Mumbai, the Lessons Learned

Business Office Editor’s Notes 517 Benfield Road, Suite 303 By James D. Hessman, Editor in Chief Severna Park, MD 21146 USA www.DomesticPreparedness.com The principal focus of the Obama administration and the new Congress in (410) 518-6900 the past two weeks, understandably, has been on spending – primarily to help Staff jump-start the ailing U.S. economy by the infusion of hundreds of billions of Martin Masiuk dollars into the system over the next several months. Publisher [email protected] Inevitably, though, the attention of both the executive and legislative branches James D. Hessman of government will reverse course and focus on ways to reduce spending, partly to offset Editor in Chief the new “stimulus” increases, and partly because the funding priorities of the Obama [email protected] administration differ considerably from those of the Bush administration – particularly, it John Morton seems likely, in the field of national defense. With the war in Iraq not yet completely over, Strategic Advisor but obviously winding down, at least some defense reductions are probably justified. [email protected] But they should be very carefully calculated, prudently implemented, and administered in such a way that they do not cut into the core strengths of the nation’s armed services. Dan Brethauer Account Executive [email protected] It should be clearly understood, moreover, that cutbacks in funding for the Department of Defense do not and should not be used as justification for similar cutbacks in the Susan Collins DHS (Department of Homeland Security) budget. Just the opposite, in fact. The two Creative Director [email protected] departments are partners in many ways, and in many of their activities. Their missions are complementary in some respects, but profoundly different in most ways. Sharon Stovall Editorial Director Probably the most obvious difference is a geographic one. DOD focuses primarily on [email protected] combat operations overseas. DHS’s sole focus is defending the U.S. homeland, and it Carole Parker carries out its mission primarily through planning and preparedness. Its goal is not to win Database Manager battles per se, but to prevent them from starting. And in that context it seems obvious that [email protected] it has probably been the most successful agency in government for more than seven years. A number of additional terrorist plots – some of them now public knowledge, but most of them classified – have been thwarted during that same time frame. Advertisers in This Issue: Which does not mean that the battle is over. Far from it. The United States still has a very Disaster Response Recovery Expo long way to go before the American people can feel reasonably safe, and will probably GovSec. U.S. Law & Ready Conference never feel perfectly safe. For that reason alone, cutting DHS funding now, or at any time ICx Technologies in the foreseeable future, would be equivalent to disarming the smoke detector because Idaho Technology Inc. there has not been another fire since it was installed, or canceling a car-insurance policy IDGA Maritime Homeland Security because the driver has not had an accident recently. Summit MSA The articles in this month’s printable issue of DPJ provide a microcosm of some of the PROENGIN Inc. important advances in preparedness recently accomplished – as well as a preview of some of the huge amount of difficult work that remains to be done: two articles, one by Joseph Trindal, the other by Neil Livingstone, on the Mumbai attacks and what not only India but the other nations of the Free World should learn from those attacks; © Copyright 2009, by IMR Group, Inc.; reproduction of any timely articles by Joseph Cahill and Warren Brown on how cold weather and the lack of part of this publication without express written permission safety gear can hinder the effectiveness of the nation’s first responders; four short reports is strictly prohibited. by Adam McLaughlin on recent homeland-security changes in California, Kansas, DomPrep Journal is electronically delivered by the IMR Louisiana, and Ohio; an article by Rick France on chemical-detection systems; and two Group, Inc., 517 Benfield Road, Suite 303, Severna Park, MD 21146, USA; phone: 410-518-6900; fax: 410-518-6020; also policy analyses – by Stephen Grainer and Michael Allswede, respectively – on changes available at www.DomPrep.com to the National Incident Management System and the National Disaster Medical System.

Articles are written by professional practitioners Finally, Ray Barishansky provides a grim anaylsis of the escalating dangers posed by in homeland security, domestic preparedness, and emerging infections. related fields. Manuscripts are original work, previously unpublished and not simultaneously submitted to another About the Cover: Firefighters attend to a fire at the Taj Mahal Palace & Tower Hotel publisher. Text is the opinion of the author; publisher holds following the terrorist attacks in late November 2008 in Mumbai, India. Indian officials no liability for its use or interpretation. declared the siege over when the remaining militants were killed when commandos stormed the building. The “lessons learned” from the Mumbai attacks are discussed, from different perspectives, by Joseph Trindal and Neil Livingstone in this issue of DomPrep Journal. (Photo by India Today Group/Getty Images)

DomPrep Channel Masters The Mumbai Attacks –

First Responders Glen Rudner Lessons for the Western World Fire/HAZMAT By Joseph W. Trindal, Law Enforcement

Stephen Grainer The terrorist attacks were frustrated in their heroic but Fire/HAZMAT two months ago in somewhat ineffective efforts to Mumbai provide a locate and contain the terrorist Joseph Cahill number of lessons commando teams. EMS for emergency-services Kay Goss agencies throughout The terrorist teams, using pre- Emergency Management the world. The attacks, which programmed GPS devices, moved represented an ever-increasing level through Mumbai’s maze of streets Joseph Watson Law Enforcement of sophistication and ingenuity of like experienced tour guides. There terrorist activity worldwide, started were only ten terrorists in all; Joseph Trindal during the evening hours of 26 divided into killing teams of two Law Enforcement November 2008 when small teams to four, they moved swiftly from of armed terrorists launched a well- one crowded target to another, Rodrigo (Roddy) Moscoso Law Enforcement coordinated series of assaults that using taxis and stolen vehicles, but challenged India’s local and national sometimes on foot. At one point, Medical Support emergency-services capabilities for a terrorist team commandeered a Jerry Mothershead four days. responding police vehicle, killing Hospital Administration its occupants, including Maharashta Michael Allswede The terrorist teams, which Police’s Anti-Terrorism Squad chief, Public Health maintained radio communications Hemant Karkare. with one another throughout the Raphael Barishansky Public Health siege, moved swiftly and brazenly A Lack of Basic Intelligence through the famous tourist city, The Indian law-enforcement and Updates initially firing on civilians and military units responding lacked Adam McLaughlin authorities alike before settling State Homeland News intelligence about the scope of the into hotels crowded with numerous terror assault, the targets, and the Infrastructure Western tourists and business weapons involved. Some responding Neil Livingstone people. The last of the hostage/ units were simply disorganized; ExecutiveAction barricade situations was resolved on others were virtually paralyzed. 30 November, leaving almost 200 One on-duty police commander Funding & Regulations fatalities and over 300 injured. Diana Hopkins (Senior Inspector Nagappa R. Standards Mahale), however, swiftly set up The terrorist tactics were relatively roadblocks, a tactic that resulted in Borders & Ports basic, but the overall operation was the interdiction of one of the terrorist Joseph DiRenzo III fairly sophisticated. In contrast, commando teams. Coast Guard the response by local and national Christopher Doane emergency-services agencies was That hasty roadblock, in fact – Coast Guard much less coordinated. The on Marine Drive on the way to terrorists used the now frequently Girgaum Chowpatty – captured the Military Support experienced “multi-prong” approach Jonathan Dodson only terrorist to be taken alive. National Guard by combining a number of IED When one of the terrorists’ stolen (improvised explosive device) sedans turned onto Marine Drive en detonations in some areas with route to the next target, the driver small-arms attacks in other areas. realized that they were facing The separate teams used the small- a police roadblock. During the arms fire to create a wider scope attempt to turn around, a vicious of carnage. The law-enforcement firefight ensued between police and and military units responding the terrorists. In an uncoordinated

