.
Some DoD medical assets are highly visible and are currently being used
effectively, albeit to a limited extent. The Navy maintains two hospital ships—in
effect, two floating medical centers. Each ship provides 12 fully equipped
operating rooms, a 1,000-bed hospital facility, digital radiological services, a
medical laboratory, a pharmacy, an optometry lab, an intensive care ward, dental
services, a CAT-scan, a morgue, and two oxygen producing plants. Each ship is
served by a helicopter deck capable of landing large military helicopters and side
ports to take on patients at sea. The USNS Mercy and the USNS Comfort are very
large medical centers.
Surpassed in length among naval vessels by only the nuclear-powered
Enterprise- and Nimitz-class super carriers, the two hospital ships were built on
the hulls of San Clemente-class super tankers. With a 33-foot draft, the hospital

ships require a deep-water berth, which limits the number of ports they can enter
to 35 in the continental United States and Puerto Rico.
The Comfort and the Mercy have served as remarkably positive public
relations tools, particularly when used in support of disasters such as Hurricane
Katrina, the Banda Aceh tsunami, or the Haitian earthquake. When considered as
an asset for rapid response to a domestic disaster, however, these medical
platforms suffer from significant operational constraints. Neither ship is routinely
staffed beyond a caretaker crew. When a ship has embarked on a medical mission,
clinical and support personnel are ferried to it while it is under way. As the
requirement for a deep-water berth limits the number of locations that can support
direct transfer of patients, patient flow is extremely restricted. The ship is, in
effect, a 1,000-bed hospital with one door reached via helicopter. Landing a
helicopter on a ship deck poses its own challenges, as the landing surface rolls
with the movement of the water. This requires special training and qualification
not routinely associated with medical evacuation flight training. But the most
significant limiting factor is that there are only two of these ships, one home
ported in Baltimore and the other in San Diego.
Far more agile and adaptable, “gray hull” naval vessels have the ability to
convert space to clinical use. This is particularly true of amphibious assault ships
(LHA [landing helicopter assault] and LHD [landing helicopter dock]), especially
once the Marine complement disembarks. The USS Iwo Jima (LSD [dock landing
ship]-7) saw service in direct support of relief operations in New Orleans after
Hurricane Katrina (U.S. Navy, n.d.). Being self-sufficient and capable of sustaining
extended flight and clinical support operations, these platforms could provide
robust support. They are limited, however, in their ability to travel significantly
inland on waterways. In addition, their availability is subject to military operational
considerations and is not likely to be maintained for an extended period.
A Square Doctrinal Peg in a Round Operational Hole
Baseball great Yogi Berra is credited with saying “When you come to a fork in
the road, take it.” In many regards, this has been the thinking behind the “all
hazards” approach to emergency preparedness (Donahue et al. 2012). The
foundational elements of addressing hazardous materials incidents or medical care
delivery have been augmented by operational expertise drawn from the military.
This has resulted in the common construct of CBRNE: chemical, biological,
radiological, nuclear, and high-yield explosives (Eldridge 2006). The clinical
commonality of these diverse threats is scant.
The majority of the plans we have surveyed reflected the training and
experience of the planners (i.e., they have been drawn from military doctrine).
This is problematic because the methodology becomes ineffective when the

