1
Military-Public Hospital Interfacein Times of
Crisis - Whos 911 toYour 911?

• Lt Gen Paul K. Carlton, Jr.
• Air Force Surgeon General
• 25 Aug 2002

2
Overview

• Causes for concern threats of bioterrorism
• Our mission and capability
• How can we respond as a nation?
• Final thoughts

3
Evolution

• Evolution of a person's reaction to a new idea
• Indignant rejection
• Reasoned objection
• Qualified opposition
• Tentative acceptance
• Qualified endorsement
• Judicious modification
• Cautious adoption
• Impassioned espousal
• Proud parenthood
• Dogmatic propagation
• HK Silver, 1965

4
Homeland Security Evolution

• Evolution of a person's reaction to a new idea
• Indignant rejection
• Reasoned objection
• Qualified opposition
• Tentative acceptance
• Qualified endorsement
• Judicious modification
• Cautious adoption
• Impassioned espousal
• Proud parenthood
• Dogmatic propagation
• HK Silver, 1965

5
An Expeditionary AFMS Supports Full Spectrum
Operations
Enduring Freedom
Somalia
Houston
Peace Keeping
Terrorist Response
Disaster Response
Humanitarian Assistance
Major Conflict
Homeland Defense
Full Spectrum Operations
East Timor HA/PK
Kosovo
El Salvador HA
6
Independent Missions
Independent Missions
Wartime Readiness
Peacetime Benefit
Military
USA
7
Interdependent Missions
Interdependent Missions
Peacetime Benefit
Wartime Readiness
USA
Military
Inherently Governmental!
8
Modular Medical Response CapabilityA Possible
Future
Local Infrastructure Baseline Capability
Units of Capability
Emergency Room Operating Rooms ICU Beds Inpatient
Beds Physical Space
Day to Day Patient Capacity
Local Response
Time
9
Finding a Balance
Current Surge Capacity Scale
Not Balanced!
Effective
Efficient
10
Finding a Balance
Balanced Surge Capacity Scale
Efficient
Effective
11
The Will of the Enemy
The Bomber was shot dead by police as he lay
grievously wounded on the street after triggering
the explosives hidden under his coat. With what
little life he had left, he was crawling towards
the second, even bigger bomb

• Suicide bombers an uncommon resolve
• Attacks are deliberate and calculated
• Individuals are revered by their peers /
  community
• Weapons suspected to involve chemicals (crude)

Source Bomber Planned Chemical Attack, The
Sunday Times 10 Dec 01 (McGrory/Walker)
12
Ample Causes for Concern
World Trade Center - 1993
Oklahoma City - 1995
Atlanta Olympic Park - 1996
Khobar Towers - 1996
Tokyo Subway - 1995
September 11, 2001 was the worst we could have
imagined
13
Intelligence Threat

• Federal Bureau of Investigation (FBI) tracked
  seven times the number of WMD-related threats
  last year than they did in 1996
• 1996 37 threats
• 2000 257 threats
• VP Cheney announced creation of Office of
  National Preparedness in May 01 (division of
  FEMA) in response to this troubling trend
• FBI reported 2100 threats during one week in Oct
  01
• Data not to scale displayed for effect

Source AF Medical Operations Center Special
Report, 13 Aug 01
14
Why The Threats Exist

• US borders are relatively open
• Security has been tightened in recent weeks
• Creating chaos fear is a common motive
• We do have some enemiesand they are serious
• Easy to transport deploy biological agents
• Detection is difficult and often delayed
• Inexpensive
• Lethal

I personally believe that the next decade is a
decade of Homeland Defense. John Hamre,
Former Deputy Secretary of Defense
15
Relative Weight to Lethality Comparison

• Anthrax has significant weight lethality ratio
• It is readily available and inexpensive
• It can be deployed easily and effectively
• It is not controlled making detection /
  tracking more difficult for authorities

Office of Technology Assessment, 1993
16
Relative Costs of Massive Lethal Deployment
Cost to kill 1 square kilometer
JAMA 262644-648, 1989
17
Some Potential BW Agents
Botulinum Toxin
Ricin
Anthrax
Smallpox
Plague
18
Iraqs Arsenal

• Iraqs arsenal between 1985 and 1990
• 25 biological weapon missile warheads
• 166 400 lb aerial bombs filled with anthrax,
  botulinum toxin, or aflatoxin
• 19,000 liters of botulinum toxin solution
• 8,500 liters of anthrax solution
• 2,500 liters of aflatoxin solution
• 18 major biological weapons sites before the Gulf
  War
• Source Air Force Magazine 2002

19
Smallpox

• Smallpox
• Quarantine and vaccination is a must
• Early detection is key to limiting propagation

20
Smallpox OutbreakNew York City, 1947

• 5 APR 1947 Unrecognized hemorrhagiccase from
  Mexico spreads to 2 others
• 18 APR 500,000 vaccinated in 1 day
• 21 APR President Truman immunized
• 26 APR 12 cases, 2 deaths
• Commissioner Weinstein without prompt
  vaccination the hospitals would have been filled
  to overflowing
• 3 May 6,350,000 New York City residents
  vaccinated

21
Anthrax

• Anthrax (aerosolized)
• Administer antibiotics can improve outcome
• Vaccination is required for a chance at curing
  the condition
• Survivability is gt90 with combination of above
  treatments
• Mortality is gt90 without combination of above
  treatments
• Actual mortality was 50 in Oct/Nov 2001 Anthrax
  problem
• Afghanistan had an operational anthrax vaccine
  production plant courtesy of the International
  Committee of the Red Cross (ICRC)1

