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Introduction:

Since the events of September 11, 2001 and the further highlighting of the state of our National vulnerability as demonstrated by the issues raised in the response to Hurricane Katrina in 2004, The Federal Government has focused enormous resources in developing a National Response Framework, Establishing National Preparedness Goals and implementing a National Incident Management System. However, in the midst of all of these changes and improvements, the Nation Disaster Medical System has been tossed like a ping pong ball from the Department of Health and Human Services (HHS) to FEMA, and then Subordinated to the Department of Homeland Security when FEMA was integrated into that new organization, and then tossed back to the Department of Health and Human Services as of January 1, 2007. During this time, publically released documents continue to claim the NDMS has the capacity to respond to National Disasters. This article will look into the foundations of the NDMS, its current standing, and its capacity to respond to the California Earthquake scenario developed by FEMA, in conjunction with the State of California, in 1980.

Background:

After viewing the destruction wrought by the eruption of Mt. St. Helens in Washington State in May 1980, President Carter became concerned about the impacts a catastrophic earthquake in California, and the state of readiness to cope with the impacts of such an event. He directed that the National Security Council conduct a review of the state of preparedness of the Nation to meet such an event. FEMA determined that "the Nation is essentially unprepared for the catastrophic earthquake (with a probability greater than 50 percent) that must be expected in California in the next three decades" (Federal Emergency Management Agency, 1980). Casualties projected for this type of event ranged between three thousand and twenty three thousand dead, and between twelve and ninety-one thousand requiring hospitalization (based upon 1980 census data). The ranges were based upon the location of the epicenter and the time of day that the incident struck. The California Office of Statewide Health Planning and Development (OSHPD) recently found that nearly half of hospital floor space that needs retrofitting to meet current codes and comply with a 2013 state seismic safety deadline is in buildings that are considered vulnerable to collapse during a major earthquake (California Health Care Foundation, 2007). Current FEMA Scenario planning estimates that nearly two thirds of the Hospital Beds in Los Angeles, Orange, Riverside, and San Bernardino County will be non-functional (Science Daily, 2008). Based upon this estimate, a service population of approximately ten million, and that the United States presently maintains 3.6 Hospital Bed per 1000 people (Nationmaster, n.d.); this equates to a loss of approximately 24,000 patient beds, which for the most part are occupied with chronic and or acute patients, as well as the infrastructure to support them. These facilities would simultaneously be experiencing a surge of new patients presenting as a result of the injuries sustained from the Earthquake event. Even assuming occupancy rates of only 60% (low for the industry) approximately 14,400 patients would be displaced and require discharge, inter-facility transfer or evacuation outside the impacted area, without regard to the casualties that were generated by the event.

In 1981, President Ronald Reagan established the Emergency Mobilization Preparedness Board to develop a national medical response system (Kramer & Bahme, 1992). The board consisted of representatives from the Federal Emergency Management Agency (FEMA), the Department of Defense (DOD), the Veterans Administration, and the Public Health Service of the Department of Health and Human Services. This Board developed the National Disaster Medical System (NDMS); which was established by Presidential Directive in 1983. Originally conceived as a partnership to respond to the scenario of large numbers returning military personnel who were injured in an overseas conflict to an overwhelmed Continental United States (CONUS) military medical system; the NDMS was never activated to fulfill this original mission (Franco, E., Waldhorn, Inglesby, & O'Toole, 2007).

The mission of the NDMS evolved to create a system whereby civilian hospital beds, in non affected areas, could be used in the event of a disaster within the U.S. and Disaster Medical Assistance Teams (DMATs) who could respond to the impacted areas of a disaster (National Association of DMATS, n.d.). Prior to the NDMS, the assets available to fulfill these type missions were the one thousand-nine hundred and thirty Civil Defense Emergency Hospitals that had been pre-positioned throughout the country by 1964. The Civil Defense Emergency Hospitals, later renamed Packaged Disaster Hospitals, were 200 bed mobile hospitals based on mobile military hospitals that used the same federally procured military equipment. These hospitals were equipped with supplies for 30 days of operations. According to the 1964 DOD Office of Civil Defense Annual Statistical Report; "the Civil Defense Emergency Hospital (CDEH) is an austere but completely functional 200-bed general hospital designed to be set up within an existing structure such as a school, church, or community center. They required 15,000 square feet of floor space which permitted the separation of wards, operating rooms and other functional sections. The staffing requirement was for 316 personnel, including 10 physicians, 4 administrators and assistants, 34 professional nurses, 18 practical nurses, 6 anesthetists, 2 pharmacists, 128 medical aides and 124 other personnel, including dentists, laboratory technicians, X-Ray technicians, maintenance engineers, clerks, helpers, messengers, and housekeepers to be drawn from local resources" (Civil Defense Museum, n.d.). A little more than one half (25%) of the Civil Defense Emergency Hospitals pre-positioned in 1964 could conceivably have provided a total of 100,000 patient beds, with a staffing requirement of about 150,000 personnel. This number of beds exceeds the worst case scenario of developed by FEMA in 1980.