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 5 albeit heroic effort to stop the of command and control between example, was in the midst of terrorist team, officers assaulted the and among the responding units. receiving injured patients when the vehicle – however, as is customary terrorist team led by Abu Ismail in India, not all of the police officers Moreover, unlike the terrorist Khan opened fire at the hospital. were armed with firearms. But they teams, the police and military fought with what they had. Sub- commanders had little or no real- It turned out that this attack was Inspector Tukaram Omble, despite time understanding of a common little more than a drive-by shooting; being unarmed, clutched the barrel operating picture during much of nonetheless, it heightened an of an AK rifle held by terrorist this deadly and rapidly moving already chaotic situation. Many of Ajmal Amir Kasab; he absorbed six event. Eventually, though, after the on-scene victims were assisted fatal shots, but other police officers the terrorist teams had settled by other citizens; a number of clubbed Kasab into submission. Abu into known locations, the Indian them were transported from the Ismail Khan, the other member of containment and interdiction actions immediate danger areas on luggage that terrorist team, was killed during became reasonably well organized carts or dollies, or were even carried the police counterattack. – and thus more cohesive and by other citizens who were on the effective. Ultimately, the terrorist scene but had not been injured. Meanwhile, the other terrorist teams Because there were not enough were continuing their attacks ambulances available, transportation against key targets – the Taj Mahal 800 police, Indian for some victims was provided by Hotel, the Oberoi Hotel (formerly private motorcars. known as the Trident), and the National Security Nariman House (also known as the Guards, and military In addition, there was little if any Chabad House Jewish Center). personnel worked on-scene triage carried out, and no All of the terrorist teams seemed hospital “distribution plan” had to have a very good understanding together to isolate, been set up. As a result, patients of the layouts of all of their targets. contain, and resolve lined the corridors and hallways as During the course of the various three area hospitals tried feverishly to assaults, the terrorist teams gathered the attacks of 10 manage a major spike in critical-care hostages and even established terrorists demand – in a medical-care system command posts in hotel rooms. The that is routinely stretched to the limit. local and state law-enforcement and Some victims died in transit; others military units responding eventually died while awaiting care. contained all of the terrorist refuges, commando teams were neutralized and the battle became a fixed- through coordinated military and barricade hostage situation. police small-unit operations. At Lethal Carnage the end of the four-day siege there And Deadly Lessons Eyewitness accounts and the were more than 800 police, Indian Despite the widespread carnage evidence collected to date indicate National Security Guards (NSGs), and the lives lost, there were some that the terrorist teams were in and military personnel working valuable lessons learned as well – communications with one another together in Mumbai to isolate, including the following: as well as with command oversight contain, and resolve the attacks of 10 elements beyond India’s borders. terrorists, who had split up into four 1. Coordinated multi-prong attack In addition, it seems evident coordinated killer teams. methodologies should be expected that some of the terrorist team and studied by all emergency- leaders possessed the hand-held The Mumbai Medical System: services agencies and jurisdictions. devices needed to gather real-time Mumbai is not the first multi-target intelligence through internet-based Overworked & Underprepared The Mumbai emergency medical attack of its type and certainly will news media reports. Conversely, system was not prepared for not be the last. Terrorist planners most if not all of the local and an event in which many of the recognize the effectiveness of national police and military units casualties were self-evacuating these types of attacks in straining responding seemed to lack even basic to area hospitals – and in which the emergency-services systems of communications interoperability. hospitals were also on the terrorist their chosen targets. There also was an almost total lack target list. Cama Hospital, for

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 6 2. Attack planning and preparations a parallel need to rapidly develop industry in Mumbai, and India as should involve all emergency- accurate, real-time situational a whole. At the strategic level, this services agencies as well as awareness and provide a intensity of pressure, because of the potential private-sector targets. common operating picture between importance of tourism to the Indian The Mumbai attack operationally responding emergency services economy, was probably designed targeted hotels (the Oberoi and the disciplines and jurisdictions. In to escalate tensions between Taj Mahal), public transportation Mumbai, the terrorist teams worked India and Pakistan. Private- services (taxis & rail), hospitals, effectively to maintain an accurate sector infrastructure assets have and dining and entertainment situational awareness of most historically been attractive targets venues (the Metro Cinema local and area law-enforcement for terrorist groups in achieving & Café Leopold) as well as a and military-response operations. broader strategic objectives. From religious-oriented community center When their efforts were effective, a profitability point of view, the (Nariman House). In addition, the they were able to stay ahead of lack of preparedness to safeguard terrorist commandos were mentally the public service interdiction customers makes poor business and operationally prepared for efforts. A case in point was that sense in the 21st century. The dramatic encounters with the the terrorists obviously had a Mumbai attacks – in which private law-enforcement and military better understanding of the Taj businesses were once again a soft personnel who responded. The Mahal Hotel’s floor plan than the terrorist target – should be another latter point was underscored by responding police and military warning to public officials and Kasab and Khan’s hasty ambush units did. Witnesses described business leaders alike. of a responding police vehicle; several instances in which the the ambush resulted in the death terrorists would “disappear” only In short, the complexity and deadly of Maharashtra Anti-Terrorism to re-appear in areas that had nature of the Mumbai attacks raises Chief Hemant Karhare and two already been swept by police and the bar of terrorist operational other police officers. Rather than military units. This cat-and-mouse capabilities worldwide. Seen in remaining hidden and let the police challenge generated additional that context, the terrorist assault on vehicle pass by safely, running confusion for the police and Mumbai ranks on the same plane its lights and siren furiously, the military officials, many of whom as the Moscow Theater siege, the terrorists chose the brazen tactic of believed the number of terrorists attacks on London’s underground assaulting the police directly. in the Taj Mahal Hotel was much subway system, and the 11 greater than it actually was. September 2001 terrorist attacks on 3. Communications interoperability the Pentagon and the World Trade should be expanded, tested, 5. Private-sector businesses must Center towers. All were watershed and significantly improved. be encouraged to participate in events in the global evolution of Communication challenges have emergency-preparedness activities. terrorist campaigns against the been identified in the United States, There was no coordinated plan democratic societies of the Western and in other Western countries, as linking local police and anti- world. Emergency-services planners a consistent emergency-services terrorism units with the private- and public officials should closely coordination soft spot. India’s sector targets of the Mumbai study the Mumbai attacks, therefore, police and military communications terrorist teams. The attacks with an objective of elevating interoperability is almost non- were initiated after business their emergency preparedness and existent. Nonetheless, facing hours, and under the cover of response posture to a new level a rapidly evolving coordinated darkness. Private-sector business that embraces the private sector assault similar to the Mumbai preparedness should include those as well as the entire spectrum of attack, even most U.S. agencies personnel assigned on all shifts. emergency-services disciplines. would be challenged to implement Most businesses are unprepared communications interoperability for an armed assault, and many are reluctant to take time out of Joseph W. Trindal, a career federal law- plans with mutual-aid partners enforcement investigator and executive, rapidly enough to effectively blunt their daily business operations recently retired as chief of the a similar attack. to plan and prepare for such Inspections & Enforcement Branch of assaults. However, a higher- DHS’s Infrastructure Security Compliance level objective of the Mumbai Division. That branch is responsible for 4. Closely associated with the need administering and enforcing the Chemical for improved communications is attack was to target the tourist Facility Anti-Terrorism Standards.

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 7 Mumbai: The Lessons Learned What Not to Do – Implications for the West By Neil C. Livingstone, Viewpoint Less than two months Mistakes, Malfunctions, The West German police had no ago – in late November And Misunderstandings actual “plan” as such for rescuing 2008 – terrorists carried Not only was India wholly unprepared the hostages, but simply deployed out a series of coordinated for the terrorist assault, despite five snipers to take out the terrorists. attacks across Mumbai, growing domestic violence in recent There were fewer snipers than there India, that resulted in 173 killed (the years, but its performance once the were terrorists, though, and none of exact number is still disputed) and attacks were underway is reminiscent the snipers was a trained sharpshooter. Moreover, their weapons were another 308 injured. At least six of other botched attempts, by other substandard, especially in low-light Americans were among the dead. governments, to address previous hostage situations, and they lacked not only The incident, which lasted for 62 crises – most notably, perhaps, the debacle at the 1972 Munich Olympics body armor and helmets but also hours and stretched over four days, the radios they needed to keep them brought India’s largest city, and abreast of developments in what was financial center, to a virtual standstill. Some Indian police an extremely tense and very fluid situation. In addition, the helicopters Initially, because of the scale of the officers demonstrated carrying the terrorists and their attacks and the mayhem that ensued, commendable hostages to the airport landed in the it was believed that there were 15 to wrong place, blocking clear shots by 25 terrorists actively participating in bravery, but many of the snipers and giving the terrorists the attacks – but later intelligence their actions were some obviously unintended cover. suggested that the number was closer to ten. In the aftermath of uncoordinated and, The snipers opened fire but initially the bloody incident, Indian officials in some situations, killed only two of the terrorists. The blamed Pakistan, its traditional rival remaining terrorists then returned – and, like India, the possessor of counterproductive fire – while also proceeding to nuclear weapons. India and Pakistan systematically murder nine Israeli have fought three wars since the hostages, who were bound and independence of the two nations. in what was then West Germany. helpless in the helicopters, with Only one terrorist is known to have During the Summer Olympics in gunfire and grenades. Two other survived the operation, a Pakistani Munich, a group of Black September Israelis had been killed during the named Ajmal Qasab, who indicated (Palestinian) terrorists infiltrated the takeover of the Israeli compound. during his interrogation that he was a Olympic village and took hostage When the incident was finally over, member of a group called Lashkar- a number of Israeli athletes and five terrorists were dead and three e-Taiba and had been trained at a camp coaches. West Germany responded others were in custody. A German in Pakistan. by attempting to rescue the hostages police officer also had been killed. – after first luring the terrorists, and Pakistan clearly bears at least part their captives, to a nearby airfield Reeling from international criticism of the blame, because all nations and promising them a safe exit. of its handling of the crisis, the West are prohibited under international The West German government had German government undertook a law from allowing their territory to refused to permit well-trained Israeli number of reforms – including the be used by armed militants to carry commandos from launching a rescue creation of the elite anti-terrorist GSG-9 commando unit – to ensure out attacks on other countries. operation and instead had relied on that it would never again be caught Nevertheless, India also must poorly trained and equipped police unprepared by terrorists. share some responsibility for to carry out the mission. Because the attacks, primarily because its of Germany’s Nazi past, the better- response to the crisis was nothing prepared West German military was Mumbai Parallels – Compounded banned under the constitution from short of disastrous. India’s response to the 26 November operating inside the country. 2008 terrorist attacks was eerily