1 New York Times, 28 Sep 01
22
Three Forms of Anthrax

• Cutaneous
• From spores entering through breaks in the skin
• Treatment with antibiotics reduces fatality to
  less than 1 percent
• Seen commonly in Texas and the Southwest
• Gastrointestinal
• From eating uncooked meat from infected animal
• Least likely to occur can be fatal in 25-60 of
  those exposed if left untreated
• Very uncommon in our country
• Inhalational
• With immunization prior to exposure followed by
  antibiotics, survival almost 100 percent
• Even without immunization, if started early,
  antibiotics bring survival up to 90 percent
• If symptomatic, even with antibiotics, recovery
  is rare, with mortality rate exceeding 80 percent
• Seen mostly in hide tanners and wool sorters
  industry

23
Estimated Survivability for Inhalation Anthrax
Estimated Survivability
Time
Pre-exposure
Pre-Symptomatic
Symptomatic
Vaccine
Antibiotic
100
93-95
Vaccine only
100
Ref MMWR, 49RR-15, 2000
90
Antibiotic only
Vaccine
Not Protective
Range 2-43 days, (usually by 7 days)
11-14
Note Antibiotic 30-60 days of Ciprofloxacin
or Doxycycline at recommended dose, ideally begun
in first 48 hours after exposure VaccineAnthrax
Vaccine Adsorbed (AVA)
(Case survival rate untreated 3)
24
Anthrax Vaccination

• Historical background on Anthrax
• Highly lethal unless treated in first 24 hours
  after exposure
• Bacterial spores can lie dormant for decades in
  soil
• Antibiotics required in vaccinated and
  unvaccinated population
• May be 6th plague of Moses All Cattle Died
• Status of Anthrax Vaccination/Immunization
  Program (AVIP)
• Contracted manufacturer has had many challenges
  (BioPort)
• US military personnel receive series of 6 shots
  (as needed)
• BioPort labs opened by FDA Feb 02 and producing
  vaccine now
• Potential attack affecting 10-100ks could be
  saved by vaccine
• Bottom line Antibiotics can improve outcomes
  vaccination is still important!

25
Additional Concerns

• Emerging bio agents
• Ebola
• Japanese encephalitis
• Cyclospora and Cryptosporidium
• E. coli (enterovirulent strains)
• Prions Mad Cow Disease
• Multi-resistant microorganisms
• Other toxins
• Flesh-eating streptococci
• Algae (Red Tide) and mushroom toxins

26
BW/CW Wallet Card

•  
• EMERGENCY ACTIONS
• TO TAKE FOR
• SELF PROTECTION
• AGAINST POTENTIAL
• BIOLOGICAL AND
• CHEMICAL AGENT
• EXPOSURE
•  
•  
•  
•  
•  
•  
•  
•  

• After any BW/CW incident
• LISTEN keep calm and listen to the radio/TV for
  official news updates. Stay indoors and maintain
  protective measures until notified by the media
  or public safety officials that the area is safe
• DECON
• - Minimize contact with all outside surfaces
  Avoid droplets and residues
• - Remove contaminated clothing as soon as
  possible/place in a sealed plastic bag
• - Wash exposed skin with soap and water and
  shampoo hair
• SEEK CARE if exposure is known or suspected,
  report to the nearest medical facility as
  directed by public health officials for
  evaluation and treatment. Inform the staff you
  may be contaminated 
•  

27
BW/CW Wallet Card

• Indoors
•  MASK put on breathing protection
• (Gas or escape mask) or cover mouth and nose with
  a cloth
• MOVE to the highest and most interior room of
  the house or building
• Shelter
• - Turn off all electrical appliances, fans, air
  conditioners, furnaces, etc
• - Close and lock all windows, vents, doors,
  fireplaces, etc
• - Seal room windows and door seals with duct or
  masking tape
• - Seal door thresholds with wet towel
• - Sit adjacent to an inner wall and away from
  outer walls and windows do not smoke, light
  candles, or use any sources of open flame

• Outdoors
• MASK put on breathing protection (gas or escape
  mask) or cover mouth and nose with a cloth
• MOVE laterally and upwind, away from any smoke
  or aerosol cloud
• SHELTER seek shelter in a building or covered
  structure (see above).
• If caught in a vehicle - pull over, shut off the
  engine, air conditioner, heater and vents, and
  roll up windows

28
Dirty Bombs

• A radiological device that combines radioactive
  material, such as spent nuclear reactor fuel
  rods, with readily available conventional high
  explosives.
• Designed to kill or injure not through its
  explosive force but by creating a zone of intense
  radiation that could extend several city blocks.
• Easy to create with radioactive material.
• According to the National Institutes of Health,
  the severity of symptoms and illness depends on
  the type of radiation, the amount of radiation,
  the duration of the exposure, and the body areas
  exposed. Symptoms of radiation sickness usually
  do not occur immediately following exposure.

Source Washington Post, June 2002
29
Dirty BombsA Case Study
30
Dirty BombsA Credible Fear?

• Little if any detection devices field tested
• U.S. businesses and medical facilities lost track
  of nearly 1,500 pieces equipment with radioactive
  parts since 1996
• Russia and Pakistan are two most likely sources
  of radioactive material for al Qaeda
• Discovery of 10 radioactive containers at border
  crossing in Kasakhstan
• 40 Russian suitcase nuclear bombs still missing
• Several other credible sources exist!