The NDMS System:

Presently the National Disaster Medical System has fifty-five Disaster Medical Assistance Teams. A Type I DMAT team is able to muster a 35 person roster in 4 hours, has 105 or more deployable personnel assigned including 12 physicians, has a Full Federal DMAT Cache of Equipment and Supplies, and is able to triage and treat 250 mixed category patients per day for three days. The DMAT is not and does not operate a field type hospital, but with augmentation from the national strategic stockpile and with additional personnel being recruited (local survivors with the needed skill sets), they can provide the Triage and Emergency room functions of a field type hospital with the patient holding capacity being provided by a co-located Federal Medical Station. The Federal Medical Station requires a team of 100 personnel and can sustain 250 stable primary care patients who require bedding services (U.S. Department of Health & Human Services, n.d.). Therefore, the maximal number of patient beds that the NDMS system can generate, providing that there was at least one Federal Medical Station (FMS) per DMAT team, and that all DMAT teams were at Type I readiness would be 13,750 patent beds, with a staffing requirement of 11,275 personnel. This number of beds does not even address the 14,400 patients would be displaced and require discharge, inter-facility transfer or evacuation outside the impacted area, without regard to the casualties that were generated by the event.

The rationale behind the apparent lack of concern for the additional 90,000 plus patient beds required for the worst case scenario presented is the over 110,000 pre-committed patient beds from the 1,800 participating National Disaster Medical System fixed facility hospitals. Community, teaching and trauma Hospitals across the nation have joined with the National Disaster Medical System, through Memorandums of Understanding, to make available their empty patient beds in times of disaster. Like the military combat medial delivery system, patients are to be evacuated out of the impacted (combat) area to the safe and secure Zone of the Interior (ZI).

The Challenges:

The challenge for this scenario is that the aero-medical and ground evacuation assets required to perform a mission of this magnitude are scarce. Mission planning factors for the aero-medical evacuation of a maximum of 6,000 patients a day from Iraq during Operation Just Cause accounted for 97% of the aero-medical evacuations assets available to the United States Military. Further, the actual mission accomplishment of 12,632 patents being evacuated on 671 Aero-medial flights averaged less than 20 patents per airframe (Green, n.d.). Thus, at this density, to evacuate even 50,000 patients would require 2500 airframes. Even assuming 250 flights per day, it would require ten days time to evacuate 50,000 patients. Other forms of transportation can also be used, such as railroad and bus assets; but these assets are not pre-configured, and the patients would require beds until such coordination was completed. It is reasonable to expect that a significant number of patients would not be able to be evacuated until at least ten days after the incident and therefore disaster level patient care beds should be planned for as they will be required to maintain the patients until evacuation assets became available.

To further confound the premise of evacuating the majority of patients requiring hospitalization to the Zone of the Interior is the harsh reality that patients must be first stabilized before they can be safely evacuated. Using techniques such as delayed closure, external fixation and the like, definitive care of some orthopedic and surgical patients can be delayed, without a significant increase in morbidity and with the attendant savings of the logistics overhead of providing the required supplies to perform these procedures in the austere medical environment expected within the impacted area. However, stabilization of internal injuries (crush) and other medical conditions must be attained before an aero-medical staging facility, or other evacuation management site will clear a patient for further evacuation. The general rule for military medical evacuation to the zone of the interior has been that the patient was expected to remain stable with onboard care supplies for at least 24 hours. In the case of an overwhelmed medical system within the impacted area, an evacuation policy that facilitated short haul evacuations for further stabilization to the closest medical facilities outside the impacted area could be envisioned; however, these facilities would likewise need to be transfer and evacuate their patients further into the zone of the interior. Additionally, to avoid becoming overwhelmed themselves, and lose their ability to receive new patients from the impacted area for lack of patient beds, they too would need to be augmented by resources from the National Disaster Medical System.

