Great Preparations

A mass-casualty incident can happen in a million different ways, but odds are, you know the most likely threats your community faces. If you're smart, you've prepared accordingly. Having the right plans in place can make a huge difference in the toll a disaster takes-not only in lives, but in dollars and your ability to function in its aftermath. There's no one-size-fits-all formula for this, but there are some principles and approaches that bear recognizing. Here we present snapshots of the measures taken by some EMS systems to prepare for specific MCI scenarios. Think about how what they've done might be adapted to your jurisdiction.

Taking the Care to the Patient
     May 24, 1981: A storm that would be remembered as the Memorial Day Flood pummels the Austin, TX, area, with some areas receiving more than 10 inches of rain in four hours. One urban creek with an average flow rate of 90 gallons a minute peaks at a staggering six million gallons a minute. Flooding kills 13 and causes $36 million in damages.

     If your community is prone to floods, it makes sense to develop your emergency medical and rescue capabilities accordingly. Austin/Travis County EMS began doing so under municipal mandate following the '81 flooding, but it's a charge they fully embrace today.

     "We talk about golden hours, yet often EMS will just stand by the ambulance and wait for the patient to be brought to them," says division commander Casey Ping, who heads A/TCEMS' special operations. "Many times, EMS could be caring for a patient as rescue is occurring. That may not be in the river, but once that patient gets to the bank or into the boat, why not be able to start caring for them?"

     A/TCEMS trains its paramedics and district commanders to the swiftwater rescue operations level and its special-ops team members to the technician level at a minimum; some are specialists. It can deploy up to five special-ops ambulances with water-rescue equipment such as PFDs, helmets, ropes and floating litters. It also has five swiftwater-capable boats and two helicopters.

     The ambulances are part of the normal response matrix, making them readily deployable for sudden flood events both locally and as mutual aid. As a state, Texas has numerous top-flight water-rescue resources, including Texas Task Force 1, the nation's first statewide water rescue team. When authorities know an event is coming-like, say, a hurricane-those resources can be prestaged.

     "The intent is to get the capability placed at least 24-48 hours in advance," says Ping. "We'll typically go in and set up a base of operations somewhere like a high school, because they'll have things like Internet and showers. The key is to be close enough to do some good, but not close enough to be in harm's way."

     There was plenty of water in Texas this summer, with severe rains and flooding stretching from the Oklahoma border all the way to Mexico. At one point Austin got 19 inches of rain in two days. A/TCEMS provided resources to affected areas first as mutual aid, then at home under state task force activation, performing several rescues.

     A state review of the response was scheduled for August (shortly after press time), but Ping says one lesson was abundantly clear.

     "The biggest thing is that you really have to have things in order and ready to go," he says. "With these evolving events, you're calling people at home; if they don't have their bags packed and gear ready, it really takes hours just to get out the door. And anyone who's in the water is going to live or die within hours.

     "On-duty units probably aren't configured to go be self-sufficient for 24-72 hours. So we have to do a better job of having folks who are rapidly deployable and able to be self-sufficient. The last thing a devastated community needs is another 50 or 100 people to take care of."

What's It To YOU?
     What are your local threats? Can you respond quickly and aggressively to them, or will you wait passively for the victims to be brought to you?

You Are Here-the Shooter's Over There
     September 22, 2003: An armed, suicidal student enters a third-floor science lab at Lewis and Clark High School in Spokane, WA, and orders its occupants out. He barricades himself inside and fires a round into a cabinet. Local police, armed with floor plans, access routes and other information about the campus, have the shooter isolated even before the school is fully evacuated. Negotiators fail to talk him into surrendering, and when he reaches for his gun, he's shot. No one else is injured.

     School scenarios such as this can be responders' worst nightmares, but in Spokane, they had a leg up. They had critical information about the school preassembled using a program called Rapid Responder.

     From a Seattle-based company called Prepared Response, Rapid Responder gives emergency personnel instant access to things like building photos, layouts, entrances/exits, utility shutoff information and more, allowing them to develop detailed preplans for incidents. In Washington, they're using it to map schools and public buildings across the state.

     "It's more than just an inventory of floor plans and photographs," says Joe Hawe, manager of tactical operational support services for the Washington Association of Sheriffs and Police Chiefs, which operates the program in the state. "We actually build tactical response plans for every facility that handle the first 10 minutes to an hour of an incident. It helps everyone get set up and working so they can roll over into their incident management plans."

     To get a community started, WASPC personnel come and orient local responders and school personnel to the program. They amass around 300 photos per facility, along with floor plans and information on things like doors/windows, hidden spaces, hazardous materials, evacuation routes and other pertinent issues. They also determine potential staging and command areas, perimeters and other components of a tactical response, tailoring plans to each community's resources.

