EMS command center in Houston, Texas. Photos courtesy American Medical Response
The year 2017 will undoubtedly go down as having one of the worst hurricane seasons to affect the United States. In the months from August through December, American Medical Response (AMR), along with other EMS agencies, responded to the call for help for back-to-back Hurricanes Harvey, Irma and Maria.
AMR was activated for Hurricane Harvey on August 25, and was eventually demobilized from Hurricane Maria on Dec. 31, 2017. These federal EMS deployments yielded 128 consecutive days of providing medical resources across the three major hurricanes. This is the longest consecutive EMS disaster deployment in U.S. history.
AMR is the prime contractor with FEMA to provide ground ambulance, air ambulance, paratransit services and non-ambulance EMS personnel to supplement the federal and military response to a disaster.
Federal initiatives launched in the aftermath of Hurricane Katrina in 2005 led, in part, to development of a National Medical Transport and Support Services Contract through FEMA. AMR was awarded the contract and assembled an internal Office of Emergency Management (OEM) to operationalize the contract, along with a large network of ambulance providers who partner with AMR to carry out successful deployments.
Preparedness Pays Off
The unpredicted and sudden intensification of Hurricane Harvey just two days before landfall marked the beginning of one of the most active years for FEMA deployment, both in geographic scope and duration. AMR was deployed by FEMA on August 25 to support the state of Texas. The response included 200 ground ambulances, 115 operations support and incident management team members, 12 communications specialists, 25 helicopter air ambulances and 29 fixed wing air ambulances. In anticipation of this disaster deployment, AMR stood up its National Command Center (NATCOM) in Dallas, and deployed a forward operating base (FOB) incident management team (IMT) to San Antonio.
AMR’s OEM works year-round to develop and maintain a strong network of partners, does ongoing accounting of the number and location of available resources, maintains a registry and pre-alert system, and has a process to activate resources when a FEMA deployment order is received.
AMR’s online Rapid Electronic Deployment System allows all registered operations, both AMR and network partners, to update their list of available personnel and response resources, and issues a notice to proceed when activated. Every resource is assigned a unique numbered placard used only for federal EMS responders. These placards are displayed on the front and rear windows of each vehicle.
AMR OEM also maintains credentials for all responders as well as the incident command system (ICS) and related forms to push forward when needed. NATCOM’s role includes deploying and tracking inbound resources to the FOB, liaising with federal agencies, sending logistics packages to the FOB, aggregating documentation, and providing leadership and support.
The FOB IMT checks in arriving resources, assembles them into strike teams of five ambulances with a strike team leader, deploys logistics and stages the resources. All of this occurs within 24 hours of the task order receipt.
The FOB IMT’s first order of business is to contact state and local leadership and set up a staging base. This process typically takes 24—48 hours, and is replicated each time the deployment moves and a new base is required.
During this deployment, AMR moved six times and set up seven staging bases, adding a layer of complexity not experienced in prior deployments.
To avoid any concerns about depleting local or state EMS resources when responding to federal disasters, AMR refrains from using EMS resources from areas that have been declared major disasters. AMR will also not utilize resources that are part of an emergency management assistance compact (EMAC) agreement and will not jeopardize the standard of care in the local communities by diverting resources to federal disasters or events.
The EMS needs of local communities are primary–participating in the AMR disaster response network is subject to availability and must not conflict with other local obligations. AMR and its subcontracted network providers are robust enough to respond to federal disasters without compromising local EMS.
All EMS providers responding to the AMR/FEMA federal EMS contract are licensed or certified in their state of origin. Nationally recognized curricula and scope of practice guidelines are used to establish minimum competency for state licensure and practice. The states generally grant reciprocity to EMS providers responding to the contract.
The state disaster declaration typically includes a reciprocity component, so EMS personnel responding from numerous states can continue working using approved protocols and medical direction during the disaster deployment.
Many of the ground and air resources were assigned to Texas immediately upon check-in and deployed forward to conduct patient evacuations–the first step during federal deployment for an event with advance notice, such as a hurricane.
Driving on flooded roads from Houston to Port Arthur.
