Jul 102016

My experience has always been that preparedness is a tough sell.  The value seems to go up after there has been an event and a bad outcome was a result.  The problem with fixing something after a problem occurs is that people have gotten hurt or worse when they didn’t have to.  Organizational spending on preparedness because it’s the right thing to do seems to not be working all that well.

I wonder what the result would be if we offered a monetary incentive based upon an organization’s elective participation in a no-notice exercise lottery.  Most states have a lottery and each state has its own formula to determine where the money collected from lotteries goes. 150211135359-2015-lottery-spending-780x439In 2014 Americans spent a total of over $70 billion playing lottery games.  States pocketed about 30% of this total, roughly 6% went to the retailers selling tickets and the rest was paid out in prizes.

My idea would be to let organizations (public or private) individually and/or as community coalitions opt-in to the exercise lottery.  By doing so they would be eligible to win various prizes based upon the complexity, scope and their performance if they are randomly chosen over the course of the year.

Each year there would be 12 (one per month) organizations chosen from all those that opt-in. Since no organization will know if they might be selected any one year , I expect they will maintain their level of preparedness at a high level just in case. Organizations would not know when the exercise might take place and would be required to submit their existing plans, policies, procedures and past training efforts. Scenarios would be chosen based on their hazard vulnerability analysis or some historical event in the area.  Organizations not chosen will have their entry weighted slightly in future lotteries to increase theirs odds of being chosen.

Funding for the administration, development, conduct and evaluation would come from existing lottery funds.  Monetary prizes would range for a minimum of $150,000 just for participating upwards to $3.5 million.  6717442411_633b0c2b70All proceeds would be required to be dedicated to correct findings in the plan of improvement that organizations would receive.

Traditional means of promoting preparedness appears to produce traditional results.  What do you think about using innovative ideas to help organizations achieve and maintain a higher level of preparedness and reward them for doing so?





Jul 052016

I’ve been involved in planning for a Cascadia earthquake/tsunami event and a New Madrid earthquake event so I know what a catastrophe will look like.  I have not been involved with planning for San Andreas but I regretfully saw the movie.  Both the Cascadia and New Madrid will require a national and potentially international response over time.

One of the biggest challenges facing injured survivors is to receive life-saving care in a medially effective time frame.  The majority of the life-saving response will be over within 72 hours. Key to meeting this Picture2need requires extensive pre-planning, dedicated response assets and pre-scripted response procedures at all levels of government.  For both events we know where local responders will need significant medical support to meet the life saving mission.

One of the challenges for “traditional” response mechanisms will be the damage caused by the events. Survivors will be trapped in isolated communities. On the ground conditions will include:

  • No potable water
  • No electricity
  • Damaged/destroyed infrastructure
  • Damaged roads/bridges            0609161007a
  • No Ground-based GPS
  • No organic communications

This means that in many cases air assets will be the only viable means of moving critical supplies and personnel in and injured patients out.  Both rotary and fixed wing, including float planes have a role.  In March of 2011 I made a presentation on the medical consequences of a New Madrid at a ASPR/RHCC meeting in Chicago.  At that time I proposed that what was needed to help meet the medical mission were teams were matched to fill the gaps we knew existed.  These teams should be:

  • Smaller (general, burn, surgical, pediatric, crush, mental health)
  • Self-sustained
  • Task Force versus Strike Team (security element critical with your medical team)
  • Appropriately trained for the mission
  • Appropriately equipt for the mission
  • Pre-planned
  • Pre-scripted

It was not until I served as the Senior Controller/Evaluator for the Oregon Disaster Medical Team (ODMT) at the Cascadia Rising 2016 exercise that I became aware of an ideal resource for these catastrophic events.  The Medical Rapid Response Team (MRRT) is essentially a pilot program of the 173rd Air National Guard (ANG) Medical Group and the Oregon Disaster Response Team.  Robert Gentry, MD recently retired as the Oregon ANG State Air Surgeon and Jon Jui, MD, MPH, FACEP are the main reasons this resource currently exists.  Jon Jui is the EMS medical director for Portland and Multnomah County, OR. and the deputy team commander for Oregon Disaster Medical Assistance Team.

The backbone of the MRRT is a twelve person unit which can be split into two six-person strike teams.  One key element to the MRRT is the equipment footprint that supports it.  The ANG ‘go-bag’ was defined as a backpack to limit the footprint to one capable of being carried in by helicopter.  That makes the MRRT maximally mobile.  A second element was the three days of self sufficiency (camping gear with MREs, water filter) to make it maximally deployable as a team as far as logistical support requirements.  The rest of the bag contains medical supplies geared toward the scenario likely seen.  Medications are pre-promised by area pharmacies and only picked up at time of the warning order (advance notice to stand up for possible deployment), thus no cost until the actual need.


The MRRTS can be placed in any area of need and can gather intelligence, provide basic medical care and prepare for a larger follow-on medical package. The MRRTs are designed as an aid for Local Emergency Managers who would make their request to the state. The ODMT in conjunction with the 173rd Medical Group of the ANG have been conducting training and exercises to improve this concept for the past several years.  

This year additional medical units from both Air National Guard and Army National Guard participated in the Cascadia exercise and were exposed to the MRRT concept. Units flew in from Idaho, Oklahoma, Nevada and Alaska. Just within the ANG are roughly 90 medical groups in all 50 states and across the country who could potentially be equipped, trained and tasked to support this mission. Add in support that could come from Army National Guard units and the potential becomes even more impressive.  

Having this type of depth and redundancy is critical since the medical personnel who make up most of these units could potentially be victims themselves if their community or state was impacted.  They may also be more valuable serving in their civilian medical capacity. Being able to have this type of quick response force from any non-impacted area fills a critical gap in meeting the medical needs of survivors. For the past three years we have had an average of 86 Presidential disaster declarations. Add in state declarations not rising to a federal level and the number of potential deployments of MRRTs could be fifty to one-hundred times a year. Having assets dedicated to “terrorism” response is great but opportunities for deployment are extremely small for the resources we spend annually. 

In my assessment the MRRT is ideally suited to provide medical support at major events. Seeing this realized will require additional work, leadership and support at a national level. Without obtaining national level tasking for other ANG or medical assets as MRRTs and minimal financial support for the go-bags this program might not survive much longer.

I’m very interested to hear your thoughts on this potential game changer in supporting local government requests for medical support. 

Jun 272016

My recommendation is to take the time to put together an operations manual that covers your entire Hospital Emergency Response Team (HERT) program.   This will keep all the important and relevant material in one document.  Topics should include:

  • Standard operational procedures
  • A copy of your hospital Hazard Vulnerability Analysis (HVA)Picture1
  • Policies
  • Reference material
  • HERT position descriptions
  • Diagrams
  • Forms
  • PPE selection charts
  • Decontamination triage process
  • Equipment and supply lists

In addition should be the application process for team members, the on-boarding, initial and refresher training for HERT members as well as the training curriculum and attendance sheets themselves.

Managing a patient contaminated with a hazardous substance is a high risk event and several things can go wrong. Consistency is one of your best forms of protection.  Do things the same way time after time. If you do have a bad outcome, attorneys will want to see your documentation to see if you followed your policies, procedures and training. It is in everyone’s best interest and risk management should insist on a HERT Operation Manual being the foundation for your program.

How successful have you been at building a HERT operations manual at your facility?

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