All successful response operations must begin with a collaborative effort between all partners. This should include planning along with information and resource sharing. North Carolina is divided into eight trauma regions with regional advisory councils that oversee trauma transfer programs and improve trauma care. WakeMed is the Level I trauma center for the Capital Regional Advisory Council.
As part of the North Carolina State Medical Response System, WakeMed is one of eight trauma centers across the state that supports a Level II State Medical Assistance Team. All of the teams were originally equipped with the same basic cache and over the years have added specialized equipment to address specific needs for their region and the state. Through a close partnership between all eight teams, North Carolina Office of Emergency Medical Services, North Carolina Division of Emergency Management, North Carolina Division of Public Health, each of the eight sponsoring hospitals and select vendors, North Carolina is able to maintain a high level of preparedness for its residents and visitors, as well as the capability to assist other states when requested.
The actual “out of door” time for a response will depend on such variables as the time of day, the mission request and the number of personnel needed to fill the mission. Having “mission specific” packages loaded and ready to roll out the door ensures a faster response time when the request is received.
Predefining your potential missions will help with subsequent planning and training initiatives. CapRAC currently has deployment plans for the following local, regional and state missions:
Rehab/Special Operation/Event Medical Care Unit (MCU): This is a 30' self-contained trailer with four beds. This setup can be expanded to a 10-bed capacity with the addition of a Western Shelter.
State Medical Support Shelter (SMSS): This is a special medical needs population shelter for up to 80 beds. Equipment would be set up in a predetermined hard structure that has a working infrastructure in place. This allows care for homebound medical patients or nursing home residents have been evacuated pre-landfall of a hurricane.
Field Medical Shelter (FMS): This is a Western Shelter Gateway system for 10–40 beds with seven shelters, hygiene and water purification system, telemetry monitoring systems, I-STAT labs, ultrasound/X-ray, expeditionary deployable oxygen concentration system, suturing and casting capability.
Mobile Pharmacy Unit (MPU): This is a 53' tractor/trailer, fully self-contained pharmacy with a dispensing room, clean room and storage that supports medication mixing and compounding capabilities.
Mobile Communications and Command Center (MC3): This is a 35' LDV vehicle that supports HAM, VHF/UHF, 800 MHz, Satellite, Wi-Fi and video conferencing capabilities. (For more on the MC3, see “Mobile Communications,” pp. 10–11.)
Special Operations Support Unit (SOSU): This is a 24' box truck logistical support vehicle with air compressor, welder, floor jacks, assorted hand and electrical/air power tools, oil, hydraulic fluid, assorted belts, bulbs, fuses and tires.
Once you have your mission plan for response and set up, verification is necessary to ensure that all of the required equipment is ready, that supplies are prepared and there is a method of notification to personnel regarding deployments.
Training remains a core foundation of preparedness. As members respond on deployments, they will understand the importance of attending the continuing education that is offered. Continuing education should be offered regularly and cover not only topics of equipment and protocols but also other information with regard to deployment issues, such as environmental hazards and emergencies, deployment readiness, base camp operations, team communications equipment, patient tracking and ICS review.
When you have team members who are not able to train together on a regular basis, all of the equipment carts and bags should be labelled and standard operating guidelines specific for setup and operations should be provided. The operation is then broken down so that each person assigned to a position has a job action sheet that details the specific duties that they are required to perform during their work cycle. There should be cheat sheets available for the operation of any equipment that personnel may not use on a daily basis. Some examples would be the I-STAT portable clinical analyzer, IV pumps, and cardiac and telemetry monitors.
Just-in-time modules should be in place predeployment and ready to be used as needed either as a group or in one-on-one training. This training can take place during predeployment activities or after arriving on site. On extended deployments, personnel will be rotated into and out of the area; personnel who will be assigned on the next rotation should attend just-in-time training prior to being deployed.
Team Preparation & Planning
Each of the eight SMAT II teams have team leaders that are charged with having their teams prepared, trained and ready to respond to any number of possible missions.
Budget cuts are affecting all agencies, but we're still expected to complete the assigned mission. As a result, we all wear multiple hats. Teamwork and prioritization of equipment needs is paramount.
The start of the process is anticipating the mission(s). These mission plans should be documented and located in an accessible place so that anyone on your team can locate and assist with the deployment phase of the operation. You should then move to the next likely mission for your team and perform similar operations to prepare for them. As you move down the list of missions, combine the needed equipment for a similar mission and this will enable you to have a smaller footprint during transport.
When developing the inventory and record-keeping system, do not do it in a vacuum. Talk to your partners, compare what they are doing and never be afraid to tap into those resources for ideas and assistance. It is easier to tweak a system and make it work for you than it is to start from scratch and build a new one. For the most part, partners might have been able to work out most of the issues that you would find yourself stuck working through.