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 8 reminiscent of the botched West German (Special Weapons and Tactics) unit, demonstrated commendable bravery, response 36 years earlier. Although Indian so – after much hand-wringing and but many of their actions were intelligence had warned management of bureaucratic bickering – a federal uncoordinated and even, in some the two principal targets – the Trident unit, the Marine Commando Force situations, counterproductive. In Oberoi and Taj Mahal Palace & (MCF), was activated. But the MCF several locations, the Mumbai Tower hotels – of a possible terrorist is based in India’s capital, New police even failed to set up adequate attack, both hotels had beefed up Delhi, which is three hours away perimeters around the attack sites. security only temporarily, but returned from Mumbai by air, and some to business as usual when nothing reports suggest that the Indian Navy In the weeks following the attacks, happened. The Indian government wanted a written request from the the Indian government has been failed, moreover, to take any steps government before it would release under fire, both at home and abroad, to increase security at Mumbai’s the commandos for the operation. for its slow and incompetent response. seaport facilities. The attackers, it Home Minister Shivraj Patil and turned out, reached Mumbai via speed A further complication was that India’s national security advisor both boats that had been launched from the MCF has no dedicated aviation resigned in the wake of the Mumbai trawlers. Mumbai is believed to have 15 resources of its own, or even the debacle. Today, India appears to be patrol boats in its waterfront inventory, but authority to requisition a commercial raising tensions with Pakistan as none of them, according to reports, were aircraft, and was forced to wait for a way of deflecting attention from used for patrolling. a military transport to be dispatched its own poor performance, both from another location. Moreover, once before and after the attacks. There It is now believed there were only the MCF reached Mumbai, the local have been a number of calls for ten attackers, a relatively small transport it was provided was in the ratcheting up India’s counter-terrorism number considering the widespread form of buses rather than helicopters. capabilities, but many observers havoc they caused, but they not only The bottom line is that it took nine despair, saying that bureaucratic were well-armed – with explosives hours for the government commandos inertia and corruption would likely and small arms – but also were to reach the scene, and it is not unfair to hamstring any substantial reform. equipped with GPS systems, body suggest that each hour’s delay clearly armor, and cell phones. Prior to the resulted in more casualties. Western intelligence and counterterrorism attacks, moreover, confederates of services are already incorporating the the terrorists apparently had carried The local police who initially “lessons learned” from Mumbai into out an extensive recon of all of the responded to the attacks – and for their own training curricula and op projected targets and the attackers hours were the only security forces orders. If there are any lessons for had studied the recon information on the scene – were hampered by India itself from the Mumbai crisis both on-line and using Google Earth. inadequate communications. In it is that the Indian government must addition, they possessed only limited be much better prepared to cope with The terrorists hit ten targets in all, body armor (which was improperly future attacks, that it must create and but the two hotels clearly were their strapped on), substandard weapons, adequately fund its own dedicated principal objectives. Hostages were few if any scopes for their rifles, counter-terrorist resources – as well taken at both hotels, and at a Jewish and no night-vision equipment. It as a clear command and control center known as the Nariman House. goes without saying that they also system to manage such incidents – The Indian government responded lacked flash-bang grenades, pin-hole and that it must provide significantly tentatively and without effective cameras, robots that could be used to more financial and other assistance coordination between the Mumbai search for and detonate explosives, to local counter-terrorist forces. police and government security and equipment that reads the heat- Only in this way will India be able to forces. The coordination problems signatures of bodies; all of these respond immediately and effectively apparently were complicated, at least and other high-tech equipment items to future terrorist attacks. in part, by the fact that Mumbai lost are now standard issue for Western three top anti-terrorism officials SWAT and elite anti-terrorism units. Dr. Neil C. Livingstone, chairman and early in the crisis when their van was CEO of Executive Action LLC and an ambushed by the terrorists. The local police also were not internationally respected expert in terrorism and counterterrorism, homeland defense, trained in room-clearing operations The city of Mumbai has no rapid- foreign policy, and national security, has and/or hostage negotiations. Some response anti-terrorism or SWAT written nine books and more than 200 articles individual Indian police officers in those fields.

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 9 Emerging Infections and Their Impact on EMS By Raphael Barishansky, Public Health

Small pox; Tuberculosis; Another recent definition/classification, of SARS was considered to be the Polio – All were once this one from Columbia University, primary accelerator of the disease in classified as “emerging refers to three circumstances that both of the countries named. infections” and under indicate the presence of an emerging that name ravaged infection – namely, that it is either: The SARS experience represents the populations in the United (1) a new previously unknown confluence of emerging-infections States and many other countries. infectious agent or disease; or (2) issues and patient-safety issues. The development of vaccines and a previously described infectious The continued awareness of and treatment modalities worked to agent in a new geographic location, search for healthcare-associated erase them from Western health as a new syndrome, in a new type infections is therefore a key factor concerns – but lack of health care in of host, or with an increased drug- both in preventing the emergence of Third World countries, lax security resistant pattern or other new infectious diseases and in improving at bio-stock facilities in the former genetic characteristic; or (3) a new patient safety. Soviet Union, and the appearance or previously described infectious of new drug-resistant strains of agent used as a bioweapon. A Focus On infections are breathing new life into these and other “old” threats. Syndromic Surveillance Their Own Worst Enemy As has been suggested by the According to statistics compiled World Health Organization, an Monkeypox; Ebola Virus; SARS – and maintained by the federal emerging infection will probably As global travel and the expansion Centers for Disease Control not be immediately recognized as of commerce continue to make and Prevention (CDC), Western such. This is one of the principal the world an ever closer community, healthcare is not only an essential reasons why EMS systems must these previously isolated illnesses find part of the solution in the battle endeavor to participate in public- themselves carried across oceans and against emerging diseases but also, health and emergency-management continents, often without warning, unfortunately, often a key part of monitoring activities. “Syndromic within days of their initial outbreak. the problem as well. The failure to surveillance” – a recent and rapidly Which brings up an immensely important follow well established personal developing procedure defined by the question: What are the responsibilities and patient protective protocols CDC as “using health-related data of emergency medical services (EMS) as simple as the washing of one’s that precede diagnosis and signal a organizations and agencies in the field of hands and the wearing of respiratory sufficient probability of a case or an emerging infections? personal protective equipment outbreak to warrant further public (PPE) has led to a significant health response” – is proving to be a To answer that question one might increase in healthcare-associated key tool in this effort. As used in the start with the generic definition of infections in the United States itself, EMS field, syndromic surveillance Emerging Infection offered by the where approximately 1.8 million involves the live analysis of data – National Association of Emergency hospitalized patients are infected e.g., 911 calls and dispatch data - to Medical Technicians in a 2005 annually, and 88,000 die as a result. identify patterns and trends as they position paper that described it as “a emerge, rather than waiting days new, reemerging, or drug-resistant Five principal pathogens are or even weeks for conventional infection whose incidence in associated with about half of all detection methods, such as the one- humans has increased within the of the reported infections. The by-one review of patient charts, to past two decades or threatens to 2003 Sudden Acute Respiratory provide actionable evidence. The increase in the near future.” That Syndrome (SARS) epidemic, which variables or triggers for a natural definition not only encompasses the caused numerous deaths in Taiwan epidemic and/or an artificially diseases mentioned above but also and Canada, demonstrated how just induced disease threat would include brings to mind certain other well- one emerging pathogen could have any cluster of pre-determined known infections such as Multi- a profound impact by serving as a key symptoms such as breathing Drug-Resistant Tuberculosis (MDR- healthcare-associated infection. The difficulties, abdominal pain, or fever TB) and HIV/AIDS. healthcare-associated transmission accompanied by a rash.