     This all takes 90-120 days; regular updates then follow. It is all accessed via computer, and the information is shared across emergency services-fire and EMS get it too.

     Lewis and Clark High had been mapped just two weeks prior to the 2003 shooting. The advance info responders had on hand proved an enormous benefit.

     "They saw the kid had access through exterior windows to I-90, so they got the Interstate shut down and traffic diverted," recalls Hawe. "Also, he'd asked for matches, and because they were able to pull up that it was a science room, they got the natural gas turned off."

     Washington officials are also using Rapid Responder to develop plans for things like natural disasters, pandemics and mass evacuations.

What's It To YOU?
     How prepared will you be for an event at your local school (courthouse, stadium, etc.)? Do you have current information readily available?

Get Ready, Granddad Is Coming to Town
     June 6, 2007: A storm dubbed "the granddaddy of all super cells" by one forecaster approaches central Wisconsin from the west, potentially bringing tornadoes, high winds and hail the size of golf balls. In Portage County, officials spring into action. Top government officials meet and begin implementing the county's severe-weather plan. A general warning goes out to the public. Schools cancel classes, businesses are encouraged to close early, and public safety and hospitals staff up. In the end, the county is spared a big hit, and second-guessers question the cautious approach, but the county was ready for whatever came its way.

     "The plan is a general all-hazards emergency operations plan," says Stevens Point fire chief Mark Barnes, whose department provides EMS for all of Portage County. "It's built on a federal template, no different than many others." Here's how it worked:

     Wednesday morning, following a warning from the National Weather Service, the county's emergency management committee met and went over its plan. It didn't open the county EOC, which would have required top leaders to operate there, but other elements were set in motion. Leaders were particularly concerned with large gatherings in their communities, and Stevens Point had two: There were 200 blind campers at the Wisconsin Lions Camp outside of town, and the Wisconsin Special Olympics was due to open on the 7th, bringing around 3,000 participants with cognitive disabilities, plus their families and caregivers, to town right as the storm was to hit. "Those," says Barnes, "were our two highest priorities. We didn't want a bunch of people in transit."

     By Wednesday afternoon, the forecast hadn't changed, and Special Olympics leaders agreed to cancel their opening ceremonies. A news conference Wednesday evening warned the public what was happening and recommended taking precautions. In Stevens Point, city officials met to determine how to handle problems like downed trees and power lines. Barnes' plan was to place police cars, front-end loaders and chainsaw crews from the local university's wildland fire squad at each of his two fire stations. "Then after the storm, we could just prioritize calls and work our way out," he says. As well, heavy assets like tractors and dump trucks were consolidated under control of the city engineer for post-storm clearing.

     With responders called to duty, the local YMCA was alerted to provide child care. The department also designated a family services coordinator to track the safety of members' loved ones.

     By Thursday morning, the forecast hadn't changed, and firefighters set to work clearing the main station's basement to serve as a potential shelter. Generators were fueled up, and loose items outside the station removed. Employee vehicles were taken to a nearby covered garage for protection and to free up space for the cops and front-end loaders.

     Post-storm plans were finalized. If power was lost, crews would start at the hospital to bring lines back up. Service from the fire department would be bare-bones: Instead of staying on scene, personnel would clear the scene, tape it off and move on to the next one. Communications were streamlined: The two dispatch centers that send calls to the FD were asked to "send 'em and forget about 'em." The department would prioritize them internally and answer them as possible. A firefighter was assigned to the radio to assign and reassign calls as they came in.

     And then…nothing happened. The storm spared Portage County.

     Some Monday morning quarterbacks derided the cautious response, but as the Stevens Point Journal noted in a Saturday editorial, "Unlike many in central Wisconsin, we knew our children weren't still at school or on a bus ride home. Our cars were safely tucked away in the garage. We'd made arrangements for our elderly parents so they weren't alone. Portage County was prepared… Officials did the right thing, and residents owe them their gratitude."

What's It To YOU?
     Any community can experience severe weather. Don't wait till you're dodging F5s to take action. Have a plan in place, and if you must err, do so on the side of caution.

Feds Announce Upgrade of NIMS Compliance Support
     The federal government has updated its program to assist emergency agencies in complying with requirements of the National Incident Management System (NIMS). The new NIMS Compliance Assistance Support Tool (NIMSCAST) reflects the compliance metrics released to state and local governments in fall 2006.

     Homeland Security Presidential Directive #5 requires NIMS adoption by state and local organizations as a condition of receiving federal preparedness grants. NIMSCAST is intended to help them achieve it.