beginning premises differ, particularly with regard to the affected population.
Soldiers, sailors, airmen, and Marines are trained to recognize and react to
CBRNE events; civilians are not. In the face of such events, the military is
equipped to take protective measures and—most significantly—continue with the
assigned mission. Experience has shown that civilian populations under attack
react quite differently (Pangi 2002). Rather than the CBRNE skills of the first
responders that will drive the response scenario, it will be the reaction of a largely
untrained public. Most of the victims of the Toyko subway sarin attacks who
presented for treatment did so outside the emergency medical services (EMS)
system, self-ambulating to emergency departments (Pangi 2002).
The construct used for military planning includes a degree of advanced
warning. Intelligence identifies the movement of aircraft, artillery, or chemical
equipment. Forces are placed on alert and work with a degree of anticipation that
a particular type of attack is likely. But terrorists and, to some extent, natural
disasters rarely give such forewarning to the civil sector. Domestic response
cannot rely on advanced warnings generated by the intelligence community.
As an example, one of the authors served as the emergency department
(ED) administrator for a New York City medical center located at the edge of an
industrial area. On one occasion, EMS personnel transported two factory workers
in full pulmonary arrest. It was not until these victims were being treated and the
accompanying EMS, fire, and police responders were briefing the ED staff that it
became obvious that this was an industrial chemical incident and that all who were
standing in the center of the ED had been exposed. The decontamination station at
the ED entrance was rendered superfluous. While this may point to the need for
more extensive training among the responder community, it is unreasonable to
expect every such event to be accurately assessed at the point of incident.
Conclusion
Systematic planning for medical response to a catastrophic disaster has been
hampered by what can be termed disjointed incrementalism. Disparate capabilities
are created to meet specific needs driven by organizational missions with little
consideration of the full continuum of operations.
Operational experience and a review of the literature reveal requirements
that we suggest should form the common foundation for contingency planning.
Disasters vary by cause, locale, and extent of the population involved. It is not the
agent of destruction that must be addressed but rather the needs of those affected
(Donahue et al. 2012). Therefore, to fully meet the wide range of potential
scenarios, robust domestic response should be
• Customizable
• Scalable

• Standardized and interoperable
• Highly mobile and multimodal
• Self-sustainable
• Focused on the needs of the population served.
As an adept mechanic includes a wide array of tools in his repair shop, a
proficient response system must include various tools to address myriad
potentialities. In the aggregate, current options offer many capabilities, but not
without altering original design configurations or combining disparate equipment
systems. Perhaps more significantly, the aggregate capabilities of all deployable
hospital assets are likely to be insufficient to address—and are not designed for
indefinite use in—the aftermath of a catastrophic disaster. We suggest that rather
than attempt to build a response contemporaneously based on the specifics of the
disaster, a better approach would be to create a robust, overarching capability
from which a customized response package can be drawn.
References
Air Force Reserve (n.d.). “Mission: Aeromedical Evacuation.”
http://www.afreserve.com/?Missions#Aeromedical Evacuation.
American College of Emergency Physicians (2006). One-of-a-Kind Mobile
Hospital from North Carolina Provides Critical Care to Mississippi
Residents after Katrina Debilitates Local Hospital. http://www.news-
line.com/onenews.lasso?-Search=Action&-token.profession=NL&-token
.target=onenews&-Table=webinfo&-MaxRecords=50&-SkipRecords=0&-
Database=newsline&-KeyValue=4431.
American Hospital Association (2009). Fast Facts on US Hospitals.
http://www.aha.org/aha/resource-center/Statistics-and-Studies/fast-
facts.html.
——— (2010). Annual Survey of Hospitals. Hospital Statistics, 1976, 1981,
1991–2010. Chicago, Ill.
Applegate, D. (2007). Statement before the Committee on Homeland Security and
Government Affairs Ad Hoc Subcommittee on State, Local, and Private
Sector Preparedness and Integration, United States Senate, December 4,
2007, U.S. Geological Survey, U.S. Department of the Interior.
Assessment of the Training Needs of National Disaster Medical System Hospitals:
Task C Data Analysis and Report (May 23, 2005). Prepared for the U.S.
Department of Veterans Affairs Emergency Management Strategic
Healthcare Group. http://www1.va.gov/emshg/docs/TASK_C_REPORT_
COMPLETE.pdf.