Early detection allows appropriate everything from paying attention same clustering of symptoms. action to be taken more quickly, not to the public-health updates only saving lives but also protecting provided around EMS stations The list of protection requirements the healthcare infrastructure. and/or medical-control facilities to for EMS must also, of course, include Unlike the conventional syndromic knowing where PPE masks and paying strict attention to the basic surveillance data sources used other gear are stored in an EMS rules of medical hygiene, including in public health monitoring – or unit to considering the principal but not limited to the following: similar reports developed from complaints and symptoms of private physician visits and/or the patients not only individually but • The use of appropriate PPE – “patterning” of pharmaceutical also collectively. this means gloves, gowns, and purchases – EMS dispatch data is not a mask with eye protection (and only exceptionally time-sensitive preferably a face shield); after but also systematically links The continued use these items must be treated gathered information with medical awareness of and as medical waste and disposed of symptoms and provides an accurate properly; geographic “distribution map” of search for healthcare- disease incidents. associated infections • A requirement that EMS providers ensure that appropriate A growing number of cities across is a key factor PPE is provided for patients; if the United States have already both in preventing there are concerns about a possible started to use syndromic-surveillance airborne contagion, the patients technology and/or procedures to the emergence of must wear either non-rebreather develop early-warning notifications infectious diseases masks or surgical masks; contact on various clusters of patients with skin lesions can be minimized suffering from specific illnesses or and in improving by wrapping the body part with injuries, and this practice has thus patient safety loose gauze, or the entire far performed above expectations. patient with a clean sheet; The possibility of developing a • An insistence that EMS providers nationwide syndromic-surveillance Here it should be noted that an network within the foreseeable future thoroughly clean all of the vehicles important but frequently overlooked used after every call – “thoroughly” is therefore no longer a concept but aspect of an EMS provider’s an achievable goal. includes the use of suitable assessment is the reconciling of disinfectants, and “vehicles” refers pertinent signs and symptoms with to all non-disposable equipment Protection for EMS the individual patient’s recent travel that was used as well as the surfaces Providers a High Priority history (which countries, and when, of the vehicle itself; Individual EMS providers can has the patient visited?) as well as actually do something personally other anecdotal evidence – contact • Finally, a similar insistence that about emerging infections. with certain animals, for example – EMS providers wash their hands Following the suspicion of the that might indicate the presence of an after every patient contact. (The SARS outbreak, governmental infectious disease. use of alcohol-based disinfectants authorities overseas immediately is acceptable for the short term, instituted certain policies, Another common-sense test would but as soon as possible the EMS including the use of full PPE gear be to ascertain if there is an unusual provider must wash his or her for each EMS provider, as well increase in the number of patients hands thoroughly with soap and as specific training – in infection- with common complaints, especially tepid water, remembering to clean control techniques, for example – when those patients represent under the nails.) and frequent updates on the general different groups (male vs. female, situation to protect EMS personnel. for example, or old vs. young). The To briefly summarize: Previously The importance of developing and EMS provider should make it a habit unseen and/or metamorphosized emphasizing personal awareness to speak to the nurses and doctors at infections are making themselves and preparedness cannot be local emergency departments and ask known all of the time. Just over overstated, and encompasses them if they have been seeing the four years ago – on 18 February

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 12 2005, specifically – two separate Changes and Clarifications – and apparently unrelated disease outbreaks were reported in the New NIMS Upgrade Released York Times. One involved more By Stephen Grainer, Fire/HazMat than 400 people near Amsterdam who had tested positive for On 18 December 2008, Reorientation, TB following contact with an long-awaited revisions Realignment, & Restructuring infected supermarket cashier. to the National Incident The initial NIMS document More frightening was the fact that Management System consisted of six primary an additional 21,000 people were (NIMS) – officially components: Command & reported to have possibly come described as an Management; Preparedness; Resource in contact with the 400 already “upgrade” by the former acting Management; Communications identified. The other case focused director of the NIMS Integration and Information Management; on an outbreak of rare pneumonic Center, Albert Fluman – were Supporting Technologies; and plague in the Congo that killed over published by the Department of On-Going Management and 60 people and had possibly infected Homeland Security (DHS) and are Maintenance. Although these major hundreds more. Several thousand now being implemented. components remain an integral workers self-evacuated the area part of the basic NIMS concept, a without follow-up with medical The effort to improve the original careful and lengthy analysis of their authorities, fleeing “into the forests,” template for the NIMS actually relationships with one another the Times reported, “to escape the began early in 2006. A stakeholder led to the determination that a highly contagious disease.” working group that included reorientation was necessary to more than 100 of the most more effectively align each and all EMS systems, and the providers of them with the original NIMS actively involved and experienced who operate in them, cannot afford policy guidelines. to live in the proverbial vacuum. representatives of various federal agencies – as well as state and What the new emergence of so This was done by first restructuring many infectious diseases means local governments, tribal nations, the organizational framework of for EMS agencies, their staffs, the U.S. military, and various the system – the document – to administrators, and medical directors non-government organizations more accurately reflect the working is that there is a much increased (NGOs) – worked together in a and conceptual relationships need for real-time information series of meetings designed to between and among the six about emerging infections; that carry out one basic task: dissect, primary components named above. need translates into: (a) consistent evaluate, and reassemble the NIMS The Command and Management communications with relevant in such a way that it would: (a) be component was the first and health-care authorities; (b) the more understandable; (b) be more predominant element of the initial constant updating of policies and applicable across a broad spectrum NIMS, but the general feeling of procedures to reflect realities such of incidents and events; and (c) the stakeholder representatives was as those described above; and (c) provide a stronger degree of cohesion that Command and Management a requirement that EMS providers among the many stakeholders. – particularly as manifested in the themselves stay constantly vigilant Incident Command System (ICS) in developing and following up on – was primarily an outcome of The net outcome, participants said, their own assessments and not be thorough and effective Preparedness. is a document that more clearly lulled into thinking that “it’s only Preparedness itself, of course, the flu.” captures the intent as well as the includes training, exercises, and mechanisms for implementing planning – all of which are necessary Raphael M. Barishansky, MPH, is currently a true National Incident the Program Chief for Public Health to develop and maintain proficiency Emergency Preparedness for the Prince Management System. What follows in command and management skills. George’s County (Md.) Department of is a capsule summary of the more Health. Prior to establishing himself significant changes and upgrades The next step was formally in this position, he served as Executive Director of the Hudson Valley Regional EMS included in the December 2008 recognizing that Command (Emergency Medical Services) Council, revision of the NIMS. and Management cannot be based in Newburgh, N.Y. effectively executed without

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 13 resources – and, therefore, effective in the order of “chapters” in the listed above. In the Preparedness Resource Management. Resource revised NIMS. During the analysis component, for example, greater Management, however, is not it was debated how Supporting discussion is directed to the simply a matter of possessing Technology could best be used relationship between NIMS and sufficient resources and assigning in executing the NIMS principles the National Response Framework them in a command context. It also and concepts. It was agreed (NRF). (Note: the efforts to revise encompasses, among other things: that, although technology is a and upgrade the NIMS document establishing performance standards valuable component of all aspects were conducted concurrently with and qualifications; inventorying of the NIMS document, the most similar efforts to revise and improve prior to need; maintaining the valuable application of Supporting the National Response Plan (NRP). resources available in an operational Technology was, is, and should Those efforts resulted in a parallel (ready) condition; and having a be in the overall Maintenance and reconfiguration of the NRP and the systematic means to acquire, deploy, evolution of the National Response track, and eventually demobilize Framework.) The Preparedness those resources. component also includes suggested Management actions that can be taken by After further deliberation the encompasses, preparedness organizations to more stakeholder participants also effectively apply the NIMS concepts determined that Command and among other and principles. Management are reliant on things, establishing effective Communications and Perhaps one of the most important Information Management. In order performance aspects of the improvements in the to be successful in Command standards and revised NIMS is a discussion of the and Management, obviously, an roles and activities of elected and Incident Commander (IC) must be qualifications and appointed officials. The numerous fully aware of the situation, able to having a systematic ways in which these officials are manage the information flowing to involved in the implementation and from the command element, means to acquire, of NIMS also are included in the and to communicate both concisely deploy, track, and Preparedness component, and are and effectively. a valuable addition to the original eventually demobilize NIMS policy statement. Here it is After several months of intense those resources worth pointing out that, although analysis and discussion, the working it may have been assumed in the group recommended that the NIMS original development of NIMS concept itself be re-formatted to that elected and appointed officials Management of NIMS. For that focus primarily on Preparedness, would recognize and understand reason, Supporting Technology was Communications and Information their important roles, the absence Management, and Resource incorporated as a primary mechanism of any guidelines or delineation Management – which would be for ensuring On-Going Management of those roles led to considerable followed on the conceptual priority and Maintenance. Thus, all of the confusion. It is expected that list by Command and Management primary NIMS components were the additional information now and, finally, On-Going Management realigned to more accurately reflect provided will alleviate much of the and Maintenance. The revised the structure and concepts of the previous uncertainty. NIMS document consists of process that NIMS is intended to those elements, in that order, and provide as the basis for improved The revised NIMS document also therefore more accurately reflects the interoperability and compatibility includes an expanded section “life-cycle” or systematic process among all response organizations. focused on the relationship between underpinning the National Incident NIMS and other preparedness Management System. Greater Depth efforts – including, for example, And Additional Clarifications identifying and describing how Here it should be noted that the Another important revision was the NIMS is integrated with other Supporting Technology component development of added “depth” Homeland Security Presidential of the original NIMS is not included for each of the components Directives such as HSPD-7,