Source Washington Post, June 2002 and Lieberman
Bill
31
Now What?

• If.
• Threats mentioned exist
• Military possesses equipment and training models
• No surge capacity currently exists
• There is a lack of trained trauma personnel and
  firemen
• Then
• Military begins to share knowledge and experience
  with civilian colleagues on disaster response
• We need to bridge the gaps in EMS response to
  mass casualty situations

32
Regional Leaders
Univ of Virginia
Rita Bass Trauma Institute
Texas AM
33
Our Mission and Capabilities
34
(No Transcript)
35
Traditional Response Whole Blood

• Multi-Purpose (Shotgun Approach)
• Effective Treatment for Acute Blood Loss

Blood
O-
36
Current ApproachComponent Therapy
Platelets O-

• Problem Specific Treatment
• Increased Efficacy
• Extends Limited Resources

RBCs O-
Plasma
FFP O-
Saline
37
Medical Building Blocks Modular Response

• Problem Specific Treatment
• Increased Efficacy
• Extends Limited Resources
• Maximizes Options for Commanders
• Flexible Force Modules

PAM
MFST
EMEDS
CCATT ECCT
SPEARR
38
Medical Building Blocks Modular Response

• Problem Specific Treatment
• Increased Efficacy
• Extends Limited Resources
• Maximizes Options for Commanders
• Flexible Force Modules

39
Expeditionary Air Force
40
Modular Units of Capability Providing Whats
needed, When needed

• The Crisis Defines the Response
• Optimizes Resources
• Maximizes Options for Commanders

Staging Aug 20 Bed
Expanded Beds 10 and 25
EMEDS
Expeditionary Medical Support
SPEAR
Staging/Crews Comm
Surgical TEAMS
CRITICAL CARE
PAM Teams
41
Prevention and Aerospace Medicine Team (PAM)

• Designed to prevent disease
• and non-battle injuries
• Missions/Tasks
• Health threat/risk assessment
• Health hazard surveillance, control, and
  mitigation of effects
• Primary/emergency care, flight medicine
• Population at risk 2-10,000
• 9 personnel in 3 modules
• Module 1 (Advon) - Aerospace medicine physician,
  public health officer
• Module 2 - Bioenvironmental engineer (BEE),
  independent duty medical technician
• Module 3- 2 public health technicians, 2 BEE
  technicians, aerospace physiologist

42
Critical Care Air Transport Team (CCATT)

• For Aeromedical Evacuation Patients
• Capability Provides in-flight critical care
  transport of 3 ICU patients with 2nd critical
  care nurse, 5 stabilized patients
• Personnel 3 - 1 Physician, 1 Nurse,
• 1 Respiratory Tech
• Equipment Light weight, compact,
• advanced and sophisticated
• patient management equipment
• and supplies
• Operating Conditions Work with 5
• member AE crews to care for
• stabilized casualties for tactical
• and strategic evacuation

43
Mobile Field Surgical Team (MFST)

• Rapidly deployable, easily transportable, small
• surgical team
• Provide lifesaving trauma care within one hour
• of injury
• Personnel 1-General Surgeon, 1-Orthopedic
  Surgeon,
• 1-Emergency Physician, 1-Anesthesiologist, 1-OR
  Nurse/Tech
• Equipment Manportable 300 lbs of medical
  equipment and supplies in 5 backpacks, 60lb
  generator, 1 folding litter
• Capability Care for up to 20 patients in 48
  hrs perform up to 10 life or limb
  saving/stabilization procedures
• Operating conditions Intended for specialized
  surgery tasks as stand alone for short periods or
  as medical augmentation unit transportable by
  any means uses shelter of opportunity no
  patient holding capability

44
Work at ASOMApplied Solutions in Operational
Medicine

• PoRDITS
• PC-based Intensive Care Unit

• ASOM functions underneath a Texas AM umbrella
  but receives direction funding from the AF
  Surgeon General

45
PORDITS Success

• The necessity of U/S and PoRDITS for our
  deployed SOF and
• conventional medical assets cannot be overstated.
  While our
• current x-ray equipment consists of a half pallet
  and 1,000
• pounds of user- and environmentally-unfriendly
  equipment,
• this equipment gives the deployed provider
  significant
• capability to evaluate truncal trauma quickly and
  non-
• invasively and to send that information up the
  MEDEVAC
• channels.
• ANDREW J KOSMOWSKI, MD, FACEP
• MAJ, MC
• 7th Special Forces Group (A) Surgeon

46
Biological AugmentationTeam (BAT)

• Advanced diagnostic identification
• Missions/Tasks
• Analyze clinical/environmental samples
• Presumptive pathogen ID
• PCR-based test results in hours
• RAPIDS and JBAID
• Tailored response stand alone
  (with ECS) or augment EMEDS
• 2 laboratory personnel
• 1 officer
• 1 NCO
• 35 teams currently established

47
BAT Recent Success

• Oct 01 Joint Navy/USAF deployed to NYC to assist
  CDC and NYC Public Health w/ Microbiology
  Augmentation Team
• AF deployed two AF Biological Augmentation Teams
• Assist civilian authorities analyze backlog of
  anthrax samples from October bioterrorism attacks
• 500 samples analyzed by the MATS
• Additional samples from Post Offices tested
• In total, 2562 nasal swabs tested, 2543 tested
  negative, 19 tested positive 100 accurate
  (validated by traditional tests)
• RAPIDS PCR system utilized to test for further
  Biological Events

