Capitol Planning

Preplanning for a presidential MCI

• Lt. James Mills, EMT-P, RN, CEN, Lloyd Parker, BS, EMT-P
• 2009 Sept 3

The Jan. 20 presidential inauguration of Barack Obama drew an estimated 1.8 million attendees, many of whom were lined up as early as 4 a.m. in freezing temperatures to watch the event. Federal, state and local officials pooled resources to prepare for this event, which was one of the largest presidential inaugurations in U.S. history, and ensure they met the medical needs of citizens and visitors. They also created contingency plans for a worst-case scenario.

Federal Resources
A state of emergency was declared for the inauguration to ensure emergency managers and planners had all the resources they needed, including city services that aren't typically available and controlling communication and public utilities to the area. It also made available about 100 ambulances through a FEMA contract, which augmented some 80 Washington D.C. Fire & EMS (DCFEMS) units.

DCFEMS also created a temporary communication center, which coordinated responses to area 9-1-1 calls and to the 40 aid stations surrounding the National Mall.

Federal resources assigned to the incident included U.S. Department of Defense (DOD) medical teams, U.S. Department of Health and Human Services (HHS) National Disaster Medical System aviation resources and teams, and U.S. Public Health Service (USPHS) commissioned corps officers. Local jurisdictions involved in the response included the DCFEMS, which was the primary transporting agency.

Command and control in the field was orchestrated by an HHS assistant secretary for preparedness and response (ASPR) incident response coordination team. This included more than 350 medical personnel from HHS who supported the inauguration Jan. 20, the largest number of HHS personnel to deploy for an inauguration in recent history.

HHS staff worked with medical personnel from the D.C. Department of Health, the National Park Service, the DOD and volunteer medical professionals from the D.C. Medical Reserve Corps. The teams helped staff about 50 federal medical stations and 16 first aid stations along the parade route, on the National Mall and in the Capitol area.

Divide & Conquer
To better plan for and coordinate care of attendees and residents, officials divided the event into three geographic areas and jurisdictions. These areas included:

1. The National Mall from the Lincoln Memorial to the Washington Monument, including the reflecting pool;
2. The U.S. Capitol building and grounds; and
3. Streets, businesses and transits systems of Washington, D.C., which were used by residents and visitors alike.       

Managing the medical care for the attendees on the Capitol grounds and the National Mall was the responsibility of the Office of the Attending Physician (OAP). This office coordinated federal health-care providers, including doctors, nurses and EMS personnel.

To prevent vehicle and pedestrian injuries, traffic in much of the downtown area was restricted. In addition, 1,000 soldiers from the National Guard provided crowd and traffic control. Despite traffic-control efforts, pedestrians made it difficult for emergency responders to respond to calls. Fire stations situated along planned evacuation routes treated injuries and assisted lost or stranded attendees. These stations were given additional medical supplies to manage the surge of expected patients.

Baseline (Level 1) Operations
First aid stations were not allowed to hold patients for longer than one hour. After triage at a first aid station, patients could either be released or transported to another care facility.

If a patient required emergency department (ED) treatment, or if they had a condition that could deteriorate, DCFEMS transported them to a hospital ED. Patients who required low-acuity care or monitoring were transported to a federal medical station (FMS).

To reduce cold-related emergencies, public-access warming stations were located throughout the National Mall.

Care on the Capitol Grounds
Responders comprised a two-tiered response system that either moved patients to treatment stations or evacuated them to a hospital. Two USPHS health-care providers made up the BLS roving teams. Each BLS team, which did an initial assessment and requested ALS from a Medical Response Team (MRT) if needed, was assigned to a specific patrol area. The USPHS consists of medical and support personnel that provide public-health services and disease prevention at the direction of the Office of the Surgeon General.

During the inauguration, the USPHS officers who worked in pairs served as an initial point of contact for patients. They were placed in highly visible positions and had to contend with a wide variety of customer service and security issues in addition to providing BLS care. After doing their initial assessments and providing BLS care, they transported patients to on-site treatment trailers with wheelchairs and stretchers.

The Capitol grounds were divided into three general population sectors by seating arrangements and were identified with grounds landmarks, which allowed for quick response by the BLS crew. Three general populations of spectators were super VIPs, VIPs and the general public. Super VIPs were foreign dignitaries and heads of state. VIPs were political leaders, presidential supporters and celebrities. These two groups required special handling and security considerations by the medical responders.

Once an MRT was requested, the BLS crews raised a red flag alerting the ALS crew members of their position in the crowd. Each MRT was accompanied by a U.S. Capitol police officer and a representative from the OAP. The Capitol police officer provided security for the MRT while the OAP representative served as a liaison to address any potentially sensitive political situations and as a Capitol grounds expert. The patients could then be removed from the field by either wheelchair or stretcher.

Once the MRT assessed a patient, they made the decision to either transport the patient by ambulance to a local ED or take them to an on-site treatment trailer. The treatment trailers varied depending on the acuity level of the patients.