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 15 “Critical Infrastructure Identification incident commanders but – for input provided by the stakeholder Prioritization and Protection.” The security reasons, primarily – should representatives, the revisions NIMS relationship with HSPD-8, not be divulged to the general public. incorporated in the new document “National Preparedness,” also is reflect an effort to truly simplify the clarified by identifying the direct To avoid future misunderstandings core components of NIMS. Rather relationship between national of this type, the terminology was than detailing intricacies of the preparedness and the preparedness changed. The function of “Intelligence components within each “chapter,” component of the revised NIMS and Information” in the ICS became those details were transferred to a policy statement. And, although “Intelligence and Investigations.” greatly expanded set of appendices the National Response Plan was This change in nomenclature has to the core document. For the user referenced in the initial NIMS helped to more clearly distinguish who needs only a fundamental draft, the revised document more between “Public Information” appreciation of NIMS, the “devil clearly establishes the closer NIMS and “Incident Information” or in the details” is re-located to an relationship with the new National “Intelligence.” Because of the appropriate appendix. However, Response Framework. technical distinctions involved, references for additional details this change also led the reviewers are included in the core text to enable those who need, or seek, An important technical clarification to recommend that a separate more information to easily locate was made in the Command and working group be established to those details. Management component that has led develop guidance and protocols for the newly coined Intelligence to additional refinements (currently In summary, the revised NIMS under way). Within the ICS element and Investigations function. That working group has recently released reflects a wealth of important of Command and Management a its first public draft of the guidance information that more clearly new function was identified. That for review. defines the doctrine, scope, intent, function was initially referred to and mechanisms of a truly useful as “Intelligence and Information.” Perhaps one of the most useful National Incident Management As those already familiar with modifications to the revised NIMS System. Most users will find the NIMS may recall, it was reasoned is the greatly expanded incorporation content, format, and design to be an that in many potential scenarios of diagrams and graphics to support appreciable improvement over the the collection, analysis, and the text. The initial NIMS can original NIMS document. dissemination of intelligence (or accurately be characterized as “dry” “information”) related to the cause reading. In addition to the use To review the entire text of the NIMS and effect of a particular situation or of “jump boxes” to highlight key revisions, including the associated incident might be a critical element points, numerous diagrams in the appendices, click on http://www. in effectively managing that incident. new document provide readers with fema.gov/emergency/nims. However, the use of the term a visual description of the points “information” created confusion presented. Throughout the revised The draft I2 guidance document can among less-experienced ICS document, the user gets the feeling be accessed at the following website: practitioners. The greatest confusion that NIMS is not merely a “concept http://www.regulations.gov under was about which “information” was paper” but is, rather, a document that Docket ID FEMA-2008-0016. Public being referenced – i.e., information the user can readily reference. comments were accepted through 21 such as “public information,” or January 2009. information that is important to Finally, and largely as a result of the Stephen Grainer is the chief of IMS Is Your Membership About To Expire or Has Expired? programs for the Virginia Department of Fire Programs. He has served Virginia fire and emergency services and emergency If YES, then visit www.DomesticPreparedness.com management coordination since 1972 in assignments ranging from firefighter to chief Enter Promo Code: RENEW officer. As a curriculum developer, content evaluator, and instructor, he currently is to extend your subscription today! developing and managing VDFP programs to enable emergency responders and others Qualified members receive complimentary subscription to achieve NIMS compliance requirements for incident management.

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 16 The Field Testing Dilemma and LRN Chemical Laboratories By Richard France, Viewpoint

During a recent but that assertion cannot be accepted Despite the association’s strong investigation of letters without also considering under disclaimer, there is still no containing a white what conditions such statements standardized validation process or powder sent to a targeted hold true. established protocol governing the company in several use of these field-detection devices. states, a common field detection To begin with, a trained first Moreover, sales personnel still make device failed to identify the white responder must know beforehand claims about their particular devices powder. First responders used the what instrument to use and what that have not been tested under device, known as the HazMatID, to it can and cannot identify. Not laboratory conditions, let alone field try to identify the white powder from all authorities agree with the conditions – and anecdotes abound one of the letters in the field. Their manufacturers’ statements about instrument gave them a result that the versatility of certain field about trained chemists working in insinuated the presence of a non- instruments. The Association a laboratory who cannot get this toxic, inert chemical. Fortunately, of Public Health Laboratories’ or that device to measure what the manufacturer claims it does. the responders had enough white powder left to send a sample to a public health laboratory for testing. For almost Such problems present a difficult a decade the dilemma for first responders with a The lab later identified the powder need to know about the efficacy of as a toxic chemical that could LRN has been field testing for unknown chemicals. potentially cause illness if inhaled responsible for Fortunately, there is an independent or ingested. The responders had organization – the Laboratory learned a valuable lesson, and maintaining an Response Network (LRN) – that were fortunate that no one had been integrated network can provide the guidance needed sickened by the white powder. The on these instruments. The LRN incident was a reminder to other first of state and local laboratories possessing a chemical responders, though, to be constantly public-health, testing/validation capability already aware of the limitations of their own are reaching out to the nation’s field-detection devices. federal, military, first responders, and to the health and international and medical communities in their New Technologies: laboratories own jurisdictions. In this way, For Better or Worse they can become familiar with the Over the last few years, first first-responder process involving responders in the field have been chemical-exposure incidents and placed in the difficult position Statement of Position is that the determine how their own roles of trying, with limited guidance, association “strongly opposes” might complement response-and- to identify various “unknown the use of biological and chemical recovery operations. The ultimate powders.” Further complicating the agent detection kits and devices goal is the protection of the first situation are the numerous new field for field testing “in the absence of responders themselves as well as instruments that promise to identify performance standardization, field “unknowns” with the push of a validation, and certified individuals anyone else coming into contact with button. On the chemical side alone, trained in the application of these suspicious substances. there are portable devices such as kits and devices [emphasis added].” infrared and Raman spectrometers, It is “essential,” the APHL Statement The Anatomy of a Network photo-ionization detectors, and gas continued, “that a standardized The LRN, which became operational chromatograph/mass spectrometers. validation, approval, and training in 1999, was established by the Many manufacturers tout their process for these kits and devices be Department of Health and Human products as the absolute best in the developed and implemented as soon Services (HHS), working in identification of unknown chemicals, as possible.”

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 17 collaboration with the Federal of toxic chemical agents, such as identify unknown contaminants Bureau of Investigation, the Centers cyanide or toxic metals present in the field. The first is to consider for Disease Control and Prevention in human clinical specimens. Ten how the results of the field test may (CDC), and the Association of laboratories participate in Level 1 change the incident response. If the Public Health Laboratories. The activities, and are trained to detect confidence in the field screening is mission of the LRN is to provide a exposure to a greater number of minimal then it is perhaps better to nationwide coordinated laboratory chemicals such as mustard agents, leave the instrument on the engine. response to bioterrorism, chemical nerve agents, and certain toxic One of the principal problems in terrorism, and other public health industrial chemicals. field testing is that the chemical threats and emergencies. For analysis could use up the entire almost a decade the LRN has been The LRN-C provides continuous responsible for maintaining an sample – leaving nothing for a support to its members, ensuring confirmation test later. integrated network of state and local they are trained and proficient in the public-health, federal, military, and use of CDC-developed protocols international laboratories and, by and methods. These laboratories The second issue, which is probably doing so, enhancing the public health participate in a rigorous quality- even more important when infrastructure by integrating the assurance program to ensure that unknown powders are involved, is expertise and capacity of labs both network labs provide precise, nationwide and globally. the perception of a credible threat. accurate, high-quality data. In a It may be out of the individual similar manner – and in an effort responder’s comfort zone to be What are called the LRN-C (LRN to work even more closely with required to identify what are, or Chemical) laboratories – which their partners – many of the LRN-C are not, credible threats. That is are headquartered at state public- laboratories are willing to help when it may be advisable to bring health laboratories in cities across train or assess the proficiency of the nation – possess varying levels programs in which hand-held and/ in an FBI WMD (weapons of mass of capability. Currently, 62 state, or portable instruments are used destruction) coordinator – and the territorial, and metropolitan public to identify unknown chemicals. LRN-C laboratories for consultation. health laboratories participate in the This guidance is designed not only to assist first responders in the LRN’s chemical-detection tasks. Those seeking the names of the decision-making process but also A designation of Level 1, 2, or 3 laboratorians in the state public defines the individual lab’s LRN-C to help them determine how much confidence to place in these devices. health laboratory nearest to them capabilities; each level builds upon and the answers to questions about the preceding level. All LRN-C the Laboratory Response Network members participate in Level 3 Valuable Partners and/or the Association of Public activities, which involve working For First Responders Health Laboratories should with the health and medical First responders obviously play contact Jennifer Beck at APHL communities, and first responders, a valuable role in coping with a ([email protected]). in the collection, storage, chemical incident or “event.” They packaging, and shipment of clinical will, more often than not, be the first specimens. All LRN-C members ones on the scene and will have to Richard A. (Rick) France, a CT coordinator also work to develop a coordinated make a number of quick decisions for the Florida Department of Health’s response plan for their state and about what they find. The goal of Bureau of Laboratories, has been a Chemical geographical regions. Terrorist Laboratory Coordinator at the the LRN-C laboratories is to help the Bureau’s Level 3 laboratory in Tampa since first responders make those decisions 2004; the Tampa laboratory is a part of the The laboratories designated as from a scientific point of view so that nationwide Laboratory Response Network. Level 1 or Level 2 are tasked with those at or close to the scene of the Level 3 CT coordinators are responsible the analysis of clinical specimens for working not only with various incident are safe. to determine the presence of federal, state, and local agencies in their certain chemicals. Thirty-seven jurisdiction but also with first responders and the health and medical communities labs currently participate in Level 2 There are two principal issues that to provide training and coordination activities. These labs are trained to must be addressed when deciding on matters related to chemical terrorism detect exposure to a limited number about using portable devices to preparedness and awareness.

