On Sept. 2, 2005, four days after Hurricane Katrina ravaged the Gulf Coast, an Emergency Management Assistance Compact (EMAC) request was received by the State of Maryland from the State of Louisiana, specifically Jefferson Parish. (An EMAC is an alternative to other federal resources in times of disaster and need. All 50 states are now part of it, and medical is a big portion of it. Their Web site iswww.emacweb.org.) The request was for a medical team to augment the depleted facilities and capabilities of the region, and included a request for "ALS capable Paramedics, EMTs, and Ambulances."The entire Operation LifeLine Team, including MIEMSS resources, Maryland National Guard resources and local law enforcement.
The Maryland Institute for Emergency Medical Services Systems (MIEMSS) was forwarded this specific part of the request in an effort to support the mission. With no specific direction about the mission, the EMS system was challenged to not only garner the resources but execute a mission with an unknown amount of resources in a potentially hostile and, at least, unfamiliar environment under difficult circumstances.
Within 36 hours of the request, MIEMSS garnered four ALS units from Harford County, Md., with 13 personnel; an ALS unit and chase vehicle from Cecil County, with seven personnel; an ALS chase vehicle and eight personnel from Calvert County; and three ALS units, a special events trailer and eight personnel from a commercial ambulance company.Harford County units lined up at Montgomery County DFRS for deployment, Sept. 5. From left to right: Joppa-Magnolia VFC P-891, Abingdon FC P-491, Bel Air VFC M-393, Whiteford VFC P-691.
The resources were deployed early Monday morning, Sept. 5, 2005, from a central meeting point where inoculations and an informational briefing took place. Although the information presented to our team was limited, continual updates were provided during our travel to Louisiana.
Relocation of transportation resources was the first of several challenges we faced as we implemented the EMAC request. It was quickly determined that air transport of units was not an option due to strict standards for vehicles to be transported by air (e.g., medical gases, vehicle mechanical condition). The most expedient option was to convoy to the location, which would take a minimum of 24 hours. In this case, the medical resources were assigned to a convoy of fire service and law enforcement resources en route to the same general locale, thus providing both guidance and security.
It was quickly learned that, while logistically sound, the effort was only as expedient as the most unreliable piece of equipment. We also learned that if such options are presented in the future, resource need should be weighed so assets arrive in the appropriate timeframe.
Arrival & initial challenges
The true challenges began on our arrival into the New Orleans area. The EMS assets split from the convoy and began making access via the causeway over Lake Pontchartrain. At this point, the EMS Lead agency noted significant difficulty coordinating escort into the affected area, primarily due to limited cellular service in the area. Although this aspect was eventually covered, a pre-arrival plan would have been helpful, with coordination by the home agencies as best as possible.
The variable of arrival time was a true logistical difficulty, which is part of any disaster response, as are communications system failures. With focused effort, our Maryland operations center was able to coordinate our rendezvous with local law enforcement and determine the mission for the Maryland EMS contingent.
Arrival at the site of operations began a series of events that would form the basis of the response (which was not truly known up to this point). The units reported to an abandoned medical facility that served as our base of operations throughout the effort. This was truly a windfall for all parties involved because it provided not only shelter but also served as a repository of medical supplies and warehouse for incoming materials. The facility was acquired by the local government prior to our arrival, in coordination with National Guard units present. This type of action should be anticipated in any disaster of this magnitude and should also be considered during any large scale event. The definitive-care resources (e.g., hospital personnel) were already present and working to make the facility habitable, because the local community had seen fit to "modify" and "acquire" some of the building and its materials.EMS Command Staff coordinated morning deployment.
The EMS crews were asked to support a mission to open and operate six medical sites and provide food, water and medical care as necessary in conjunction with the hospital resources. It's important to point out that search-and-rescue missions were already being conducted by FEMA resources. However, community health care was suffering, because 15 of the 18 local medical facilities were inoperable. The NDMS and DMAT resources were committed to augmentation of those facilities already operating, and this mission, named "Operation Lifeline," was an augmentation of the community health efforts for those who did not truly need definitive care resources. This is a critical aspect of disaster response because it limits disease, properly re-allocates resources and, most importantly, enables those resources to offer psychological relief to those in the communities who remain after the disaster hits.
