Rx: A Medical Support Plan for Homeland Defense

by Duane Caneva

The National Response Plan (NRP), National Incident Management System (NIMS), and National Preparedness Goals spell out the general rules for dealing with future terrorist incidents and/or natural disasters on U.S. soil. States and cities throughout the nation have followed through with more detailed, and considerably more specific, plans for protecting their own communities and their own citizens, as have various first-responder organizations and associations.

Ensuring the availability of adequate medical support in times of national disaster is one of the most important components of all of the readiness plans developed to date at any level of government, but for various good and understandable reasons that support cannot be guaranteed either now or in the foreseeable future. Simply identifying the types and quantities of medical support likely to be required is a massive challenge in itself. Even after that has been done, though, the real-time management of the medical resources available will be an even more difficult task in future times of disaster on the scale of the 9/11 terrorist attacks or Hurricane Katrina. As a minimum, information-management tools that are both simple and elegant will be needed simply to keep track of what response teams are available, what capabilities those teams have, and what additional resources are needed.

Even that information will not be enough to deal with truly major disasters –for which, it has become apparent, a national medical-support plan will be required. The creation of such a plan, though, requires the use of a systematic approach that provides the basic organizational structure on which more complex components can be built. Among the more important building blocks of that structure should be detailed capabilities-based plans (accompanied by a capability-classification scheme and a clear definition of the medical capabilities and resources needed to meet various types of disasters); a wiring diagram showing the hierarchical layers of management likely to be needed; reasonable and detailed standards for compliance and assessments; guidelines for continuous improvement as the plan matures and experience accumulates; and a workable program-management scheme that assigns specific responsibilities – and authority over resources – to specific individuals at every level of government.

Varying Levels of Capability

Medical support necessarily begins at the baseline-capability level. First receivers or responders at that level can and should be grouped into squads in accordance with their own functional response capabilities (the requirements for and definition of which should be standardized throughout the organization). The baseline squads can be grouped into larger teams to provide a larger and more flexible tiering of capability when more of that particular capability is needed – but the initial squads will still represent the smallest unit size that can provide a given capability in a mass-casualty situation.

If additional capability is needed, adjacent squads or teams can be mobilized under mutual aid agreements and/or regional compacts, or by the federal government (in response to a NIMS-level tasking). Assimilation into the system will necessarily require compliance with the standards defining the capability.

The next step should be to ensure that the readiness metrics of response teams are defined, adhered to, measured, and reported to and through the appropriate organizational command chains. During preparedness or response operations, these metrics will usually be the key to ensuring that the most judicious risk-management decisions are made. For example, although one team may be farther away from an incident site, it may be more operationally ready than a team that is geographically closer, and thus would be a better choice to employ in the response.

Without defining and standardizing readiness objectives and requirements, such preparedness and response decisions cannot be made. In emergency management, the intelligent use of available assets requires first knowing the current status of those assets, and then assessing the risks involved in using them across a “capabilities gap” to meet operational requirements. Identifying critical informational factors in the preparedness phase, then monitoring those factors during the response phase, provides greater knowledge and permits faster and more effective action.

Pragmatism Vs. Conjecture

Capabilities-based planning also provides the foundation for a strategy that can be adjusted to rapidly changing situations. Identifying what might reasonably be achieved with current resources allows pragmatism to overcome the analysis paralysis sometimes experienced in the “what if” approach used in scenario-based planning. Essentially, by defining capabilities at the functionally elementary (i.e., squad) level and defining standards at a national level, capabilities can be developed on a national scale, adequately spread-loaded throughout the nation and achieving economies of scale not otherwise possible. More important than the basic personnel, equipment, and training, however, are the much more detailed attributes necessary in the design specifications set for these squads.