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 18 Cold Calculations and the Search for Inner Warmth By Joseph Cahill, EMS With arctic air masses the cold as anyone else. But there is not the initial or principal focus of moving across the country is an aggravating factor involved: the gathering. this week, the issue of cold During the course of their duties, has moved to the forefront EMS staff are often required to spend of many people’s minds. extended periods of time either in At a minimum, ambulance heating For EMS (Emergency Medical their vehicles or outside, waiting systems should be tested – and, Services) agencies and organizations at an incident scene where they are if necessary, repaired – well in there are particular concerns about two exposed to the weather. advance of winter weather. The groups of people – patients, and EMS same maintenance check-off list crews. recommended for the family car In many cities, ambulance crews should be used for emergency are required to remain in their vehicles, paying particular attention Extreme cold puts added stress on vehicles, usually parked on the street, when not on a specific to ensure that the coolant is checked patients who are already ill or injured, and that the entire cooling in ways not necessarily connected to assignment. These long periods of system is flushed if needed. The the cold. Cold stress makes shock check-up also should include a states worse, and for that reason extra close examination of the exhaust steps must be taken to ensure patient Warming a patient warmth. Finally, in addition to these systems; carbon monoxide buildup problems, which make the handling “from the inside” is within the cab of a vehicle with of the normal patient load that much the most medically tightly closed windows could be a more difficult, there are a number of significant hazard. Vehicles lacking additional patients whose principal effective process to a fully operational heating system or only medical problems are caused should be taken out of service until by the cold itself. follow, because the they are repaired. human body starts Isolated areas of skin exposed to to shut down one extreme cold over a period of time Blanket Protection, can freeze, creating a condition, part at a time, IVs, and Flexible Garments popularly known as frostbite, that starting with the skin During the winter months, additional is extremely damaging to the tissue blankets should be added to the involved. A greater danger is the and extremities equipment usually carried in each lowering of body temperatures. vehicle. Ideally, provisions also The delicate chemical reactions should be made to ensure that the that make up the human body can recommended temperatures for operate within only a limited range time sitting in the ambulance can intravenous (IV) fluids and oxygen of temperatures. Exposure to the create major health problems if the can be maintained; warming a cold – or exposure to any conditions heating in the cab is not sufficient patient “from the inside” is the most that rob the body of its own natural to help the EMS staff maintain medically effective process to follow, warmth – lowers the patient’s body their own body temperatures. This because the human body starts to shut temperature; this condition is known problem is exacerbated by the fact down one part at a time, starting with as hypothermia, and is also extremely that EMS crews are often called the skin and extremities. In contrast, dangerous. As the body loses heat it on to “stand by” at the scene of warming from the outside causes the eventually reaches the point where it incidents (fires, for example) or shuts down completely. cold blood that has been trapped in mass gatherings – e.g., the recent the extremities to return to the inner New Year’s Eve celebrations, and core of the body, thereby lowering Shivering in a Stand-by Status last week’s Inaugural Parade in the temperature of the inner core. The members of ambulance crews Washington, D.C. – even when EMS are of course just as susceptible to

Special care is required to ensure How the NDMS Can Be Made More Effective that EMS crews also are provided By Michael Allswede, Public Health with outer garments that not only provide the warmth needed but also “The art of progress is That is no longer true. Looking allow the flexibility to perform their to preserve order amid ahead to the potential disruptions work without significantly shedding change and change amid that might be caused by such events those garments. A sometimes more order.” in the future, it seems obvious that important need – on the scene of an the American way of life may indeed incident where an EMS crew may be Alfred North Whitehead be placed at much greater risk in kept waiting for a long period of time the future, if only because of flaws – is to ensure that there is adequate and/or built-in weaknesses within shelter from the elements. Alfred North Whitehead was a the medical response system itself. physicist, mathematician, and Today, for example: With the radio communications philosopher who witnessed the now available in almost all political demise of Newtonian physics • Because of financial pressures, jurisdictions throughout the and advance of Einstein’s Theory most state and local medical country it is unconscionable to of Relativity during the early systems have much less excess force EMS staff (and/or other first 1900s. Whitehead was classically capacity than in years past; responders) to simply “stand by” educated to believe that matter is in the cold – or, during the summer unchanging and always constant, • The U.S. population is not months, in extreme heat – until they but he ultimately embraced the only growing older but also are actually needed. Stationing the fundamental concept of relativity becoming ever more dependent EMS staff in the lobby of a nearby (that matter and energy may upon outpatient services – which building, or in their own vehicles, exchange) and helped usher in the are not a built-in component of the until they are actually needed nuclear age. His wisdom, cited nation’s disaster medical service decreases the risks to their own above, on the art of progress may capabilities; and health without decreasing their also help to guide the development operational effectiveness. of medical responses to meet future • Certain future disasters, challenges in the era of terrorism. particularly terrorist incidents, pose a greater threat than in the past, The first responsibility of any if only because of the need for emergency agency is to ensure the Today, disaster medical response is undergoing fundamental shifts, detection and characterization safety both of its own staff and of primarily because of financial of such incidents before an other responders directly involved in pressures, a long series of natural effective response can be mounted. EMS operations. Preparation for the disasters, and the escalating threat cold is vital not only for the safety posed by international terrorism. Definitions, Descriptions, of the crews themselves, but also In years past, adequate disaster And Determinations for the survival rate of the patients medical response could be For all of those reasons, and to plan they serve. reasonably expected to cope with the stockpiling of the resources the occasional weather emergency, needed to deal with the next crisis some if not all natural disasters, or (rather than the last one – i.e., the Joseph Cahill, a medicolegal investigator even a major industrial mishap in for the Massachusetts Office of the Chief one most recently encountered), it Medical Examiner, previously served which a specific disaster area could may be useful to divide disasters as exercise and training coordinator be both determined and defined, into two principal subtypes: for the Massachusetts Department of after which resources could be “overt,” and “covert.” An overt Public Health, and prior to that was gathered and lives would be saved. an emergency planner in the Westchester disaster could be described as County (N.Y.) Office of Emergency Although the loss of life is tragically one that is both recognizable and Management. He also served for five inevitable during such events, in the definable – e.g., a bombing, a flood, years as the citywide advanced life support past those events seldom had the or a hazmat (hazardous materials) (ALS) coordinator for the FDNY - Bureau of event. There would be a defined EMS, and prior to that was the department’s capacity to destabilize the American Division 6 ALS coordinator, covering the way of life. start to such an event, a defined South Bronx and Harlem. geography (i.e., the area where the