Unpredictable Hurricane
Harvey defied predictions to remain a tropical storm and made landfall on August 26 as a Category 2 hurricane north of Corpus Christi. From there, it again ignored projections to move inland and dissipate, instead hovering inland for two days before returning into the Gulf of Mexico, where it would make several more landfalls as it moved northeast along the Texas coast.
Between landfalls, it tended to hover and drop torrential rains, with the greater Houston area receiving more than 50 inches of rain in five days. Devastating flooding wreaked havoc on many communities as the storm progressed through Houston, Beaumont and into Louisiana, causing death and destruction and isolating populated areas so that they essentially became islands surrounded by floodwaters.
On August 31, with most rescue and recovery activity occurring in the Houston and Beaumont areas, but with some remaining need around San Antonio, the FOB IMT was split and a second base was set up on the grounds of NRG Stadium in Houston, joining the state EMS IMT to coordinate federal resources along with state EMAC assets deployed there.
The vast flooding along hundreds of miles posed significant challenges to rescuers. AMR and partner crews were assigned missions to large and small communities to evacuate people who were ill, injured or isolated without the basic resources to survive. EMS crews were taken into these areas by boat, aircraft and, in many cases, navigated through flooded roads to reach patients.
As the hurricane progressed northeast, bases were established at Ford Field and Jack Brooks Regional Airport, joining an army of state and federal resources all working together to help Texans in need.
Ground and air ambulances transported patients to the airport, where they were flown out on fixed-wing aircraft. In many cases, ambulance crews that had reached small communities cut off by floodwaters became their primary source of EMS and these crews worked with local, largely volunteer services to care for their communities.
Supporting Responders
At this point, deployments and IMTs were spread over nearly 300 miles from San Antonio to Houston to Beaumont. With the majority of resources deployed in Texas, the FOB IMT began working with leaders to ensure that the crews were supported. In some cases, the forward local areas were devastated and didn’t have the capacity to support our crews.
In those instances, the FOB IMT pushed out supplies and support, or rotated strike teams back the staging base for rest and rehab. The crews also held twice daily briefings with strike team leaders following each 12-hour operational period.
Local, state and federal resources relied on each other to maximize rescue and support over this long area of devastation, and did so effectively with the common recognition that all were there to help the same people. EMS is often referred to as a “community,” and disaster circumstances bring home what that really means. There’s no “us vs. them” in this environment. Rather, there are people who come together from across the country with a singular focus: to help others without regard to turf, role or responsibility.
By Sept. 4, the immediate rescue and recovery efforts were wrapping up in San Antonio and beginning to wind down in Houston and Beaumont. The last federal EMS assets deployed for Hurricane Harvey were demobilized on Sept. 8, making this a 15- day deployment.
Even before resources were completely demobilized from Harvey, additional EMS resources were deployed for Irma, which was approaching Florida with an uncertain, but powerful path.
FEMA staging in San Antonio, Texas.
Hurricane Irma Strengthens
As focus moved to Hurricane Irma, FEMA issued forward-leaning deployment orders on Sept. 6 to stage federal EMS resources in Florida, the U.S. Virgin Islands and Puerto Rico. This was a first on several levels for FEMA and AMR:
>>It was the first time the federal EMS contract was activated for Florida;
>>The first time fixed-site (non-ambulance) EMTs and paramedics were deployed to staff medical shelters;
>>The first time FEMA-contracted EMS resources were deployed jointly and in coordination with the Department of Defense U.S. Transportation Command (USTRANSCOM) at Scott Air Force Base; and
>>The first time federal EMS resources were deployed beyond the continental U.S. to a U.S. territory. (AMR’s contract with FEMA requires response to the 48 contiguous states. Response to a U.S. territory is “best effort.” This wouldn’t be the last time that AMR was called upon to make this extraordinary effort.)
These decisions would prove to be very intelligent foresight by FEMA leadership. All federal EMS assets deployed for Hurricane Irma were finally demobilized on Sept. 25, making it a 19-day deployment.
On Sept. 12, when the scope of need was better understood, air and ground ambulances were partially demobilized.
On Sept. 14, remaining resources were relocated to the fire training and support center in Boca Raton, Florida. It was the sixth base throughout the deployment, and under the leadership of Chief Tom Wood and Assistant Chief Mike LaSalle, the Boca Raton Fire Department was welcoming and accommodating with open arms.
