Columns, Major Incidents

Why Ambulance Strike Teams Will Improve Homeland Security Response

EMS is a primary responder, along with law enforcement and fire, in everyday emergencies and in manmade and natural disasters. Yet, EMS has never fully participated in homeland security issues nor has it been fully recognized as a primary partner in that effort. This lack of engagement has led to poor planning, underutilized resources, a lack of gap analysis and lack of funding for EMS and direct patient care issues related to disaster response. It is time for EMS to come to the table and be treated as equals in this important endeavor, since the lives of patients depends on how local and regional EMS responds in a homeland security incident.

Coordination at local and regional levels is essential for an appropriate response, however state and federal coordination and resources are also required to meet the needs of the public and those affected when the scope of a disaster overwhelms local and regional EMS capabilities. State and federal cooperative efforts can help local and regional EMS structure their response plans and efficiently augment current agency resources with other available resources throughout the state and outside state lines. This coordination will help local agencies meet their response goals and provide better outcomes to residents and visitors affected by disasters and emergency situations. One of the most important issues that must be addressed by EMS is how to respond to natural and manmade disasters when their local and regional systems are overwhelmed. A national Ambulance Strike Team model is needed to meet shifting needs in a potentially unstable environment.

Since 9/11

With the creation of the Department of Homeland Security (DHS) and the placement of the Federal Emergency Management Agency (FEMA) under DHS, a new and important direction was put in place to coordinate efforts to diffuse, defeat, mitigate and respond to both manmade and natural disasters. This effort has largely been successful for law enforcement. Federal coordination and funding has helped local and regional law enforcement agencies get prepared for and execute planning, cooperation, purchases and personnel toward achieving a single goal of successful national defense, response and management of manmade and natural disasters. Unfortunately other disciplines, such as EMS, have not benefited to the extent of law enforcement and have not been recognized as an essential component of this disaster team in some areas.

With billions in funding already spent on homeland security issues, less than 4% of the total funding has been used to improve EMS preparedness or response to homeland security incidents or events. Some estimate the funding to EMS has been less than 2%. With such limited funding, it is hard to expect EMS personnel to achieve the training, understanding, protocols or equipment to adequately do the job when called upon. Currently, the status of education about homeland security issues, response training and equipment available to respond to disasters varies greatly by state, region and local jurisdictions. There is no standard to measure adequate EMS response, no requirement that EMS agencies be included in planning efforts and no national coordinated plan to use the resources that currently exist in each local EMS jurisdiction. There currently is no national plan in place for a coordinated region-by-region or state-by-state response to disasters that can be initiated within hours.

What is a Homeland Security Incident?

There are many definitions of what a homeland security incident or event is. Without trying to define it too closely, the widely accepted scope is any incident or event, whether manmade (such as terrorism) or a naturally occurring disaster (such as a hurricane), that has the potential to cause death, bodily harm or damage to property, and threatens the infrastructure of the nation. Disasters of course do not care about definitions, so for the purposes of EMS, the definition of an incident or event should be, in most cases, an emergency that overwhelms the resources of a local EMS agency or regional set of EMS agencies so it cannot recover by itself within several hours. If patient care is negatively affected by the demand of an incident or event, and it becomes a problem greater than can be handled by local and regional resources, then it could be a homeland security incident or event, and state and federal coordination could help in these instances.

The Strike Team Model

The ambulance strike team (AST) model has existed for a few years in different locations around the nation, including California and Florida. It is a proven model that has allowed these states and regions to scale up and down resources with good results in a wide range of disaster situations. The model fits well within existing incident command structures and has the ability to be flexible enough to meet targeted, specific needs.

On its most basic level, an AST consists of five ambulances that have at least two personnel on each ambulance and a separate leader in a separate vehicle that has been trained in strike team operations. The main idea behind the AST has been around since EMS was established—it is neighbor helping neighbor, or what many call mutual aid. When a region or state is hit by a disaster, ASTs are put together from areas that are not affected directly by the incident or event. Each local EMS agency can contribute vehicles, personnel and equipment at a level they can afford. Larger EMS agencies may offer several ASTs, while a small rural agency may only be able to provide one ambulance with a crew. All of these resources are combined to create the right amount of ambulance and personnel response to mitigate the disaster situation until the local agency can handle the load once again.

For example, in Florida, all licensed EMS agencies—both ground and air, large and small—are partners in the state’s ambulance deployment plan. The model is scalable so that as a disaster expands or contracts, resources are added or relieved of duties as needed. In the event of a large disaster, the model shifts from a simple AST to a medical task force (MTF).