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 21 event occurs and is limited to), and Unfortunately, because the Fundamental Differences a defined population at risk. Each NDMS is based primarily on And Other Complications type of overt disaster could then volunteerism, the system lacks Covert disasters – e.g., an infectious be characterized by victim injury both rapid-response and sustained- disease epidemic, food or water patterns, and the resources needed response capabilities. The reality contamination, or bioterrorism – to cope with it could be logically is that most of the working create a fundamentally different estimated and planned. professionals on the NDMS roster order of priorities. Because a covert not only must extricate themselves event will, in most cases, initially A key factor in the development of from their “regular day” duties seem to be some type of illness, such estimates, obviously, would but also, in most situations, would the nature of the disaster must first be a thorough understanding be limited in the duration of their be recognized by the local medical of perhaps the most critical system, then officially characterized component of the estimate: the (particularly in the case of a relevant response time involved. bioterrorism event) by a local public- Each specific type of disaster The NDMS health and/or law-enforcement is usually characterized by a investigator before a national recognizable “velocity” of victim did not play a response can be ordered. Because deaths – most of which, in most significant role such illnesses will progress steadily incidents, would occur in the first – and sometimes very rapidly – 24 hours following the start and/or either during the until containment is achieved, initial recognition of the disaster. To anthrax events of the medical response to victims be a useful resource, however, such must proceed concurrently with the estimates must be available within 2001-02 investigation. Complexities such as a relevant timeframe. Obviously, it or in the less a patient’s right to medical privacy, does little good to have the world’s the constitutional law protections best equipped decontamination publicized responses mandated for potential criminals, facility available 24 hours after all to more recent and the duties and responsibilities victims have either died or fled a assigned to a national command hazmat scene. infectious-disease authority can be expected to events impede the investigation of ill What is called the National Disaster victims who also may be witnesses Medical System (NDMS), a major to a bioterrorism event – and/ agency of the U.S. Department or, in certain cases, even create of Health and Human Services difficulties in investigating the (HHS), was developed specifically deployments. To cite but one terrorists themselves. to provide an effective response example: Of the approximately to overt disasters. The NDMS 200,000 medical evacuations carried There are other complications that is composed of: (1) a deployable out during Hurricane Katrina, only must be considered in determining response arm, consisting of about one percent were carried out if and when a national disaster volunteer teams such as the 54 by NDMS agencies and personnel. medical response may be needed. Disaster Medical Assistance Teams Because of the inherent limitations One such complication is that there (DMATs) strategically positioned of almost any volunteer system, throughout the country; and (2) are at present either no NDMS in fact, most of the disaster care a nationwide network of NDMS assets available for toxicology, during and after not only Hurricane hospitals. The latter, originally infectious disease, or radiation Katrina but also after the bombing intended to serve as excess capacity health, or such assets are available of the Murrah Building in Oklahoma for the Veterans Administration in very small quantities. It is largely for City and the 11 September 2001 hospital system in time of war, are that reason, in fact, that the NDMS terrorist attacks in New York City expected to make at least part of did not play a significant role and Washington, D.C., was provided their existing capacity available for either during the anthrax events the care of disaster victims. But that by local medical agencies and assets, of 2001-02 or in the less publicized may not always be possible – for a not by the NDMS. responses to other, more recent, number or understandable reasons. infectious-disease events. Moreover,

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 22 instead of developing a cadre of also have affiliations with whether a given asset should remain trained personnel to deal with covert- state and local response teams. in the current NDMS organization, event response contingencies, the Although well intended, such dual or perhaps be distributed to state or federal government has instead assignments would obviously create local teams. paid much greater attention to the a “double jeopardy” situation for development of a Strategic National response personnel. For similar Special attention also would have Stockpile (SNS) of the medicines reasons, such covert events as to be given to the detection assets and equipment needed to support the outbreak of a communicable and strategies needed to cope existing medical facilities throughout disease could be expected to with covert events. Because such the United States. degrade or defeat outright the events would almost always first volunteerism component of the be detected locally, augmenting Unfortunately, the little-known DMAT strategy. In short, although university medical centers, trauma secret in coping with covert events most U.S. medical providers – centers, and/or poison centers to is that communicable diseases doctors, nurses, emergency medical develop and maintain an effective and/or contamination usually will technicians, ambulance drivers, response capacity would be another create secondary victims within the etc. – are generally receptive to high-priority concern. By investing local medical and other healthcare voluntary service, an undetermined in the nation’s existing medical facilities mobilized to cope with but perhaps rather large number can system to develop the capabilities such events. In addition, at least be expected to want to serve their needed for a true national disaster some – and perhaps quite a few – own communities first during a time medical response system, the local medical and allied support of widespread crisis. existing U.S. healthcare system may personnel may not report to work also become part of the NDMS. during a communicable-disease or Given the need to fight the next contamination event because their war, not the last one, it seems These and other remedial actions own first priority may be to save clear that the NDMS must evolve would necessarily require a rather themselves and/or their families. By from its current system of generic large investment of taxpayer dollars not providing trained personnel as volunteer medical teams into more – always difficult, but even more so well as the SNS assets, the federal relevant units – possessing a broad during and because of the current government has made it possible spectrum of specialty skills, and economic crisis. However, the for a covert event to thwart the SNS available for rapid deployment. The cost of not evolving the current strategy through reductions in the challenge here is to promote such NDMS into a larger and more local work force. an evolution while preserving the comprehensive – as well as more stronger elements of the current effective – organization specifically The Dual-Assignment Path to system. A potential methodology designed to meet the most likely A Double-Jeopardy Dilemma for this process could start by: (a) future challenges is that the victims The threat of terrorism further taking a much closer look at the of the next disaster may be waiting complicates the issue of NDMS 15 situations that the Department for a non-existent or poorly designed response, if only because overt of Homeland Security (DHS) has “cavalry” to come over the hill to events such as the recent bombings described as the “most likely” their rescue. And the cost of waiting in Mumbai are planned by and scenarios for future terrorist attacks; would be paid not only in dollars, under the control of America- and (b) calculating the medical assets but also in lives lost that might hating fanatics who have the habit needed and the relevant response otherwise have been saved. of repeating successful attacks times related to each of those until they are stopped. Because scenarios. By developing both Dr. Michael Allswede is the Director of the of their volunteer status, DMAT a list of the resource needs and Strategic Medical Intelligence Project on the probable time frames available forensic epidemiology. He is the creator of members may defer deployment in the RaPiD-T Program and of the Pittsburgh anticipation of a future attack on for the primary set of homeland Matrix Program for hospital training and or within their own communities. security threats, a more accurate preparedness. He has served on a number of determination can be made as to expert national and international groups Moreover, many DMAT members on preparedness.

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 23 No Time to Cut Back on Safety – The Cost Is Too High By Warren K. Brown, Building Protection Workplace safety processes Prudent and Practical instead of requiring face-to-face must be in place at all Preventive Measures settings in a classroom for safety times and are even more Although most companies are training. In addition, having on-site critical during business always looking for ways to cut safety and training professionals downturns – if only to costs, even and perhaps particularly available at the workplace reduces prepare for unexpected incidents and in the current very difficult economic costs by allowing training to take prevent worker injuries, illnesses, or climate, they should not forget that place both on-shift and at jobsites, even death. Companies that have a there are many ways to save money thereby eliminating the need for strong safety culture and continually without cutting corners on business overtime sessions and/or taking invest in and implement effective safety measures and programs. employees off the job for extended safety processes see positive results, The South Carolina chapter of periods of time. including a reduction in worker the American Society of Safety injuries and illnesses as well as a Engineers (ASSE) has suggested Accidents and incidents will still parallel reduction of costs associated that employees can take a number happen, of course, but companies with injuries to employees – e.g., of prudent and easy-to-implement that continue to invest in safety – and, worker’s compensation payments measures to help companies save of perhaps even greater importance, and time lost from work. money without compromising that create and maintain a safety safety and health in the workplace. culture – will almost always reduce During financially difficult times, Among the most important, and the number of injuries and illnesses cutting costs by reducing safety most obvious, of those measures associated with unexpected events at ultimately hurts businesses, leaving are: (a) following safe working the workplace and/or during working procedures and practices to not them unprepared for unexpected hours. When incidents do occur, only prevent injuries but also those same companies should and incidents that end up costing them to reduce related downtime and will have in place the tools needed more in the long run. Businesses expenses such as costly fines; (b) to protect people, property, and the spend an estimated $170 billion properly using, cleaning, and caring overall work environment. a year on costs associated with for personal protective equipment workplace injuries and illnesses, (PPE); (c) re-using gloves whenever and pay almost $1 billion every possible – and for as long as week to injured employees and their In short, establishing and maintaining possible; and (d) keeping track of medical providers. In addition, when a comprehensive safety program safety glasses and re-usable hearing companies do not invest in safety continues to be essential for business devices and equipment. they may face a damaged reputation operations not only now, during and brand when employees are difficult economic times, but at all times, not only to prevent unnecessary injured, especially if the incidents Laura Comstock, president-elect are or were preventable. tragedies – the most important of ASSE’s South Carolina chapter, objective – but also to reduce normal emphasized that when safety-related everyday operating expenses. The Investing in safety pays off in many items – e.g., employee PPE such bottom line, employee and customer ways and contributes positively to a as hardhats, safety glasses, and safety, is good business, always. company’s bottom line. For example, respirators – are critical to operations a recent study of an investment firm in their purchase must not be deferred. Australia showed clear links between Safety training during tough economic Warren K. Brown is safety supervisor of workplace safety and health factors times also should not be deferred, she DMAX Ltd. of Moraine, Ohio. He also is a and investment performance. The added, pointing out that some safety- 30-year member, and current president, of related training is time-sensitive and the American Society of Safety Engineers. results of the study indicated that Prior to affiliating with DMAX he served as companies that did not adequately therefore cannot and should not be a plant layout engineer, OSHA coordinator, manage workplace-safety issues delayed. She also suggested, though, and both supervisor of safety and associate did not perform as well financially as an alternative, that some training administrator of safety for General Motors as companies that did pay greater costs can be reduced by using online and Delphi. A certified safety and health or electronic-based training services manager, he has won a number of national attention to safety. awards in the field of industrial safety.