Atkinson, W. (1989). The Next New Madrid Earthquake. Carbondale: Southern
Illinois University Press.
Barbisch, D. F., and K. L. Koenig (2006). “Understanding Surge Capacity:
Essential Elements.” Academic Emergency Medicine 13 (11): 1098–1102.
Cantrill, S.V. (2007). Preparing for Pandemic Influenza: The Hospital and
Community Perspective. http://biotech.law.lsu.edu/blaw/flu/Cantrill_Flu_
05_07.ppt.
Carlton, P. K. (2007). “Affordable Healthcare for the Future.” http://faculty.arch
.tamu.edu/gmann/Architecture%20for%20Health%20Lecture%20Series/P
KCarlton/poster.pdf.
Carmona, R. H. (2004) ‘SURGE’ Hospitals: A New Concept in Disaster Medical
Care. Symposium conducted at the Texas A&M University at the Medical
Readiness Conference, College Station, Tex.
Carolinas Medical Center (2010). Carolinas MED-1 Equipment.
Carter T. (2006). “Military Anesthesiology: An Out-of-the-Box Experience.” ASA
Newsletter 70 (3).
http://www.asahq.org/Newsletters/2006/03-06/carter03_06.html.
Centers for Disease Control and Prevention (CDC) (2006). Crisis and Emergency
Risk Communication—Pandemic Influenza. http://www.bt.cdc.gov/cerc/
pdf/cerc-pandemicflu-oct07.pdf.
——— (2010). Interim Results: State-Specific Influenza A (H1N1) 2009
Monovalent Vaccination Coverage—United States, October 2009—January
2010, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5912a2.htm#tab.
——— (n.d.). Federal Medical Station Profile, http://www.texasjrac.org/
documents/FMSfactsheetv3-1.pdf.
Dash, N., and B. Hearn Morrow (2001). “Return Delays and Evacuation Order
Compliance: The Case of Hurricane Georges and the Florida Keys.”
Environmental Hazards 2: 119–128.
Donahue, D. A., S. O. Cunnion, C. D. Balaban, and K. Sochats (February 2012).
“The All Needs Approach to Emergency Response.” Homeland Security
Affairs 8, Article 1. http://www.hsaj.org/?article=8.1.1.
Eastman, P. (August 2006). “IOM Reports Reveal Alarming ED Crisis.”
Emergency Medicine News 28 (8): 44–46.
Eldridge, J. (Ed.) (2006). Jane's Nuclear, Biological and Chemical Defense 2006–
2007 (19th ed.). Coulsdon, Surrey, UK, and Alexandria, Va.: Jane's
Information Group.
Elnashai, A. S., L. J. Cleveland, T. Jefferson, and J. Harrald (2008a). Grim Social
Expectations for New Madrid Fault Earthquake. http://www.semp.us/
publications/biot_reader.php?BiotID=566 (site no longer accessible).

——— (2008b). Impact of Earthquakes on the Central USA. MAE Center Report
No. 08-02. Urbana, Ill.: Mid-America Earthquake Center, University of
Illinois at Urbana-Champaign.
Farmer, J. C., and P. K. Carlton Jr. (March 2006). “Providing Critical Care during
a Disaster: The Interface between Disaster Response Agencies and
Hospital.” Critical Care Medicine 34 (3 Suppl): S56–59.
Flacks, A. G. (2007). HHS’ Role in Medical Emergency Preparedness. New
York: Office of the Assistant Secretary for Preparedness and Response.
Franco, C., E. Toner, R. Waldhorn, T. V. Inglesby, and T. O’Toole (2007). “The
National Disaster Medical System: Past, Present, and Suggestions for the
Future.” Biosecurity and Bioterrorism 5 (4): 319–325, http://www.upmc-
biosecurity.org/website/resources/publications/2007/2007_article_pdfs/20
07-12-04-natldisastermedsystempastpresfut.pdf.
Hartman, W. K. (n.d.). 1908 Siberia Explosion: Reconstructing an Asteroid
Impact from Eyewitness Accounts. Tucson, Ariz.: Planetary Science
Institute. http://www.psi.edu/epo/siberia/siberia.html.
Hildenbrand, T. G., V. E. Langenheim, E. Schweig, P. H. Stauffer, and J. W.
Hendley II (1996). Uncovering Hidden Hazards in the Mississippi Valley.
Memphis, Tenn.: U.S. Geological Survey. http://quake.wr.usgs.gov/
prepare/factsheets/HiddenHazs/.
Joint Commission (2003). Health Care at the Crossroads: Strategies for Creating
and Sustaining Community-wide Emergency Preparedness Systems.
Chicago: Joint Commission. http://www.jointcommission.org/assets/1/18/
emergency_preparedness.pdf.
——— (2006). Surge Hospitals: Providing Safe Care in Emergencies. Chicago:
Joint Commission. http://www.jointcommission.org/assets/1/18/surge_
hospital.pdf.
McCann, D. G. (2008). “National Disaster Medical System: NDMS—Do Not Go
Gentle into That Good Night.” The National Emergency Management
Summit; Agenda Day One, Monday February 4, 2008. http://www
.emergencymanagementsummit.com/past2008/agenda/day1.html.
Morgenstern, J. (May 29, 1995). “The Fifty-Nine-Story Crisis.” The New Yorker,
45–53.
Office of the Assistant Secretary for Preparedness and Response (2008). FY 2008
Annual Performance Report. http://www.hhs.gov/aspr/.
National Medical Response Team (NMRT) (n.d.). DMAT and NMRT Team
Information. http://www.nmrtcentral.com/.