     NIMSCAST is billed as the "premier Web-based self-assessment instrument for state, territorial, tribal [and] local governments to evaluate and report their jurisdictions' achievement of all NIMS implementation activities."

     Previous users of NIMCAST will have their established accounts, user permissions and assessments carried over. Officials with the Incident Management Systems Division of FEMA's National Integration Center request that reactions be voiced and problems reported through the Questions/Comments link at www.fema.gov/nimscast/index.jsp.
-John Erich, Associate Editor

Baby, It's Cold Outside (And You're Toxic)
     Alaska gets cold-real cold. That matters if you have to strip down and hose down contaminated patients. But the fire department in the state's largest city has planned for such a contingency. In fact, it helped write the book on it.

     In 2001, representatives of the U.S. Army Soldier and Biological Chemical Command (SBCCOM) visited Anchorage and consulted with Anchorage Fire Department personnel as part of an effort to develop cold-weather decon guidelines. That helped inform SBCCOM's 2002 publication Guidelines for Cold Weather Mass Decontamination During a Terrorist Chemical Agent Incident, which now represents the basis of AFD's cold-weather decon plan.

     The gist is that there are four levels of decon that correspond to outdoor temperatures:

• At 65°F or warmer, collection/assessment of patients, decontamination and post-decontamination can all occur outside.
• Between 35°F-64°F, post-decon occurs in an enclosure heated to 65°F or warmer.
• When the ambient temperature is below 35°F, collection/assessment can be done indoors or out, but the rest of the process occurs inside.
• In extreme weather or when other methods aren't available, everything moves indoors and dry decon is performed by blotting.

     Flexibility is a must. For instance, AFD has invested in tripartite shelters from Reeves that provide heated sections for undressing, showering and redressing. Those can be deployed in areas without other usable facilities. But in more urban locations, firefighters might use nearby buildings for shelter, or indoor pools at places like hotels and schools for rinsing. (At 40ºF in the summer, hydrant water isn't an option.)

     "Many of the pools are chlorinated, and that creates a pretty good system for removing some of the contamination," notes deputy chief Wade Strahan. "But we have to consider the problems we'd create by doing a decon in a school during the school year. It's a matter of what resources are available given the time and location and conditions you have."

     The good news is that some common threat agents (e.g., mustard gas, hydrogen cyanide) freeze at fairly warm temperatures, making them ineffective in cold weather. But others have much lower freezing points, including ammonia (-107.9ºF) and chlorine (-150ºF), both commonly used by local industry. Fortunately, most of those facilities are located away from populated areas.

     The bottom line is that with variables such as weather and location, AFD needs many tools in its toolbox.

What's It To YOU?
     How might weather conditions affect what you do? Are you prepared to adjust for them?

For Best Results, Use Often
     Familiarity equals comfort when it comes to the Incident Command System. Increasingly, services are deploying the ICS at everyday multicasualty incidents so that their front-line personnel will be calm and quick with it if something really big goes down.

     "I think people are coming to understand that ICS isn't something you keep in a closet and break out when you have a big one," says Wake County (NC) EMS Chief Skip Kirkwood. "If you do that, you won't be proficient at it. You won't be comfortable with the terminology, you won't have worked out the bugs."

     Wake, in coordination with Raleigh Fire, uses ICS on any call where more than one unit responds. In Boston, the threshold is five patients-still plenty of opportunity to practice.

     "We have MCIs on a regular basis: motor vehicle crashes, school bus crashes-[in July] we had a boat crash," says Boston EMS Chief Richard Serino. "So we get opportunities to exercise it, and people are familiar with it, because we do it often."

     Use of ICS as a framework for incident response is of course required under the National Incident Management System. The wise agency will ensure top-to-bottom comfort with it among personnel-any one of whom might be first to The Big One. Achieving that broad competence is prudent not only for NIMS compliance, but for the sheer safety of your citizenry.

     If you're a smaller service that doesn't get a lot of five-patient MVAs on which to flex those muscles, that means regular exercises and drills are all the more important.

     "We don't get much chance to exercise it, which is a problem," says Raymond Barth, executive director of Pennsylvania's Susquehanna Township EMS. "That's why anytime there's a chance to drill, we'll get people out there to participate. Since we can't do it in real life, we have to do it somehow. Your fingers need to know those skills so that if your brain freezes, you can still perform them. And the only way you get that is to actually do it."

What's It To YOU?
     The key to mastering the ICS is to practice, practice, practice. Maximize your opportunities.

For more on MCI preparedness, visit www.emsresponder.com/onlineexclusives.