One issue for logistics is creating a loading system where anyone can assume the role of loadmaster for any trailer. The easier you make it to locate equipment and supplies in the support trailers and vehicles, the easier it is for the logistics personnel to perform their duties during the setup and demobilization of the unit.
This is where planning and documentation come into play. You want to anticipate and identify all of the equipment and supplies that will be carried on the truck/trailer. Color coding containers and labelling them on four sides will assist in locating specific items. Determine whether equipment should be loaded based on what needs to come off the trailer first, or based on best use of space.
One example is the WakeMed “First-Out Trailer.” We carry an H20 Gateway Western Shelter with an air conditioner, generator, WestCots, medical equipment in carts and other supplies. The shelter and A/C need to be accessible first, but the generator must remain close to the rear of the trailer for weekly checks and monthly load testing. To evenly distribute the weight in the trailer, the shelter must be placed over the wheels with the A/C just in front of it with the other medical carts and supplies while the cart of 14 WestCots are loaded at the rear of the trailer along with the generator.
This requirement maintains the safety of the weight balance as well as only needing to remove one extra cart prior to removing the shelter for initial set up. The other medical carts, equipment and supplies are loaded on shelves close to the front of the trailer. Always remember that safely distributing the equipment within the trailer and maintaining the proper weight for the trailer take precedence over ease of unloading. A tire that blows en route to a scene not only places the team in danger but delays team's arrival.
Once you have the trailer packed and ready, develop a loadmaster layout and inventory list. Keep in mind that some team members may work better using diagrams and pictures rather than an inventory list. Whereas an alphabetized inventory list is a great resource in quickly determining what is in the trailer, a floor layout picture works very well for unpacking and packing the trailer or locating a specific item (see p. 15). A good practice is to use the diagrams during an exercise with a non-medical team member serving in the position of the loadmaster. This will reinforce that the documentation is easily understood by both medical and non-medical personnel.
These documents will help free up your team to manage other duties during deployments and demobilizations.
Each mission has a basic footprint that will need to be followed. Dependent on the parameters of the area for setup, the design of the footprint may change. Having several different layouts preestablished and printed in a mission book will assist in setting up the base of operations. On arrival, the command staff will use the mission book to determine the most efficient layout for the area. In addition, the mission books can be utilized during continuing education to train personnel on the different setup scenarios.
As with any medical equipment, good record-keeping is a must. This includes inventory systems, preventive maintenance and equipment charging schedules. We are lucky to have a great relationship with the WakeMed clinical engineering and point of care testing departments that help keep medical equipment up-to-date with the preventive maintenance. It is a constant evolution maintaining documentation on all other equipment.
Again, a methodical approach to documentation works well. Start with the things that you use most often or that would cause the largest delay or most problems if they malfunctioned. You will find that as you are updating the list, either new equipment arrives or older equipment is taken from service.
In addition to documentation, an equally important component of maintenance is working within your local area to find contacts for repairing and maintaining the equipment. Check backgrounds and references to ensure vendors are qualified to do the work and will stand behind their work. In the EMS, fire and disaster world, we all have the personnel who can do the welding, automotive and other types of repair jobs, but will they take the responsibility for a piece of equipment that breaks and causes an injury?
After several mechanical and tire issues during missions and exercises WakeMed developed a support truck with the equipment listed above for SOSU. We have equipped two trucks with spare fuel tanks and pumps for diesel and gasoline.
Having one of the state’s two mobile pharmacy units, we work closely with WakeMed pharmacy services to maintain the SMAT pharmaceutical go pack. The go pack is a set list and amount of medication that all teams are provided and are expected to maintain.
The pharmacy team has also been instrumental in completing the MPU equipment and supplies cache, maintaining its readiness for deployment. This is one example of finding a good partnership with subject matter experts and assisting them with their needs to properly maintain the equipment and supplies that may be deployed.
Keeping your team assets ready to deploy out the door is a never-ending job. Proper and continuous documentation, planning, training and exercising, along with reviewing policies and procedures, are the only ways to guarantee that you will maintain your team at the highest level of readiness and ensure a successful mission. A team leader should always have backup plans in mind while preparing for a mission, working closely with both internal and external partners prior to and during a mission.
The team should always hold a hot wash session to discuss what went well and what could be improved. On long deployments this should occur during the demobilization of each group rotated back home. A final after-action report should be sent to the team to increase learning opportunities for everyone.
Working in the proverbial “silo” only creates more work for you and your team, and possibly sets up your team for failure. We are all in this business to achieve the common goal of assisting others in a time of need, while making sure that all of our personnel return safely from the mission. Working as one team, we can all achieve these goals.