The MFT includes multiple ASTs in addition to a wide variety of support resources that may include vehicle maintenance, food services, medical supply, air components and much more. The idea behind this model of disaster response is to have a coordinated approach based on need and reduce the incidence of “self-dispatching” of EMS resources that can become a hindrance at an emergency incident or event.

The ambulance deployment plan works for Florida due to the EMS constituency’s active participation in development and support of the plan. It is important for local and state agencies to have input into the plan so they understand their role in statewide and national disasters, and also know what resources are available to them if they are directly affected by a terrorist incident or natural disaster. According to Michael Frenn, AST program manager for the California Emergency Medical Services Authority (EMSA), “The strength of the ambulance strike team model derives largely from it being based on the incident command system (ICS). It provides a typed resource of specific capability that is organized, has leadership, and a span of control of assets.”

Nationwide coordination of a network of local, regional and state EMS assets to combine into one sliding scale AST that could shift one way or another based on circumstances and need, still needs to occur. The logical agency for the suggested model development, creation of training objectives and help in coordination would be FEMA. FEMA could establish a set of suggested operational protocols, specific model outlines, interstate agreements and training classes to help states begin to adopt this model of disaster operations for EMS and help them determine best practices in disaster mitigation.

With a strong network of ASTs in each state, combined with adequate existing agreements in place before disaster strikes, there is great potential to have a smooth and concerted response within hours of any disaster nationwide, even across state lines. This model should include all different types of EMS assets such as fire, private, hospital and third-party service assets, as well as credentialing of EMS personnel from those services. With a clear understanding of what assets are available to respond and pre-existing agreements to know what to expect, all local and regional services would understand expectations if a threat becomes a reality. In addition, a gap analysis could be performed by each state and region to determine areas for improvement if specific services do not exist within a particular region. This analysis could lead to potential identification of specific funding to meet the needs of those EMS agencies in regions with deficits. Finally, with a network in place, uniform metrics could be applied to each state and region to begin measurement of response capabilities and to highlight areas of improvement and need.

Florida’s plan was first tested in 2007 during the Bugaboo Scrub Fire in Columbia County. State Emergency Support Function 8 Public Health and Medical (ESF-8) was able to assemble 30 ambulances to the area of operation within four hours. The model has been tested and proven and, given the opportunity, could be put in place as a national network of functioning teams to be called upon in a moment’s notice.

Response

With this AST model of response, many other issues in addition to patient care must be taken into account. Pre-planning is the real strength of success, so all entities involved must clearly understand what steps need to be taken and what resources are required to sustain a team for the term of the deployment. Depending on the type of disaster that has occurred, normal availability of food and water can be disrupted in the area affected. Teams may need to bring their own supplies and determine what shelter and supply is available in the affected region for them. Also, the normal flow of patient care can be negatively impacted. Responding ASTs need to know what medical facilities are open and what their capabilities are. In some instances, air assets may need to be deployed to move specific patients to facilities that can handle their injuries or illnesses. At its very core, the coordinating state or region would be responsible for making incoming teams aware of what equipment, supplies and expertise are needed in the disaster area. Each AST or MTF should be self-sustaining in most any situation and not become part of the burden of recovery efforts.

As with any response, communication is a key component. Pre-planning is essential to determine how all of the different agencies represented in an AST or MTF can communicate across all of the differing radio and information platforms. Predetermined channels and processes must be in place, taking into account the possibility of disabled systems that may exist in the disaster zone. Varying layers of planning must be in place, which may include non-traditional use of both technical and basic forms of communication, such as the internet, cellphones, satellite phones and such, yet also something as simple as runners who deliver messages as needed.

Training of course is a major part of being prepared for disasters, and AST training is essential to meeting the goals of appropriate response. Strike team leaders need to be prepared not only to respond but to coordinate efforts within their team and coordinating team efforts with other agencies and other ASTs. Frenn, with California EMSA, said, “In California we require ambulance strike team leader trainees to complete a position task book (PTB) as part of their training. The PTB is similar to documenting calls and skills demonstrated during a paramedic internship. It can be really difficult for the trainees to get the opportunities to do this. We strongly encourage local jurisdictions to include ASTs as part of functional exercises to provide these training opportunities.” In short, we should practice like we actually respond, so including this type of training in exercises would lead to improvements in overall response.

Additional Strike Team Model Assets

The strike team model can also be used by EMS and different disciplines in other venues and can allow EMS personnel and agencies to add value to other types of strike teams. EMS will need to think outside of the normal operational parameters that have been established.