An Incident Command Structure was already in place on our arrival, and an EMS Command position for our operation was quickly identified. The challenge became to plan, develop and implement a mission plan within a 20-hour window while being given little to no information prior to our arrival. Given the large amount of EMS personnel and multiple transportation resources, a logistical approach was taken to manage the transport of personnel and materiel to each site with proper security measures. With an execution goal of 9 a.m. the next morning, an all-night effort was required to appropriately allocate the proper resources and build an EMS command staff to support the operation. This included maintaining site status checks every two hours, maintaining patient counts, identifying security, supply and personnel needs, and accountability of all of the team members.Team Foxtrot's site was regularly re-supplied via National Guard Black Hawk helicopter.
The morning of truth
The first deployment of our teams on Wednesday, Sept. 7, proved to be organized chaos, to say the least. All teams were eventually deployed, and five of the six sites were able to be up and running prior to noon (although the actual goal was 10 a.m.) This was commendable given the resources and time frame to coordinate such a massive effort. (The hospital resources numbered nearly 150 people, and each team had approximately 500 pounds of equipment and supplies to transport to each site.)
The old adage of "no plan ever survives first contact" certainly applied, and a significant re-thinking and re-organization was necessary to reduce the confusion and stress of all personnel. After the initial deployment, the command staff met, and the EMS section was again charged with much of the concept redesign because the primary transport resources fell within that sector.Team Delta takes a break outside their "clinic," which was based at a local elementary school.
By the afternoon of Sept. 7, a revised plan was devised, with each team being designated to its own room where supplies could be housed and meetings held, including the morning marshalling of personnel. Previously, each EMS resource team was numerically designated. However, this designation conflicted with the hospital resource approach, which also used numerical designations but not in the same order (e.g., EMS Team #1 was paired with hospital team #4). To alleviate conflict, all sites were renamed phonetically, and the teams associated with them fell under that moniker (e.g., Site Alpha's resources were renamed Team Alpha, etc.).
The deployments were to be staggered each morning, with the furthest site and closest site deployed first to maximize time and security resources. At no time was more than one team to be present in the hospital portico for loading and deployment. This allowed for improved efficiency and accountability. The command staff was each appointed as a Team Liaison for the morning deployment and afternoon recall for their respective teams in addition to their daily duties. This would prove to be pivotal in the execution of the task and allowed for personal interaction between one of the command staff and the team leaders. This was an important aspect from a psychological point of view, so as to have the teams "personally cared for."A local fire station, which served as Team Foxtrot's clinic, was stocked with supplies.
Sept. 8 proved to be a smother execution, with teams loading appropriately and full accountability completed. The largest logistical hindrance was security resources; the area was still not deemed truly "safe," and law enforcement presence was limited. Teams had to wait for security assets to return from one escort duty prior to deploying, which caused much frustration, especially to those who are not familiar with such limitations. However, all of the sites were functional prior to 11 a.m. that morning. The process was repeated in reverse that evening, and the return of the teams, although somewhat hindered by the security assets, allowed for the safe return and accountability of all personnel.
At this point, two teams had to be deployed to the same site, since the sixth site was not secure, and Team Alpha's site experienced a higher than expected patient load. Team Echo's augmentation proved to be extremely helpful in the following days, as the patient load continued to climb. This also assisted in security efforts, as the two teams could be deployed in a single convoy.
This process continued on Sept. 9, but was to be challenged again on the Sept. 10, when Team Echo was re-allocated to a "new" site. In addition to this challenge, a new transport resource was procured in the form of public transportation buses. The buses augmented the units already in place. The ambulances on hand were used in their "regular" capacity as emergency transport units just 10 times up to this point. However, the clinics had seen more than 380 patients during the same time period. (There was more of a demand for public transportation to get sick or walking wounded to the clinic than there was a need for the transportation of stretcher-bound patients.)