Resource typing to standardized specifications provides the foundation for other critical components in the system design. The development of a classification scheme for capabilities allows a linkage to requirements and to scenario-based planning. Linking such factors as emergency support functions and programs – e.g., emergency management, force protection, and critical infrastructure – to specific types of hazards (earthquakes, tornadoes, WMD attacks) and then identifying the specific capabilities required for various types and levels of response allows for regional differences in hazard typing.

It is a given that, if an incident requires more capability than is available locally, mutual aid agreements, regional compacts, and/or national-level resources can be used to identify and provide the additional assets needed. Capabilities become commodities, in effect – the tools, in other words, with which response plans, concepts of operations, and mutual-aid agreements can be developed and implemented.

Hierarchical layers of management recognize and demonstrate the different command chains – operational and administrative as well as tactical – required for the optimum use of personnel and capabilities. From the single-unit first-responder resource to the federal level, all layers must be recognized and accounted for in a national plan, and a “theory of relativity” should be both applied and understood. Time, to use but one example, is often measured in longer intervals at the federal level, where the rotation of response teams into and out of an incident-response area may be for days or weeks, with response-and-recovery operations measured in months or years. At the first-responder level, however, time might well be measured in minutes or even seconds. Critical life-saving decisions occur at all layers of the hierarchy, though – and may cause or lead to higher-order effects that ripple out in unpredictable ways.

Judicious Yardsticks and Periodic Assessments

The use of system metrics permits a meaningful comparison of capabilities. The defining of capability standards and attributes allows the development of reliable metrics for readiness and preparedness. By attaching score values to the various program standards established for each capability, a quantitative measure can be obtained. The ability to quantify the readiness of a squad, and to measure the specific factors comprising its readiness, gives incident managers the yardstick they need to carry out their consequence-management and risk-assessment tasks more judiciously.

It is not always necessary that every capability of every squad be at the 100 percent level of readiness. But it is mandatory that on-scene commanders know the specific readiness capabilities of the squads under their jurisdiction. For that reason and others, there should be reliable checks in place to ensure the fidelity of reporting within a system.  Periodic assessments of performance as well as capabilities allow for a more advanced analysis of the system. An understanding of such intangibles as how readiness is related to effectiveness, and identification of the key factors contributing to improved performance, also is helpful. Ultimately, though, the standards established should be evidence-based rather than the consensus-based “best practices” criteria currently used.

The continuous-improvement guidelines referred to earlier would formalize the process of converting after-action reports and other data into lessons learned – each of which should be logged, with date/time groups included, the process or program standard it is linked to, and the change or changes recommended. When evidence cannot be gathered or is simply not available, a qualified consensus recommendation must be judiciously developed.

Program management addresses the business rules needed for the system and the real-time management processes that should be followed. The development, adjustment, and application of system metrics, various measures of effectiveness that might be applicable, the lessons learned, and the best practices involved require a diverse mix of medical and non-medical disciplines and inputs.

As the information age matures, the significance of the medical-support data accumulated, and the management of that data, can play a significant role in developing and managing the medical support capabilities required to deal with the problems encountered in all phases of a major homeland-security incident. A data point assimilated into a well-designed information-management system may provide critical knowledge on many matters not even remotely related to the incident during which the data point was developed and defined. In a similar fashion, current as well as future assets in the U.S. medical-industrial complex may be used in various homeland-security applications not yet even being considered.

Commander Duane Caneva (Medical Corps), USN, is head of Medical Plans and Policy at the Navy Medicine Office of Homeland Security, and a medical consultant on chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE) matters to the Office of the Attending Physician at the U.S. Capitol. Prior to assuming those assignments he served as senior medical officer of the U.S. Marine Corps’ Chemical Biological Incident Response Force. A graduate of the University of Chicago’s medical school, he is qualified as a Navy undersea medical officer/diving medical officer, and board-certified in emergency medicine. He also is co-director of a graduate-level course on weapons of mass destruction and the Uniformed Services University of the Health Sciences and a member of numerous panels and working groups investigating the medical aspects of various homeland-security issues.