EMS personnel could be valuable additions to law enforcement strike teams, search and rescue teams, damage assessment teams and other teams that respond during and after disaster situations. The addition of EMS personnel who are used to working in the field can strengthen other types of response teams by allowing instant availability of medical services if patients from the disaster are discovered. Also, these EMS team members can provide medical monitoring of team members and be the medical liaison for a wide variety of medical problems that may arise among team members. This peace of mind for team members can be important when working in areas where conventional medical services have been disrupted and even basic 9-1-1 services are not fully functional.

EMS agencies should look at local disaster response teams and evaluate if there are opportunities for EMS personnel to become team members and provide expertise where needed. EMS personnel may find expanded roles to play before, during and after disaster incidents or events. As EMS finds useful roles to play in these emergencies, we should expect greater responsibility, identify the potential for increased funding and become a fully recognized player in all aspects of disaster operations.

One other potential area of AST response could be if an area has been negatively affected by a pandemic (i.e., H1N1 influenza, Ebola, etc.) to assist in providing service when EMS systems personnel need additional resources to respond in their jurisdiction.

Conclusion

A better way to respond to disasters of all types is essential in today’s world of limited resources and just-in-time delivery of services. A solid AST model on a national basis can provide much-needed services after a disaster hits and can fill in the gaps of most any local or regional EMS system. Putting local and regional teams together into statewide systems that are overlaid with state-to-state plans for response simply makes sense, so the closest resources available are the ones responding to the disaster need. A national network of EMS systems can only strengthen our local response and national approach to terrorism and natural disasters.

Resources

  • California Emergency Medical Service Authority. (n.d.) Ambulance strike team /medical task forces (AST/MTF) guidelines. Retrieved June 13, 2016, from http://www.emsa.ca.gov/Ambulance_Strike_Team.
  • Alexander Y, Prior S: Terrorism and Medical Responses: U.S. Lessons and Policy Implications. Ardsley: New York, 2001.
  • Barbers J, MacIntyre A, DeAtley C: Ambulance to Nowhere: America’s Critical Shortfall in Medical Preparedness for Catastrophic Terrorism. George Washington University John F. Kennedy School of Government: Washington, D.C., 2001.
  • Berne R: Emergency Medical Services: The Forgotten First Responder. New York University, Center for Catastrophe Preparedness and Response: New York, 2005.
  • Bratton W, Tumin Z: Collaborate Or Perish!: Reaching Across Boundaries in a Networked World. Crown Business: New York, 2012.
  • Campbell J, Smith J: Homeland Security and Emergency Medical Response. McGraw Hill Higher Education: Boston, 2008.
  • U.S. Government Accountability Office. (Oct. 2011) National Preparedness: Improvements Needed for Acquiring Medical Countermeasures to Threats from Terrorism and Other Sources. Retrieved June 13, 2016, from http://www.gao.gov/assets/520/511470.pdf.
  • Donnelly J. Effect of Assessment Processes on Measuring Homeland Security Capability [course study]. Naval Postgraduate School, 2007.
  • Elliott R. Measuring Disaster Preparations of Local Emergency Medical Services Agencies [course study]. Naval Postgraduate School, 2010.
  • Furbee P, Cohen J, Smyth S, et al. Realities of rural emergency medical services disaster preparedness. Prehospital and Disaster Medicine. 2006;21(2):64–70.
  • Hauenstein L, Gao T, White D. A Cross-Functional Service Oriented Architecture to Support Real-Time Information Exchange During Mass Casualty Events [conference session]. IEEE EMBS, 2016.
  • Mears G, Armstrong B, Fernandez A, et. al. (Dec. 2012) 2011 National EMS Assessment. EMS.gov. Retrieved June 13, 2016, from http://www.ems.gov/pdf/2011/National_EMS_Assessment_Final_Draft_12202011.pdf.
  • Mims L. Improving EMS in the United States through Improved and Centralized Federal Coordination [course study]. Naval Postgraduate School, 2011.
  • Moore L. Measuring quality and effectiveness of prehospital EMS. Prehospital Emergency Care.  1999;3(4):325–331.
  • Ostrow L. The controversy over EMS, homeland security and the feds. Best Practices in Emergency Services. 2005;8(6):61–63.
  • Smiley D, Loboda A, Starling C, et. al. Transformation from planning to operations: emergency medical services in disaster response. Annals of Disaster Medicine. 2004;3(1).
  • Tierney K. Emergency medical preparedness and response in disasters: the need for interorganizational coordination. Public Administration Review. 1985;45:77–84.