A new challenge
Sept. 10 dawned as a new day to revise our efforts with the hope of new assets arriving to ease the efficiency of our operations. Of course, the assets did not arrive as timely as we would have hoped they would, but because of our operational efficiencies and earlier experiences, our actual deployment went smoother than in previous days.
The command staff was able to enjoy a six-hour break in between their deployment and recall, allowing them to catch up on much needed administrative matters and, more importantly, personal issues. The command staff was extremely dedicated to their mission; however, the non-stop work effort began to wear on their psyche. Therefore, this short relief period was extremely welcome, the recall of the teams was well-coordinated and needs were rapidly addressed, particularly because supplies began to arrive to support the mission.
Transportation resources remained a problem and the timeliness of the buses was continually addressed. The security aspect was also revisited, with a new threat-assessment determining safety was no longer as much a concern as when we first arrived. This then reduced the need for security escorts in many areas and allowed more freedom for the crews to deploy in the morning and return in the evening. It also freed up more assets needed for security at other sites.On the way out of the region, the team captured the experience with a tour through New Orleans.
The other new aspect to consider was the arrival of replacement crews. With operations nearing a week in duration, the original crews and command staff were nearing their physical and emotional limits, especially after organizing and executing a mission in such a short time frame. While rest periods were sufficient for most crews, the execution and continual refinement of the operation took its toll.
Replacement EMS crews arrived on Sunday, Sept.11, and we integrated them into our operation on the Sept. 12 so that the transition would be seamless. This integration process is an extremely important area to consider in an operation of this nature since there is no "manual" available to guide new personnel.
Our focus was on the proper logistical deployment of assets, support for the command staff and personnel interaction. As the integration day progressed, it was obvious that most of our operational plan was grasped by the new EMS leadership and that the operation would continue. However, there was concern that some of the operational crews did not fully understand much less like their roles. This is a critical aspect that must be considered; one must ensure that personnel assigned to work in an area fully understand their mission. Additionally, each responder deployed to the area must understand that each role is as important as the other, even if not as glorious. Of course, no one can anticipate the changes that will occur in the system, but preparation must include defined duties if the roles are already established.A picture of the devastation as seen by the team as it departed the New Orleans area.
The return home
On Tuesday, Sept.13, we completed the transition over to the replacement EMS staff, and most of our original EMS assets departed the area. Our return trip was planned by our EMS staff. A critical point that should not be overlooked is the continual maintenance of equipment and vehicles necessary even during such a deployment. Logistical concerns, such as tire replacement, engine maintenance for vital fluids and functioning electrical systems, must be addressed so that units may return to normal operational status. In our case, one unit developed an oil leak that required constant maintenance on the trip back to its service area.
Personnel and vehicle accountability was maintained throughout the trip with all units having communications with each other via radio or cell phones. All units were recovered successfully, with the proper debriefings completed.
This unique deployment by MIEMSS in repose to the Jefferson Parish EMAC request proved to be a test for the EMS aspect of disaster response. The innovative approach to the integration of EMS and hospital resources proved to be a great challenge, especially with little known about the specific mission. Especially, in a disaster area, crews and missions must be self-sufficient for an extended period of time and any resources found at the site should be considered a windfall, and not relied upon. The response demonstrated by this effort in the aftermath of Hurricane Katrina showed a concerted effort by all agencies involved-agencies that overcame significant logistical challenges to successfully execute a critical mission during the recovery.
Todd Dousa is chief of EMS for the Whiteford Volunteer Fire Co. and has been an EMS provider in Harford County, MD for over 15 years. His full-time job (since 1997) involves disaster response planning, training and exercises, with expertise on CBRNE events. E-mail (firstname.lastname@example.org).
Greg Dietrich is a paramedic with the Abingdon Fire Company, also in Harford County, and has been active in EMS for more than seven years. He is a full-time biologist with the U.S. government.