The Reality:

This returns our discussion to the present DMAT teams within the National Disaster Medical System. Unfortunately not all DMAT teams are at the TYPE I level of readiness. In fact, according to David G.C. McCann MD, Former Chief Medical Officer of FL-1 DMAT since 2003, a 2008 Senior Policy Fellow in Homeland Security at George Washington University's Homeland Security Policy Institute, and Current Chair of the American Board of Disaster Medicine (ABODM), the "NDMS is being marginalized as DHHS (Department of Health and Human Service) prepares to upgrade the Commissioned Corps of the USPHS (United States Public Health Service) to serve as the "first-line" in disaster response" (McCann, 2008). To support this assertion Dr. McCann reflects that the number of voluntary members of the DMAT teams has dropped from over 7000 to about 5,000; that the contract that provided the training to DMAT members that was required for teams to be certified as being Type I expired October 31, 2005 and has not been renewed or replaced (University of Maryland, Baltimore County, 2005); that despite a budget increase of 6.3% for FY08 over FY07, teams have had their budgets significantly reduced and their administrative officer is forced to maintain the team's credentials and records on little over 20% of the budget he had last year. Further, he asserts that there had been a complete freeze on hiring new NDMS personnel lasting over 2 years; consequently, "Maybe 10% of the 55 teams are at Type 1". According to the RI-1 DMAT team Deputy Commander, Tom Lawrence, their team is one of the 31% of all NDMS team assets that have reached Type I readiness, and that they are also "very short on nurses" (Rhode Island Hospital, 2008).

Bill Hall, Spokesperson for the Department of Health and Human Services disputes Dr. McCann's claims; he says the department remains "fully committed" to NDMS. "We are not closing down or eliminating teams. In fact, for fiscal 2009, HHS is proposing a $7 million increase for NDMS". The commanders of six Florida-based DMATs posted a letter online on the National Association of DMATS website (Kruschke, et al., 2008) saying they had "confirmed through multiple independent sources" within the department that HHS officials are "engaged in a systematic plan to deemphasize" NDMS and to replace DMATs with new PHS Commissioned Corps Health and Medical Response (HAMR) teams; but Hall insisted that the HAMR teams will play a "complementary role" to DMATs. "Nobody is being replaced". (Garza, 2008)

Regardless of the validity of the claims made by either the Commanders of the Florida DMATS or the Spokesperson of the Department of Health and Human Services, it becomes readily evident that the current status of the DEMAT teams within the National Disaster Medical System is sub optimal. In a presentation on their website targeting elected officials, the National Association of DMATS express their concern over the HAMR teams, Budget Issues, the loss of Warehouse Space, Inability to use Team owned equipment, Training, and Delays in Application Processing. They close their remarks with the statement "NDMS team members feel we are less prepared now to respond to a disaster than before Hurricane Katrina. This is a direct response to action taken by ASPR to dismantle NDMS. As the primary disaster medicine response agency we feel our elected leadership must look into the problems facing NDMS and the citizens of the United States who are the potential victims of the next disaster, natural or man-made" (National Association of DMATS, n.d.) .

In September 2008, The National Biodefense Science Board (NBSB) provided feedback to the U.S. Department of Health and Human Services on the review of the National Disaster Medical System (NDMS) and national medical surge capacity as required by the Pandemic and All-Hazards Preparedness Act (PAHPA) and as specified by Paragraph 28 of Homeland Security Presidential Directive (HSPD)-21. (National Biodefense Science Board, 2008). The report, marked confidential was available on the open web. It made thirteen recommendations which have been condensed and listed below:

1. Strategic Vision: NDMS...does not represent an overall system to provide for the medical needs of patients at a time of national need.

2. DEVELOPMENT OF AN NDMS / ESF-8 ADVISORY GROUP: The establishment of ongoing civilian advisory groups for the National Disaster Medical System.