48
Small Portable Expeditionary Aeromedical Rapid
Response (SPEARR)

• Deployable within 2 hours
• Flexible -- Highly Mobile (one pallet)
• Sling Loadable -- not tied to a forklift
• Relatively Broad Scope of Care
• Initial Disaster Medical Assessment
• Emergency/Flight/Primary Medicine
• Emergency Surgery (General/Orthopedic)
• Critical Care/Transport Preparation
• SPEARR team deployed to Houston in support of the
  disaster (flood) response efforts

49
SPEARR/EMEDS/AFTH Modular Approach
SPEARR
BASIC
10 BED
Gen
25 BED
SPEARR
ECU
50
SPEARR In Action
51
Inpatient Capability

• Expeditionary Medical Support (EMEDS) detail
• 25 person package with medical, surgical, dental
  capability
• Alaska Shelters, equipment, supplies for full
  capability
• Each increment (10 25) is additional
  capability, not a whole assemblage
• CP-EMEDS (Collective Protection for EMEDS)
• Additional liners, HVAC, accessories to protect
  an existing EMEDS
• Good against biological and chemical attacks
• With training, assemblage can be operational in
  less than 24 hours anywhere in the continental
  U.S.

52
Alaska Shelterin Extreme Environment
This environment
53
Alaska ShelterDurability
EMEDS Site, Brooks AFB, TX, after 90 MPH Winds
54
CP EMEDS
55
CP EMEDS
56
What This Means for the Country

• Continental US is the new battlespace
• Coverage is in planning stages needs to be
  civilian led!
• These assets can serve as a model for capability
  at the State level
• National Guard based or Academic Health Center
  based

57
Weight/Cube Factors
What used to take 10 aircraft in Desert Storm,
now can be done with one. SecDef, 29 May 02,
USAFA
Airlift
Pallets
11 C-130s
55
25 Bed ATH
17 21 22.5
EMEDS25 CP W
4 C-130s
3 C-130s
EMEDS10 CP W
10 13 14.5
EMEDS Basic CP W
3 4 5.5
1 C-130
1 2 3.5
SPEAR CP W
1 C-130
58
Collision of Doctrine

• USA
• Clear battlefield
• Get ready for new flow

• USAF
• AE Stabilization
• 7-10 day post-op

59
Collision of Doctrine
USA
USAF
Casualty Care CCAT
Seamless Continuum!
60
Reducing Theater Medical Assets

• AFMS medical airlift enables Army/Navy to plan
  for long haul
• AFMS/USA CCAT teams perform post-op care normally
  done by forward-deployed Army assets
• Result Fewer deployed post-op care assets in
  theater

61
Building Block Approach forMedical Response
UNITS OF CAPABILITY
TIME
62
The Red Wedge Concept
HUMANITARIAN OPERATIONS
BATTALION AID STATION
SHIPBOARD/PORT OPERATIONS
AIRFIELD/AIREVAC OPS
Stable Baseline Operations

• Wedge begins with an immediate need for medical
  care or a surge temporary chaos is typical
• Goal is to move medical assets in to achieve a
  stable baseline

63
Multiple Support RolesJoint Medical Operations
Total Force
AFTH/MASH/FLEET HOSPITAL
REQUIRES INTERCHANGEABLE JOINT PARTS
25 BEDS
50 BEDS
BIO
ORTHO
Nursing 14 Beds
ISO SHELTERS
LAB
TRIAGE
X-RAY
MPH
DENTAL
PHARMACY
USAF OR TEAM
ARMY MFST
NAVY MFST
SURGERY EQUIP
HUMANITARIAN OPERATIONS
BATTALION AID STATION
SHIPBOARD/PORT OPERATIONS
AIRFIELD/AIREVAC OPS
64
Theater Casualty Movement1991
BAS
Ship
CCP
BAS
BAS
Rotary Wing
Rotary Wing
MFST
MFST
Mother Hosp USA/AF
CCAT
CCAT
FST
FST
Fixed Wing AE AF
65
Theater Casualty Movement5 Dec 01
I.
CCP
Ship
Ship
BAS
BAS
II.
FSB
MFST
Navy Resuscitative
FST
CCAT
CCAT
MFST
MFST
Mother Hosp USA/AF
III.
Rotary Wing
CCAT
CCAT
Rotary Wing
FST
FST
Fixed Wing AE AF
IV.
66
Theater Casualty Movement
FSB
FSB
FSB
MFST
CCAT
FST
Rotary/Fixed Wing
Rotary/Fixed Wing
MFST
MFST
Mother Hosp USA/AF
CCAT
CCAT
FST
FST
Fixed Wing AE (Strat) AF
67
Theater Casualty Movement
MFST
MFST
Mother Hosp USA/AF
Combat Support Hospital
CCAT
CCAT
FST
FST
FSB
FSB
MFST
MFST
Mother Hosp USA/AF
CCAT
CCAT
Combined Hospital
FST
FST
68
Casualty Care
Definitive Care
Resuscitative Care FST MFST NRT
Recovery Room ICU CCAT CCTT
Army
Army
Army
Air Force
Air Force
Air Force
Navy
Navy
Navy
TIMELINE
Well
Injury Occurs
Lives Saved
69
Low Patient Flow
FST
AE CCAT
AE CCAT
MFST
MFST
Mother Hospital
CCAT
CCAT
FST
FST
Definitive Care
70
High Patient Flow
FSB
FST
MFST
MFST
GCAT
AE CCAT
Mother Hospital
GCAT
Definitive Care
71
Recent Support of War EffortImpalement Injury
Injury Scenario Military and Civilian Care
Comparison
Elapsed Time Post Injury Care Received Military Setting Civilian Setting
25 min Emergency Surgery Damage Control MFST personnel Level I Trauma Center
6 hours Emergency Surgery Further stabilization CCATT enroute / Surgical Team at AmSurg Center Level I Trauma Center
24 hours Definitive Surgical Care CCATT enroute / Surgical Team in Military Hospital Setting Level I Trauma Center
48 hours Definitive Surgical Care Stateside Military Medical Center Level I Trauma Center / Tertiary Hospital
1
2
3
4
Times locations are estimated
72
Recent Support of War EffortApache Crash 10 Apr
02
73
Recent Support of War EffortApache Crash 10 Apr
02
74
Recent Support of War EffortApache Crash 10 Apr
02
Injury Scenario Military and Civilian Care
Comparison
Elapsed Time Post Injury Care Received Military Setting Civilian Setting
50 minutes ParaRescue EMT-P
1.9 hours Intubation/ Fracture Stb / Blood / Volume Expansion Army Forward Surgical Team Level I Trauma Center
6.9 - 8.1 hours CCATT/ AE enroute Level I Trauma Center
8.1 - 9.2 hours (transload to C-17) 9.2 - 16.5 hrs CCATT / AE enroute Level I Trauma Center
Rescue
1
2
Stabilization / ICU Care in Air on C-130
3
ICU Care in Air Arrival in Germany
4
Times locations are estimated
Currently in Hospital in Germany
75
Apache Crash on 10 Apr 02