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 24 California, Ohio, Kansas, and Louisiana But it may be the smaller, longer- lasting disasters, such as a worse- By Adam McLaughlin, State Homeland News than-average flu season, that cause greater hardships not only Los Angeles County as a whole has California for patients but also for medical a meager 1,500 “excess” beds on Overworked Hospitals personnel, said Lewis, who has any given day, according to a 2007 Under Heavy Stress written extensively about surge- study by Price Waterhouse Cooper, capacity problems. “Surge is not just a nationally known consulting about a shortage of physical beds,” It is not a Friday night, firm. More than half of all of the he said. “You are also talking about or even the peak of flu season. It area’s hospitals are “on diversion” a shortage of [the] staff needed” to is a normal weekday afternoon at – meaning they have to turn away care for the additional patients. the County Harbor-UCLA Medical ambulances because they are already Center, a facility near Torrance that too crowded – at least 20 percent of treats some of the county’s poorest the time. The numbers are worse for Ohio and sickest patients. Nonetheless, highly specialized facilities. Three- Emergency Radio System the average wait here – depending quarters of the teaching hospitals in Passes Initial Tests on the severity of a patient’s injury the area – Harbor-UCLA, for example or illness – is about eight hours. – are either at or over capacity in their Butler County’s new emergency The problem is neither financial emergency department at any given communications radio system has nor political, but simply the result time, according to the 2007 study. been successfully tested at more than of an overburdened hospital system 2,000 locations across the county, the capacity of which has been Harbor-UCLA, on Carson Street according to project manager Matt stretched thin. in an unincorporated area between Franke, who said that, despite some Harbor Gateway and Carson, is earlier delays, the county would be The recent domino effect of hospital almost literally bursting at the ready to flip the switch on the new closures and bed reductions – four seams. A 2008 survey, carried out $35 million system in early 2009. hospitals have closed in the South from January to May of last year by First, though, emergency responders Bay area, 10 emergency rooms in the California Department of Health will be trained on the system (in the county also have shut down, Services (which runs the hospital), January), and roughly 2,200 handsets and at least two other hospitals have showed that, when the hospital is will be distributed. reduced bed capacity – has left many operating at optimum capacity, even healthcare experts worried that the a slight patient surge of 5 percent Franke said the system worked increasingly fragile network will or so pushed waiting times to over acceptably at the spot where Butler not be able to cope with a major 14 hours. State inspectors cited and County Sheriff’s Deputy Brandon event resulting in a massive number fined the hospital twice last year for Roberts was nearly killed in a 2005 of casualties. That event could be lapses in care; one of the incidents shooting – a time when emergency anything from a natural disaster or cited was a direct result of emergency responders had to relay messages terrorist attack to a freeway pile-up, room crowding. through cell phones. Once the new the outbreak of a pandemic flu, or a radio system is operational, said plane crash. In a major disaster such as an Sheriff Richard K. Jones, “We will earthquake or a terrorist attack the not have to use cell phones … [to normal rules for care – nurse-to- “If Southern California’s hospitals talk to] the different jurisdictions. patient ratios, for example – although cannot handle patient inflow even … There were spots back then [in during the course of a normal day, not ignored, may be impossible to 2005] when you couldn’t even I have grave doubts about how follow, according to Dr. Roger Lewis, communicate with each other.” the region would do in a disaster an emergency-room physician at scenario,” said James Lott, executive Harbor-UCLA (and a professor More recently (on 14 September), director of the Hospital Association in the Department of Emergency Franke said, the system “operated of Southern California, a trade group. Medicine). “When you’re talking flawlessly” – even though few “Any increase in demand would about hundreds of victims, you are jurisdictions were equipped with stretch the system beyond what it operating with a different mind-set,” it – after power had been knocked could handle.” he commented. out countywide by a windstorm. The

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 25 unexpected outage “ended up being a their vehicles so there would be no proved fatal to a number of New good test for us,” he said. “It showed misunderstanding if someone talked York City firefighters at the time [that] everything worked.” about “engine five,” for example. of the 11 September 2001 terrorist attacks. “Sometimes, when the … After this month’s training sessions In addition to being able to [NYC firefighters] would go into have been completed, the county’s operate even in remote parts of the buildings,” Jones said, recalling 21 fire departments and 14 police county, Jones said the system’s that situation, “they would have no departments will start coming on line 800-megahertz signal strength will communication whatsoever.” one at a time, a process that could allow emergency responders to take several months. To prevent communicate from inside thick- Franke listed several other benefits confusion, Franke said, local fire walled buildings. The inability provided by installation of the new stations have had to rename some of to do this was a shortcoming that system: fewer garbled signals, for example, and the ability for different jurisdictions to communicate directly with one another. By using the new system, he said, “A salt truck driver in West Chester could talk to an animal control officer in Oxford.”

Kansas Manhattan Will Be Home To National Bio & Agro-Defense Facility

The Department of Homeland Security (DHS) has announced the selection of Manhattan, Kansas, to be the site of the new National Bio and Agro-Defense Facility (NBAF). U.S. Senator Pat Roberts (R-Kan.) said the decision to locate the new $650 million federal animal and plant disease laboratory on the Kansas State University (KSU) campus represents “one of the most significant investments to the Kansas economy in state history.”

The NBAF will replace the aging Plum Island facility in New York. The research conducted by NBAF will be designed to find new ways of protecting animals, food crops, and consumers from disease threats. The new center will research high-consequence biological threats involving foreign animal diseases as well as those classified as zoonotic – i.e., capable of being transmitted from animals to humans. Its operational charter calls for, among other tasks: basic research; diagnostic development, testing, and validation; advanced

Copyright © 2009, DomesticPreparedness.com; DPJ Weekly Brief and DomPrep Journal are publications of the IMR Group, Inc. Page 26 countermeasures development; and system will be the largest number we even 1,000-year storms – similar training for high-consequence award in any given year,” said Army to or stronger than Hurricane livestock diseases. Corps of Engineers Col. Gregory Katrina itself – remain in a holding Gunter, In addition to the $4 billion pattern. The Corps of Engineers The new federal bio-containment in new flood-protection contracts has missed several deadlines for will also: – all for the greater New Orleans providing recommendations to area – several other federal and state Congress for providing the higher • Assess and research bioterrorism coastal-restoration projects costing level of protection, commonly called threats evolving over the next close to $1 billion are expected to “Category 5” protection, but has five decades; start construction later this year. promised to deliver a more definitive report by June of this year. • Enable the U.S. Departments of Homeland Security and Research conducted This biggest contract expected to be Agriculture to fulfill their related awarded this year – to finance a new homeland defense research, by the NBAF gate complex to block storm surges development, test, and evaluation will be designed from entering the Harvey and Algiers (RDT&E) responsibilities; and canals – is expected to cost more to find new ways of than $500 million. That project is not • Integrate those aspects of public protecting animals, expected to be completed until 2013. and animal health research that have been determined to be food crops, and Several other contracts, estimated essential to national security. consumers from to collectively cost more than $100 million, will raise hurricane- The KSU site was selected over disease threats protection structures surrounding St. potential sites in four other states. Bernard Parish to similar 100-year Roberts attributed the state’s levels. The corps has reduced the success in attracting the facility to The new contracts represent a cost of those projects somewhat by a collective effort that including the major additional allocation for the planning to build sturdy floodwalls, state government, a special NBAF multi-year effort to build a flood- shaped like an upside-down T, task force, the Kansas Bioscience protection system capable of atop earthen levees in most of the Authority, and senior officials at protecting against so-called “100- areas covered; the floodwalls will KSU and the city of Manhattan. “We year” storms – which are defined as significantly reduce the amount can really be proud of our teamwork particularly dangerous hurricanes of land needed to build the higher to prove that Kansas is the best home that have a 1-in-100 chance of structures, Gunter said. The for this laboratory based on the making landfall during any given floodwalls will be “a change in what merits,” said Roberts. year. The corps expects to meet its they are used to seeing out there, goal of providing a 100-year level of which is a clay levee,” Gunter said. protection by 2011. Louisiana “It [building of the floodwalls] will be a more economical alignment. New Orleans to Receive $4 Billion The new round of contracts – But that is really in terms of the In New Post-Katrina Contracts combined with earlier contracts for cost of the additional real estate initial repairs to the levee system that would be required, should a The Army Corps of Engineers plans so heavily damaged by Hurricane traditional levee … [cave] in.” to award more than $4 billion in Katrina, and for improvements to new post-Katrina contracts this year the area’s interior drainage system – Adam McLaughlin is with the Port Authority of for construction of new levees and brings to almost $15 billion the total NY & NJ, and is the Preparedness Manager additional drainage projects that funding that, when the last projects of Training and Exercises, Operations should make the entire coastal region are completed in 2013, will have & Emergency Management, where he safer and provide a major economic develops and implements agency-wide been spent in the area to prevent a emergency response and recovery plans, boost to the local economy. Katrina repeat. business continuity plans, and training and exercise programs. He designs and facilitates “The 113 contracts for the hurricane Meanwhile, longer-range plans for emergency response drills/exercises for agency and storm-damage risk-reduction responders, state and federal partners, and providing protection from 400- or senior Port Authority executives.