3. MONITORING AND DOCUMENTING NDMS IMPROVEMENT; previous studies have identified opportunities for improvement in the NDMS... there does not appear to be an organized methodology to track and monitor attempts to address these identified issues.

4. MEDICAL RESPONSE PERSONNEL: To achieve full staffing and operational status for all NDMS response teams... An improved, streamlined application process for DMAT membership is necessary. A training curriculum should be developed, adopted and implemented.

5. NDMS FIELD PERSONNEL CAPABILITY AND GAP ANALYSIS: Consideration should be given to improving the NDMS personnel capability especially in terms of volunteers' conflicting obligations and time to respond, for multiple specified national scenarios.

6. DEFINITION OF THE NDMS PATIENT: The definition of what constitutes an "NDMS patient" should be reviewed and expanded for the purposes of reimbursement.

7. REFINEMENT OF PATIENT MOVEMENT CONCEPT OF OPERATIONS: The ability to implement an effective, smooth mass evacuation of patients from an impacted area remains an unresolved issue.

8. NDMS ELECTRONIC MEDICAL RECORD (EMR): Although the advantages of the EMR are many... Its use must not compromise the efficiency of the healthcare providers in the field.

9. IMPROVED COMMUNICATION WITH STATE/LOCAL REPRESENTATIVES: Serious consideration should be given to returning the DMAT program to its original intent of first building local and state capability, and then exporting these volunteer resources through the NDMS for federal assistance to other parts of the country impacted by a disaster.

10. DEVELOPMENT OF IMPROVED NDMS STANDING CAPACITY: Serious consideration should be given to establishing improved alliances between NDMS and the public/private healthcare sector to provide assistance in field care, patient transport and definitive patient care.

11. FEDERAL REGULATIONS: Criteria should be developed in advance to specify when health-related federal regulations (e.g. HIPPA) should be considered for temporary suspension.

12. OVERALL NDMS FUNDING: It is clear that the funding level for NDMS is inadequate to support even the current level of the NDMS operation.

13. The Department of Health and Human Services is requested to respond to these recommendations in writing during their summer 2009 Public meeting.

Conclusion: The materials presented herein clearly show a National Disaster Medical System that is not ready to respond to an earthquake of major magnitude in California. The NDMS system can currently be safely called broken, and the challenge of the next administration is to address these issues in a timely manner before the system needs to be called upon to respond to the medical needs of our citizens during a major or catastrophic event.

Selected References:

California Health Care Foundation. (2007, January 18). Nearly Half of California Hospitals Unprepared to Meet Deadlines for Seismic Safety. Retrieved October 15, 2008, from California Health Care Foundation Press: http://www.chcf.org/press/view.cfm?itemID=129513

Federal Emergency Management Agency. (1980, November). An Assesment of the Consequences and Preparations for a Catastrophic Californis Earthquake: Findings and Actions Taken. Retrieved September 24, 2008, from The Project Gutenberg: http://www.gutenberg.org/files/18527/18527-h/18527-h.htm

Garza, M. (2008, May). Special Report: DMATS in Danger? Retrieved October 15, 2008, from JEMS.Com: [http://www.jems.com/news_and_articles/articles/jems/3305/dmats_in_danger.html]

Kruschke, G., Hendrickson, B., Wrona, N., Ketchie, K., Caprio, J., Parker, L., et al. (2008, February 1). Florida Commanders Letter. Retrieved October 15, 2008, from National Association of Disaster Medical Assistance Teams: [http://www.nadmat.org/File/FLCommadersLetter.pdf]

McCann, D. G. (2008, February 4). NDMS: Do not Go Gentle into that Good Night. Retrieved October 15, 2008, from The National Emergency Management Summit; Agenda Day One, Monday Febriuary 4, 2008: http://www.emergencymanagementsummit.com/past2008/agenda/day1.html

National Association of DMATS. (n.d.). Presentation to Elected Officials. Retrieved October 19, 2008, from National Association of DMATS: [http://www.nadmat.org/index.cfm/m/5/dn/Presentation] to Elected Officials/

Dan A. Niederman FAEM
Lieutenant Colonel, Medical Service Corps
United States Army Reserve, Retired

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