• Pat 1 (Back Seater) - Severe facial injuries,
  (Le Fort III and open mandibular fx) compression
  fx T-12, burst fx of L1-2, posterior elements
  unstable, suspected cord injury, mild sub
  arachnoid hemorrhage
• Intubation to protect airway, 2 units PRBCs, 3 L
  crystalloid at FST, CCATT continued to stabilize
  and monitor in flight
• Taken to German Hospital for spinal stabilization
• Neurologically intact

76
Apache Crash on 10 Apr 02

• Pat 2 - (Front Seater) Bilat Tibia Fx,
  hypotension, Severe facial injuries to include
  possible maxillary Fx, L 3-4 Fx with
  retroposition, 50 spinal canal compromise, motor
  deficit below injury, bilat Tibia fx (rt fx open)
  
• Intubation to protect airway, DPL neg,
  hypotension resolved after intubation, 2 units
  PRBC and 3 L of Crystalloid, rt Tibia fx external
  fixation, other leg in bivalved cast
• Taken to German Hospital for spinal stabilization
• Neurologically intact with minimal LE motor
  problems

77
Timelines on AE

• 1304Z - Apache Crash
• 1355Z - MH-60 with PJs on scene
• 1500Z - Arrival Forward Surgical Team
• 1902Z - C-130 with CCATT / AE departs air base
• 2000Z - C-130 arrives FST
• 2110Z - C-130 returns to air base
• 2110 - 2215Z - Transload to C-17
• 2215 - 0535Z - C-17 flight to Germany
• Total Time - Crash to arrival in Germany - 16.5
  hrs

Now that is how we do AE in 2002 RAPID,
RESPONSIVE, FLEXIBLE!
78
OEF Patient Movement17 Oct 01 10 Aug 02


Routine 724 Urgent/Priority
335 Total 1,059
79
OEF Patient Movement


17 Oct 01 10 Aug 02 Total Urgent/Priority Moves
335 227 Priority / 108 Urgent

OPR GPMRC Source JPMRC
80
EMEDS In Action
81
EMEDS In Action
82
Modularity Evolution

• Evolution of a person's reaction to a new idea
• Indignant rejection
• Reasoned objection
• Qualified opposition
• Tentative acceptance
• Qualified endorsement
• Judicious modification
• Cautious adoption
• Impassioned espousal
• Proud parenthood
• Dogmatic propagation
• HK Silver, 1965

83
The Red Wedge ConceptIncreasing Medical
Capability
Rapid responding medical assets are required if
local system is overwhelmed
Surge in Medical Need
Federal Others
Additional partners bring assets to assist
Local EMS / Hospitals begin to feel strain
Disaster Occurs!
Local
D1
D-O
DX
Medical Baseline
84
Tropical Storm Allison The RAIN of Terror
Houston, June 2001
85
Houston Timeline
86
Houston Timeline
Saturday
Federal Disaster Decleared FEMA Assessment Teams
Arrive
Units of Capability
100 Capacity
X
Friday
Saturday
87
Houston Timeline
Sunday
Units of Capability
100 Capacity
X
Friday
Saturday
Sunday
88
Houston Timeline
Saturday
Sunday
Monday
Units of Capability
100 Capacity
X
Friday
Saturday
Monday
Sunday
89
Houston Timeline
Friday Floods
Saturday
Sunday
Thursday
EMEDS25 (59 MDW) Operational ER/ICU Capacity
increased Wait times decrease
Units of Capability
Local ER/ICU Capacity
100 Capacity
25
X
Tuesday
Monday
Wed
Friday
Sunday
Sat
Thursday
90

The Red Wedge Concept Houston Disaster Scenario
100 Capacity
Military Assets building block in to meet the
requirements dictated by local leadership