Inside the Trailers
The Capitol grounds included two treatment trailers that reduced ED transports by providing ALS care, minor trauma care and full resuscitation efforts. Some of the minor care trailers not only treated minor injuries but also acted as warming stations from the cold. Other treatment trailers that provided a much higher level of care were capable of advanced airway skills, mechanical ventilators and fibrinolytics. All trailers were manned by ED physicians, nurses and paramedics and had separate treatment areas for adult and pediatric patients.

The MRTs and treatment trailers were the responsibility of disaster medical assistance teams (DMATs) that included doctors, nurses, paramedics and other logistical and health-care personnel.

Rapid Response Resources
Several resources were pre-positioned adjacent to the inauguration in the event of a mass casualty incident (MCI).

DMAT personnel with equipment caches, known as Rapid Response Teams (RRT), were pre-positioned in close proximity to the event. They had the ability to rapidly deploy a mobile field hospital and manage a wide variety of medical emergencies. The RRT formed rapid intervention teams (RITs) to augment the existing conventional response capabilities without affecting their ability to respond to an MCI. Small units of three to four personnel with EMS or ED experience, the RITs would respond similarly to an MRT if a medical emergency happened near their staging area.

Mass Casualty and/or Surge Response (Level 2) Operations
If an incident involving mass casualties had occurred or DCFEMS officials determined that ED surge capacity had been exceeded, a Level 2 response would have been initiated. At such a time, patients triaged as "yellow" would be transported to the FMS for stabilization and held until transport to definitive care or discharge could be arranged. This would have required 24-hour operations of the FMS until definitive care and/or ED capacity became available.

Patients who were triaged as "red" or had immediate critical care needs would have been transferred to EDs. If stabilization/holding or patient evacuation had been required, they would have been taken to pre-determined HHS casualty collection points. Patients who had been evaluated and treated at the FMS and who subsequently became critical would have been transferred to local EDs or the casualty collection points.

DCFEMS supplied ambulances that were pre-positioned throughout the event area and rotated them to provide constant coverage. These local EMS operations were augmented by a 100-ambulance strike team contracted by FEMA specifically for the inauguration.

Hospital Surge Teams
In the event that the hospital became overloaded, a hospital surge team (HST) of DMAT personnel could have managed 200 overflow patients in mobile field hospitals. This federal team was integrated into the hospitals' existing incident management system.

The HST, which was capable of managing major resuscitation efforts, was designed to enhance the hospitals' ability to manage a large number of patients but not to replace it. An incident commander (IC) from the hospital would assign a triage officer to determine which patients would be transported to the hospital and which would be transported to the HST overflow facility. The HST would primarily treat minor injuries.

Once the HST evaluated a patient, it had the ability to treat and release, upgrade patient acuity, or provide transportation to other medical facilities. If the patient required additional resources or long-term care, the patient could be transferred to the hosting medical facility for treatment. Finally, several pre-planned transportation resources and receiving hospitals were identified in the region to allow for a mass evacuation of critical patients.

Outcome Statistics
DCFEMS reported receiving a record 2,100 9-1-1 calls and transporting 211 people to area EDs during the event. More than 750 patients – including ones on the Capitol grounds -- received care from HHS personnel. Sixty-three of them required medical transport.

The greatest number of medical emergencies by far were cold injuries and dehydration related to weather. Those who were predisposed to cold stress were mostly pediatric and elderly patients, as well as those with chronic medical conditions. Traumatic injuries were isolated to strains and sprains, although at least one trampling injury was reported. Most patients were assessed and treated on site before being released, which minimized overcrowding at area hospitals.

Conclusion
Leading up to the inauguration, medical teams provided coverage for several mass gatherings. These included the swearing-in ceremony, the inaugural parade, the national prayer service and a concert in honor of Dr. Martin Luther King Jr. The management of these incidents consisted of several layers of responders and precautionary measures. Personnel also attended a series of training sessions on security, emergency procedures, and medical response to bioterrorism and weapons of mass destruction. This training, practice and planning was crucial to the success of the event to balance the need for medical assistance with security needs.

Lt. James Mills, EMT-P, RN, CEN, is a 15-year veteran of fire, EMS and emergency nursing. He's the Florida-6 DMAT and Holmes Regional Medical Center Emergency Department. He can be reached at jmills13858@aol.com.

Lloyd Parker, BS, EMT-P, is team commander of Florida-6 DMAT in the National Disaster Medical System (NDMS). He serves as an assistant chief with Lake-Sumter (Fla.) EMS. He can be reached at Lloyd.Parker@HHS.gov.

The author would like to thank Elleen Kane, HHS ASPR APR Public Affairs Specialist, for her assistance with the article, members of Florida-6 DMAT for photographs, and all the professionals who assisted with the event.

Resources

1. Fleitz R: "DC Fire & EMS Says It's Ready For Inauguration." VAFireNews.com:  http://www.vafirenews.com/2009/01/dc-fire-ems-says-its-ready-for-inauguration/. Jan. 15, 2009.
2. Kane E: E-mail regarding official information regarding the presidential inauguration. March 16, 2009.
3. Kovac AL: "D.C. Fire, EMS Receive Record Calls." Voices.WashingtonPost.com.  http://voices.washingtonpost.com/inauguration-watch/2009/01/dc_fire_has_received_143_calls.html. Jan. 20, 2009.