The Emergency Preparedness and Response Triad (the Triad) depicts three critical components that deal with the preparation for and response to an act of terrorism or mass casualty incident. The components of the Triad are emergency management, health care delivery systems, and public health systems (Fig. 27-1).

The health care delivery system includes hospitals, Emergency Medical Services (EMS), federally qualified health centers (FQHC), facilities related to care for the aging (long-term care), psychological treatment facilities, and other medically related organizations. This is the category most associated with the medical response to terrorism. Integration of this component with the public health system and with emergency management organizations provides a complete approach to readiness and response. When preparing for a medical response to terrorism or any public health emergency, all three components must individually plan how they would respond to such an event. However, it is just as important for individual plans to complement each other in order to ensure a complete and integrated response to a disaster.

The Emergency Preparedness and Response Triad is applied to a cycle of events surrounding a public health emergency, act of terrorism, or mass casualty incident. This cycle, designated the Disaster Management Cycle (DMC), depicts the phases of an incident, emergency, mass casualty event, or disaster from prevention through recovery. The cycle is divided into four phases (Fig. 27-2). Although depicted as sequential, there may be overlap or jumping of phases and concurrent activities that simultaneously address different phases. The following describes the objectives and activities that occur within each phase.

Preparedness is the phase during which governments, organizations, and individuals develop plans to save lives, minimize disaster damage, and enhance disaster response operations. Preparedness measures include preparedness plans; emergency exercises/training; warning systems; emergency communications systems; evacuation plans and training; resource inventories; emergency personnel/contact lists; mutual aid agreements; and public information/education.

Response includes those activities that provide emergency assistance for casualties, reduce the probability of secondary damage, and speed recovery operations. Response measures include activating public warning; notifying public authorities; mobilizing emergency personnel/equipment; providing emergency medical assistance; manning emergency operations centers; declaring disasters and evacuating; mobilizing security forces; initiating search and rescue; and activating emergency suspension of laws.

Recovery includes those activities that continue until all systems return to normal or better. Recovery measures, both short and long term, include returning vital life-support systems to minimum operating standards. It encompasses damage insurance/loans and grants, temporary housing, long-term medical care, disaster unemployment insurance, public information, health and safety education, reconstruction, counseling programs, and economic impact studies. Information resources and services include data collection related to rebuilding, claims processing, and documentation of lessons learned.

Mitigation is the elimination or reduction in probability of the occurrence of a disaster, or the lessening of the effects of unavoidable disasters. Mitigation measures include building codes, vulnerability analyses updates, tax incentives and disincentives, zoning and land use management, building use regulations and safety codes, allocations and interstate sharing of resources, preventive health care, and public education. Information resources and services important in mitigation activities include GIS-based risk assessment, claims history, facility/resource identification, land use/zoning, and building code information. Use of modeling/prediction tools for trend and risk analysis is also important (1).

The medical preparation and response to terrorism may take place during any phase of the Disaster Management Cycle.

The tempo of the DMC will frequently determine the availability and use of resources. For example, during the preparedness phase, in the absence of an infectious disease outbreak, a hospital may have the needed months to construct adequate isolation facilities. However, an outbreak of SARS might accelerate this same hospital into the response phase prior to isolation facility completion, and the same hospital may have only days to prepare itself for numbers of highly contagious patients. Likewise, a public health system may be able to adequately vaccinate a number of health professionals for smallpox during the preparedness stage of the cycle and, as part of the response phase, would be able to accelerate this process to include additional health professionals and first responders. However, the ability to effectively mass vaccinate millions in a timely fashion is a significant challenge.

Tempo control of the DMC is the most critical component of the preparedness for and response to any act of terrorism, public health emergency, or mass casualty incident. Access and use of appropriate resources at the appropriate time is a means of tempo control.

Traditionally, many medical planners focused only on the prehospital and hospital components of the response phase of the DMC. This focus understandably occurs for two reasons. First is the degree of comfort and expertise that medical professionals have in these areas. For example, fire and law enforcement first responders may depend
on the medical community to treat the victims of an incident so that they may focus on the causes and effects of medical emergencies (i.e., hazmat incidents, fires, criminal actions, or search and rescue). The second reason that medical planners key on prehospital and hospital issues is the traditional stovepipe of programs. Until recently, cross-pollination of ideas, interaction of different preparedness and response communities, and integration of horizontal and vertical preparedness and response plans has been the exception rather than the rule. Fortunately, there is a shift in this paradigm. So while medical planners continue to focus on prehospital and hospital components, they now are expected to integrate these components into a holistic view of preparedness and response and to be subject matter experts for these components for others who plan for the DMC. This integration is occurring across all areas. The result is a tremendous amount of resources and assets available to the medical response to terrorism.