AF Theater Hospital 114 beds
Aeromedical Evacuation Support
UNITS OF CAPABILITY
Lost capacity
SPEARR - PAM - ECCT - MFST
25 Capacity
114 Beds
EMEDS 25 Beds PAR 3-5K
79 Beds
NCA
TIME
Hold Until Tasked
91
Disaster Response (CAP) A Tiered Tailored
Response
Military Assets filled in capacity (5) until
local hospitals are back to baseline Increase to
30 critical
ER Treatment Delayed ICU capability limited
Patients At Risk
Units of Capability
100 Capacity

• Local
• ER/ICU
• Capacity

Hospitals On-line At 50
25
St Luke On-line
TIME
92
Recommended Actions

• Entry criteria should be well-defined for DoD
• Federal Response Plan (FRP) covers this
• Period from 24-72 hours is uncovered
• Memorandums of Understanding required should be
  in-place and current
• Executethen inform
• Process should be no harm, no foul and
  pre-approved as much as possible
• Launching on probability is key for medical
  response
• Process must be practiced!

93
(No Transcript)
94
The Real World

• Im here to tell you, the exercise prior to 9-11
  saved
• lives. It is real. Lt Gen Paul K. Carlton Jr,
  AF/SG

95
Air Force Medical Service Response to Events of
11 Sep 01

• Position vital medical equipment
• Ventilators and other essential Patient Movement
  Items (PMI)
• Ensure civilian hospitals receiving patient are
  equipped
• Provide Day 2 relief of strained medical
  facilities
• Medical personnel / equipment staged at McGuire
  AFB and Andrews AFB
• Support needs of National Disaster Medical System
  (NDMS)
• As patient movement requirements dictate (airlift
  / aerovac)
• Off-load patients to other hospitals (nationwide)
• Recommend Nation pursue capability-based
  medical posture
• National Guard and Health and Human Services led

96

The Red Wedge Concept Andrews AFB Summary from 11
Sep 01

• Pentagon support with CISMs (3)
• AE hub 6 C-9s (final count)
• 12 AE crews
• CCATT (18 total)
• Andrews (10)
• Scott (3)
• Keesler (2)
• Travis (3)
• Transported skin

Aeromedical Evacuation Staging
UNITS OF CAPABILITY
Standing by
PMI
CCATT (18)
Pentagon Support
CISM

EMS
TIME
97

The Red Wedge Concept McGuire AFB Summary from 11
Sep 01

• Medical PERS (organic) 272
• Augmented PERS 539
• EMEDS 25 (3)
• EMEDS Basic (1)
• SPEARR (1) - Baltimore
• MFST (4)
• CCATT (5)
• CISM (5)
• 250 ASF beds
• gt2000 units blood

NDMS
FEMA
Aeromedical Evacuation Staging
PMI
UNITS OF CAPABILITY
SPEARR
Standing by
CCATT
Local Response (NYC)
MFST

CISM
CISM
EMS
TIME
98
Response Request
99
How Can We Respond as a Nation?
100
Lack of Surge Capacity

• Common misconceptions
• There is a robust medical system to support a
  mass casualty event.
• 2001 Inauguration (Washington, DC) 7 ICU beds
• 2002 Mile High Stadium Demolition (Denver, CO)
  7 ICU beds
• 2002 Ohio Exercise (Cincinnati, Dayton, OH) 1
  ICU bed
• Current shortage of surgeons, laboratories,
  andfirefighters
• The military will be able to respond during a
  mass casualty event.
• Medical assets are currently deployed to theater
• 15 step process to get assets there if we had
  them
• Bottom Line There is currently no surge capacity
  in the U.S. to support a mass casualty event.
  Military and civilian relief must overlap to be
  effective.

101
Bioterrorism WargameImproving Healthcare
Preparedness Response

• Government and industry teams conducted dynamic,
  interactive dialogue to respond to a simulated
  bioterrorism attack
• Examined choices, dilemmas and consequences of
  actions
• Identified ways to improve real-world
  coordination, cooperation, and capabilities
• Scenario involved release of a weaponized,
  infectious disease pneumonic plague
  simultaneously in two cities (Detroit and
  Norfolk)
• Game model predicted wide range of outcomes,
  depending on nature and speed of response
• Worst case 1.8 million deaths in Detroit if
  prophylaxis given to 50 of population (40 of
  population dead)
• Best case 16 thousand deaths in Detroit with
  100 prophylaxis
• Game design allowed participants to adapt
  decisions and responses to achieve favorable
  results

Source Booz/Allen/Hamilton
102
Impact on Detroit50 Prophylaxis Approach

• Total Dead 1.8M
• Hospitals out of cash by Day 63
• Hospital Net Loss - 240M
• Insurers Net Loss - 290M

103
Impact on Detroit80 Prophylaxis Approach

• Total Dead 380,000
• Hospitals out of cash by Day 63
• Hospital Net Loss - 240M
• Insurers Net Loss - 290M

104
Impact on Detroit100 Prophylaxis Approach

• Total Dead 16,000
• Hospitals out of cash by Day 75
• Hospital Net Loss - 170M
• Insurers Net Loss - 200M