Pangi, R. (2002). Consequence Management in the 1995 Sarin Attacks on the
Japanese Subway System. BCSIA Discussion Paper 2002-4, ESDP
Discussion Paper ESDP-2002-01, Cambridge, Mass.: John F. Kennedy
School of Government, Harvard University. http://belfercenter.ksg.harvard
.edu/files/consequence_management_in_the_1995_sarin_attacks_on_the_
japanese_subway_system.pdf.
Piggott, W.J. (n.d.). National Disaster Medical System (NDMS). FEMA
PowerPoint presentation to the Bureau of Public Health Emergency
Preparedness & Response, Arizona Department of Health Services.
http://www.azdhs.gov/phs/edc/edrp/es/pdf/ndms_piggott.pdf.
Redlener, I. (2006). Americans at Risk: Why We Are Not Prepared for
Megadisasters and What We Can Do Now. New York: Alfred A. Knopf.
Senate Committee on Government Affairs (2001). Hearing on FEMA’s Role in
Managing Bioterrorist Attacks and the Impact of Public Health Concerns
on Bioterrorism Preparedness, July 23, 2001. Testimony of Tara J.
O’Toole, MD, MPH, Johns Hopkins Center for Civilian Biodefense
Studies. http://www.upmc-biosecurity.org/website/resources/To%20USG/
Testimony_Briefings/2001/20010723femarole.html.
Texas A&M Health Science Center (2004). Improving Homeland Security:
Innovations for Better Medical Care in Disasters, College Station: Texas
A&M University College of Architecture and the Office of Homeland
Security, Texas A&M Health Science Center.
Trabert, E. (2006). The Role of the Federal Medical Station (FMS) in Disaster
Response: Lessons Learned from Hurricanes Katrina and Rita.
Alexandria, Va.: CNA Corporation.
U.S. General Accounting Office (GAO) (1998). Air Force Aircraft: Reorganizing
Mobility Aircraft Units Could Reduce Costs. GAO Report to the Secretary
of Defense. January 21, 1998. http://gao.gov/assets/230/225077.pdf. As
cited in Franco, C., E. Toner, R. Waldhorn, T. V. Inglesby, and T.
O’Toole (2007). “The National Disaster Medical System: Past, Present, and
Suggestions for the Future.” Biosecurity and Bioterrorism 5 (4): 319–325.
——— (October 2003). Bioterrorism: Public Health Response to Anthrax
Incidents of 2001, GAO-04-152. http://www.gao.gov/new.items/d04152
.pdf.
U.S. Navy (n.d.). History, USS Iwo Jima. http://www.iwo-jima.navy.mil/.
Wilhite, D. R. (1996). “USAF Civil Reserve Air Fleet Aeromedical Evacuation
Airlift Capability.” Master’s thesis. Dayton, Ohio: Air Force Institute of
Technology, Wright-Patterson Air Force Base. http://stinet.dtic.mil/oai/oai
?&verb=getRecord&metadataPrefix=html&identifier=ADA309954.

Article - Medical Response Capabilities to a Catastrophic Disaster - Journal HSEM (Vol 9 Issue 2) 2012

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Article - Medical Response Capabilities to a Catastrophic Disaster - Journal HSEM (Vol 9 Issue 2) 2012

Similar to Article - Medical Response Capabilities to a Catastrophic Disaster - Journal HSEM (Vol 9 Issue 2) 2012 (20)

Article - Medical Response Capabilities to a Catastrophic Disaster - Journal HSEM (Vol 9 Issue 2) 2012