Maria Makes Landfall
FEMA deployed AMR assets to support victims of Hurricane Maria on Sept. 20.
Most of the dialysis facilities on the U.S. Virgin Islands and Puerto Rico were inoperable following Hurricanes Irma and Maria. This resulted in dialysis patients being relocated to Miami and Atlanta. To transport patients to and from dialysis centers, AMR sent six ground ambulances and 32 paratransit vehicles to Miami and 23 paratransit vehicles to Atlanta.
By Sept. 20, in Florida, 30 ambulances had been deployed to Lee County, 25 to Collier County, 20 to Monroe County and 35 at the staging area in Boca Raton. Primary missions were 9-1-1 and hospital support until regular providers could return and resume full activity. In each location, AMR was embedded with local EMS to provide relief for their personnel and augment capacity to respond to increased call volume.
On Sept. 22, following additional partial demobilizations, personnel and resources were moved to a seventh staging base in Miami to support two strike teams remaining in Key West and paratransit resources supporting the dialysis patients in Miami.
Finally, on Sept. 24, the remaining IMT was demobilized, leaving a paratransit IMT in south Florida for a few more days.
Ongoing air support was focused in Puerto Rico and the U.S. Virgin Islands, which had increased to 11 critical care fixed-wing aircraft and six fixed-site paramedics to support shelters. Operations support teams, communications support teams and neonatal clinical specialists were also provided.
Critical care air ambulances remained in U.S. Virgin Islands and Puerto Rico until Dec. 31, when they were demobilized.
FEMA shelter at Florida A&M University.
Air Medical Transportation
Air medical transportation was a major component for all the 2017 hurricane deployments. A combined total of 98 private air ambulances were used.
Most of the 68 hospitals in the U.S. Virgin Islands and Puerto Rico were significantly damaged. AMR/FEMA-contracted fixed wing air ambulances were used to transport patients daily from the islands back to the U.S. mainland. While in the islands, private fixed-wing aircraft provided most of the individual critical care and neonatal transports, while the larger aircraft provided en masse transportation, especially for dialysis patients.
The clinical skills of the air crews in critical care and neonatal care is unsurpassed. In addition to providing clinical expertise, AMR’s air transportation partners also provided IMT for the Air Medical Branch at FOB and NATCOM.
They also provided air medical liaison officers to the USTRANSCOM at Scott Air Force Base. Although AMR contributed to this effort, special recognition goes to Air Medical Group Holdings (AMGH), who coordinated and managed most of the air operations.
USTRANSCOM is the single manager of the country’s global defense transportation system. USTRANSCOM is tasked with the coordination of people and transportation assets to allow the country to project and sustain forces, whenever, wherever, and for as long as they are needed.
For the first time in history, FEMA assigned AMR liaison officers to USTRANSCOM. Together they worked tirelessly to manage the air medical evacuations for these disasters.
Teamwork & Commitment
Checking in resources, mission deployment, logistics management, crew support, tracking mission types and patient contacts, federal/state/local interface and demobilization–are all normal parts of a deployment.
What made this year particularly challenging was moving six times and setting up seven bases over a path covering nearly 1,400 miles, from San Antonio to Miami. Each base set-up is normally an all-hands process that includes 24—48 sleepless hours.
But, with talented and motivated people working together, nearly anything can be accomplished.
Many crews and IMT members have deployed multiple times, and thus a deployment is a reunion of sorts. They’re all problem solvers. It doesn’t matter which agency they work for–on a deployment, everyone is logo-blind and part of the same team, committed to helping people devastated by a disaster.
Everyone who deployed did so voluntarily to join local responders–many of whom were victims themselves–to help others in need. They deployed knowing conditions would be austere, often sleeping in their ambulances, eating ready-to-eat rations and foregoing showers and other normal daily amenities for extended periods.
Acknowledgment: AMR wishes to acknowledge the federal partners who worked side-by-side with us during the 2017 disasters. They include the U.S. Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA), U.S. Department of Health and Human Services (HHS), Assistant Secretary for Preparedness and Response, U.S. Department of Defense (DoD), Scott Air Force Base and the Department of Defense U.S. Transportation Command (USTRANSCOM).