Governmental resources are available at federal, state, and local levels and may support all phases of the DMC. This chapter will later address specific programs; however, as an overview, major federal resources are available through the Centers for Disease Control (CDC), U.S. Department of Justice Office for State and Local Domestic Preparedness (ODP), Federal Emergency Management Agency (FEMA), Health and Human Services (HHS) Health Resources and Services Administration (HRSA) and Agency for Healthcare Resources and Quality (AHRQ), and the U.S. military, specifically the U. S. Army Medical Research Institute of Infectious Diseases (USAMRIID). The Federal Bureau of Investigation (FBI), the Central Intelligence Agency (CIA), the National Domestic Preparedness Consortium, the National Health Professions Preparedness Consortium, and the National Disaster Life Support Educational Consortium (NDLSEC) have courses and background materials supporting planning and intelligence related to the medical response to terrorism. The NDLSEC is a collaborative effort of federal, state, and academic centers with financial support from the Centers for Disease Control and Prevention (CDC). The overarching goal of the NDLSEC is to standardize emergency response training nationwide and strengthen our nation’s public health system. The resources listed in various forms provide for planning, training and exercise, equipment, funding, and response. (Note: Many programs listed now fall under the Department of Homeland Security; however, it is best to associate them with the organizations listed.)

The federal government, through Homeland Security Presidential Directive 5, has developed the National Incident Management System (NIMS) to provide interoperability between the federal, state, and local levels. A specific program supporting the medical response to terrorism is the Hospital Emergency Incident Command System (HEICS). HEICS is a hospital disaster management system that is based on the general disaster incident command system (ICS). Although HEICS is an Orange County, California, product, this system has become a model for most hospital incident management organizations. HEICS features a flexible management organizational chart that allows for the customized hospital response to a crisis to include the organized division of tasks and a realistic span of control for managers. The San Mateo County Emergency Services Agency provides information and download of the HEICS’s project and plan on their web site (2).

The National Oceanic and Atmospheric Association (NOAA) provides weather and environmental information that could provide insight into deployment of terrorist weapons of mass destruction (i.e., plume dispersion, temperature, humidity), and the climatic conditions that responders would operate under during the medical response to an incident (3).

In the area of response, governmental teams are available for deployment to an affected site. These include CDC epidemiological investigation teams; CDC Strategic National Stockpile (SNS) Technical Advisory Response Units (TARU) to assist in state and local deployment of the SNS; FBI investigative teams; National Guard Civil Support Teams (CST), and the U.S. Marine Corps Chemical Biological Incident Response Force (CBIRF) both able to assist local, state, or federal agencies by providing capabilities for (a) agent detection and identification, (b) casualty search, rescue, and personnel decontamination, and (c) emergency medical care and stabilization of contaminated personnel. This book addresses governmental partnership teams later in this chapter.

State governmental resources vary in scope, responsibility, and comprehensiveness; however, there are some general resources available through state programs. State statues significant to the medical response to terrorism may address the emergency powers of the health response system (emergency powers acts), the role and responsibilities of the health system within a state’s emergency management structure, and the cross-credentialing and mutual aid agreements. State emergency management plans are critical in defining how a state will organize and respond to a major incident, as well as the responsibilities of different organizations within these plans. State emergency management organizations will manage and operate a state’s Emergency Operation Center (EOC). Within the state EOC, state health departments generally represent the medical community. However, the scope, guidance and responsibilities of individual state health departments vary greatly. One specific role of a state health department is as a conduit of CDC and HRSA policy and procedures to a state’s constituents. Other key resources provided by state health departments include isolation and quarantine procedures, biological specimens transfer protocol, and pharmaceutical and medical stockpile distribution.

Depending on a state’s organization, the departments of energy, environment, and agriculture and state’s attorney general’s office may play roles in the medical response to terrorism. Few states are organized identically; however, these listed departments are sources for information on communicable disease, nuclear/radiological incidents, water-borne threats, agricultural and animal-related terrorist events, and generalized counterterrorism. In addition to providing information, experts from these departments should be considered important resources in medical planning and response. Also at the state level, the FBI’s Joint Terrorism Task Forces (JTTF) are sources of intelligence that can assist the medical community. Sixty-six JTTFs made up of federal, state, and local law enforcement members are located throughout the country. These teams share international, national, and local terrorism information and intelligence and serve as conduits of information to state agencies.

Major funding sources that provide states with funds specifically related to the medical planning and response to terrorism include federal grant money from CDC, HRSA, and ODP. These funds may be allocated by the state or passed through to localities for distribution. State subsidies vary greatly across the country with possible sources from specifically designated terrorism funding, health services funding, and EMS funding. In general, most states rely on FEMA funding to provide recovery assistance after a major incident, although some may have an emergency fund for this purpose.

Local governmental resources, normally from a health department, are limited. An exception is the federal contributions directly to localities funded by the Metropolitan Medical Response System (MMRS). The primary focus of the MMRS program is to develop or enhance existing emergency preparedness systems to respond effectively to a public health crisis, especially a weapons of mass destruction (WMD) event.

In March 2003, the MMRS joined FEMA and other programs from the Departments of Health and Human Services, Energy, and Justice to become the Emergency Preparedness and Response Directorate of the new Department of Homeland Security (4).