105
Civil Support Getting There Matters
As it stands now DoD does not get there quickly
When we do We bring a lot of unique
capabilities to the fight!
106
Big Patient Flow (US)
Disaster Occurs
107
Big Patient Flow (US)
AE to Definitive Care (If Necessary)
Omaha Mother Hospital
Wichita Mother Hospital
AE to Definitive Care (If Necessary)
FSB
MFST
FSB
CCAT
AE to Definitive Care (If Necessary)
MFST
FST
FST
MFST
GCAT
CCAT
St. Louis Mother Hospital
FST
FSB
108
An Integrated Approach Gap 24-72 Hr Medical
Response, Detect/Prevent CB Attack
Military Assets can provide building blocks to
meet the requirements of lead agency and local
governments
HHS / FEMA-DOMS (AFNSEP) / OEP
Aeromedical Evacuation Support
UNITS CAPABILITY .
SURGE GAP
State assets WMD-CSTs
TIME
3-5 hrs
30 days
72 hrs
24 hrs
109
Organization of Armed Forces

• U.S. Air Force
• Organizes
• Trains
• Equips
• CINCs
• Employ

110
Multiple Support RolesJoint Medical Operations
Total Force
AFTH/MASH/FLEET HOSPITAL
REQUIRES INTERCHANGEABLE JOINT PARTS
25 BEDS
50 BEDS
BIO
ORTHO
Nursing 14 Beds
ISO SHELTERS
LAB
TRIAGE
X-RAY
MPH
DENTAL
PHARMACY
USAF OR TEAM
ARMY MFST
NAVY MFST
SURGERY EQUIP
HUMANITARIAN OPERATIONS
BATTALION AID STATION
SHIPBOARD/PORT OPERATIONS
AIRFIELD/AIREVAC OPS
111
Multiple Support RolesJoint Medical Operations
COALITION/AFTH/MASH/FLEET HOSPITAL
REQUIRES INTERCHANGEABLE JOINT PARTS
25 BEDS
50 BEDS
BIO
ORTHO
SPEARR, IMSURT
Nursing 14 Beds
ISO SHELTERS
LAB
TRIAGE
United States
United Kingdom
X-RAY
MPH
DENTAL
PHARMACY
Canada
Germany
Korea
Belgium
BATTALION AID STATION
Spain
Jordan
HUMANITARIAN OPERATIONS
France
Czech Republic
Italy
Poland
AIRFIELD/AIREVAC OPS
SHIPBOARD/PORT OPERATIONS
112
Regional Response andPotential Partners
113
AFMS Disaster and Trauma Global Health Program

• Leadership Program in Regional Disaster Response
  and Trauma System Management
• The AFMS flagship mobile education course
• 26 countries and 1,200 participants (I/3
  civilian) since 99
• 15 host countries, 25 regional participants in
  02
• Train-the-trainers format
• Hungary, Czech Republic Course FY 02..host
  country medics taught course with US counterparts
• Outcomes
• El Salvador hosted 2 civilian-military courses
  and taught 5 courses
• South Africa establishing a Trauma Institute
• Czech-Republic incorporated curriculum into
  military medical academy

114
AFMS Disaster and Trauma Global Health Program

• Internationally deployed comprehensive course
• Over 25 of eligible world will be trained by
  close of FY 2002
• Six-Day Train the Trainer Course
• Comprehensive Disaster and Trauma Management
  Concepts
• Taught by ten U.S. Mobile Education Team
  Instructors
• Tri-Service, Total Force, officers, and enlisted
• All highly credentialed in trauma management and
  disaster response
• 30 - 42 students per course
• 3 Prototype Courses in 1997 and 1998
• First formal E-IMET September 1999

115
2002 IGH Leadership and Trauma Course Host
Countries
116
AF OfferingsCurrent Courses

• 8 new courses developed since Oct 01
• Leadership Program in Disaster Public Health and
  Public Health System Management
• Early Intervention Terrorism, Disaster, and
  Public Mental Health
• Debut Course..Apr 02South Africa
• Eye Trauma Management Course
• Critical Infectious Diseases Improving Outcomes
  for Patients and Populations
• Hospital-Focused Response to Biological Weapons
  and Toxins
• Debut Course..Dec 01USA
• UVA Charlottesville..20-25 May total cost 5K
  (paid by civilian)

117
AF OfferingsCurrent Courses

• International Aeromedical Evacuation-Critical
  Care Transport Course
• Debut Course..Mar 02..Chile
• Forensic Science and International Law for Public
  Health officials and Health Care providers
• Trauma and Critical Care Pararescue Course
• Debut CourseAug 02Nepal

118
Where Have We Been?

• Alpena, MI Joint exercise between Missouri ANG
  and Kansas ANG
• Baltimore, MD (Baltimore Shock Trauma)
  Participated in bioterrorism exercise at Ravens
  Stadium
• Greenville, NC (E. Carolina Health Systems) -
  Observed EMEDS Basic exercise at Seymour Johnson
  AFB
• Richmond, VA (Medical College of Virginia) -
  SPEARR team from CSTARS participated in Richmond
  city-wide CBRNE exercise
• New York City, NY (NYC Fire Dept) - Exploring
  procurement of EMEDS equipment to preposition as
  C2 possible training at Brooks AFB
• Denver, CO (Denver Health) - MFST and CCATT team
  participated in an exercise at Mile High Stadium
• Tucson, AZ (U of A Medical School) - Pending
  agreement to establish C-STARS in Tucson
• Rochester, MN (Mayo Clinic) - City-wide table top
  on bioterrorism and integrating EMEDS

119
Potential Partnerships for AF IOH
Thomas Jefferson University (Philadelphia)
Mayo (Rochester)
University of Colorado (College of Medicine,
Denver)
University of MD
Med. College of Virginia
Univ. of VA, Charlottesville
Eastern VA Medical School
Rita Bass Prototype for Nation
Washington Hospital Ctr, DC
University of Missouri (Kansas City)
AF Institute for Operational Health AF IOH
University of Arizona
University of Texas Health Science Center (San
Antonio)
Texas A M
All Addressed by AF/SG in Last Year
120
"What Do We Do Next?"
121
Office of Applied Solutions in Operational
Medicine and Homeland Security--ASOMHS

• ASOM-HS is a think-tank to find innovative ways
  to surge and respond on a homeland battlefield
  without surge capacity.
• Wrote the National Pharmaceutical Stock Plan for
  the City of San AntonioCDC is using it as the
  template for interface
• Helped create the Regional Emergency Medical
  Preparedness Steering Committee (REMPSC) 
• Charter member of the San Antonio Military
  Council
• ASOM-HS and TC-MEDSTAR are running the Laredo
  Project
• Running the Las Vegas Initiative
• Supporting the Denver Rocky Mountain Trauma
  Conference
• Initiated a national conference on the legal
  aspects of terrorism and homeland security
• Integral to the UMD-Baltimore-CSTARS chemical
  mass casualty exercise, providing planning,
  training modules, evaluation tools, and exercise
  evaluation

122
A New Organization Might

• Brings together all of the key functions
  necessary for successful consequence management
• Rapid development of products/plans for to
  improve Homeland Security
• Provides avenue for partnership with AF medical
  assets / experience
• Establish South Texas as center of Homeland
  Security for USA
• Texas AM lead
• Possible state liaison with HHS

Texas Center for Medical Strategy, Training and
Readiness
Law Enforcement
Communication
Force Protection
Environment
Transportation
Force Protection AFIERA
Aeroevac
Medical/IOH
Navy
Army
AFIOH
Public Health Service
Universities
ASOM/DCOM
GCCI
GHI
IHS
123
A New Organization Might

• Texas Center for Medical Strategy, Training and
  Readiness
• TC-MEDSTAR Providing Immunity for the
  Community
• Mission Assist rural and urban communities to
  plan, organize, train, educate and equip their
  Community Health Resources to provide an
  integrated response to homeland security issues.
• Currently 3 communities in Texas San Antonio,
  McAllen, Brazos Valley
• Partnerships Texas AM, U.S. Air Force,
  University of Texas Health Science Center

124
What Opportunities Exist?

• Formalize Relationships with Partners
• MOUs
• Team Briefings to Potential Sponsors
• Joint Proposals for Grants (academic and govt)
• Shape Doctrine and Planning JCAHO Federal
  Response Plan
• Respond to Requests for Help
• Laredo Cross Border Health and Security Issues
• Las Vegas Medical Homeland Security
• Denver Planning Partnership
• Transfer EMEDS to ANG and Civilians

125
What Opportunities Exist?

• Exercises
• Baltimore Shock-Trauma Planning Execution
• Denver (Mile High Stadium)- Combined City/Mil
  execution
• Dark Screen Planning and Medical SME
• Safe-at-Home Surge Capacity for the Homeland
• Pale Horse With the Army and City of San
  Antonio
• Technology Transfer
• EMEDS
• Educational Courses
• Symposia and Speaking Engagements
• Homeland Security Legal Conference
• Rocky Mountain Trauma Conference

126
A List of Possible Options

• Demonstrations, visits, tours throughout the AFMS
• RAPIDS, LEADERS, GEMS, EMEDS and PoRDiTS
• EMEDS-XTI (Fort Detrick), SPEARR (Baltimore)
• Letter from Agency to NORTHCOM, Other TBD to
  discuss
• Requirements, plans, funding, disconnects
  (process, resources), partnerships, MOUs,
  opportunities
• As a follow-on, offer to speak at
• Lower or higher level group in the organization
• Meet with some other applicable department or
  agency
• Other as discussed during the meeting
• Develop plans aimed at
• Strategic, marketing, RD, test and development,
  demonstration, funding or grants, implementation
  functional levels
• Offer to observe/participate in upcoming
  base-level EMEDS/medical disaster response
  exercisesfield/table top
• Grant access to MDG staffs for discussions

127
A List of Possible Options

• Develop agenda or outline for follow-on
• Seminar, summit, conference, workshop
• Study and analysis (jointly select topic)
• Pilot project
• Offer to share and provide or acquire
• Course, training, exercise materials
• CONOPS, plans, checklists
• Equipment and price lists
• Subject matter experts to work project or issue
• Establish a team(s) to address issues
• Task Force, IPT, AD Hoc, Working Group
• Ask for funding to support agreed upon efforts
• Get 10 GME fee back focused on creating a Dept
  of Disaster Medicine

128
The Answer!

• No reason to reinvent the wheel!
• Use the National Emergency Response and Rescue
  Training Center (NERRTC) at Texas AM as
  benchmark
• Answers Who is 911 to your 911
• Set of courses to prepare public officials,
  emergency medical services, law enforcement, fire
  protection, and public works for the threat posed
  by weapons of mass destruction
• Excellent training source of much needed
  emergency personnel
• Add medical modularity training/equipment to
  support NERRTC mission
• Attend our courses and train with us to fill the
  gaps in responding to Who is 911 to your 911

129
Final Thought
Good leaders know the right thing to do great
leaders have the courage to do it." Author
Unknown
Our future includes sharing what weve learned
over the last 100 years with our civilian
counterparts. Lt Gen Paul K. Carlton, Jr. AF/SG