Symposium sponsored by:

Johns Hopkins Center for Civilian Biodefense Studies

Department of Health and Human Services

Infectious Diseases Society of America

National Disaster Medical System
Robert F. Knouss, M.D.

Today I want to spend a few minutes just telling you a little bit about what the Office of Emergency Preparedness is all about in the Department of Health and Human Services, and the fact that when one of these events happens, there is an infrastructure that's available to at least begin the federal response and to try to amass some resources that might be appropriate to address the problems that might be created for the health care delivery system.

Our office, the Office of Emergency Preparedness, is really responsible for a variety of responses or responses to a variety of events in which local and state health systems are overwhelmed, and that might be as a result of natural disasters. It could be transportation disasters. For example, we do all of the victim identification when we have commercial airline crashes; for counterterrorism when we might have a terrorism event that would overwhelm local health care system's ability to response; and technological disasters, such as the Y2K if we would have experienced some significant shortfalls in health care capacity during the millennial change.

Now, the federal response plan was referred to earlier. It was referred to as something that's fairly complicated. Actually, I think the federal response plan has made something very understandable out of something that could be very difficult to understand. And essentially the federal response plan says that during any major disaster in the United States, there are 12 essential functions that have to be performed in order to be able to have an appropriate response to the consequences of that disaster, and they involve everything from mass care to transportation needs to urban search and rescue to environmental health, to environmental issues, to health and medical services.
And the health and medical services piece is called emergency support function number eight, and our department is responsible for that, and we have 12 other departments that work with us in providing their resources to assist in meeting the challenges that would be faced by the health care system in the event of a significant disaster creating mass casualties.

Now, actually ESF-8, which is referred to, has four principal functions: preventive health services, environmental health services, medical services, and mental health services. There are a large number of different functions that are mentioned, but basically it falls into those four categories. Now, two of those are really resource intense, both the medical services that might have to be provided to mass casualty victims or mass casualties or mental health services both during the acute phase or in the long term after the disaster, and those two resource intense responses are largely accommodated through what's called the national disaster medical system, which has been in existence for the last 15 years. It's a public-private partnership. At the federal level it's made up of a partnership of the Department of Health and Human Services, the Department of Veterans Affairs, the Department of Defense and the Federal Emergency Management Agency. And it was created to address tow kinds of overwhelming medical care requirements. One is from a civilian disaster where we need to address extraordinary community needs, and the second is in a military contingency in which we might have a large number of casualties that could not be accommodated by the Department of Defense or Veterans Affairs.

Various departments have different functions in this system. The Department of Health and Human Service, which has the lead for the system, is responsible for providing primary care both at the scene and at places where people might be distributed if the local health care system cannot accommodate them. The Department of Defense is responsible for patient evacuation, and both the Department of Veterans Affairs and the Department of Defense are responsible for providing definitive care. And now that is not through their own facilities, but through hospitals that they have asked to join in the national disaster medical system from the private sector that are in their vicinity where their facilities are located.

Just to elaborate a little bit more from a medical response point of view, we have between seven and 8,000 volunteers, health professionals around the country organized into teams which are affiliated with the national disaster medical system. About 35 people from each one of these teams is at least the requirement for the initial response. so that because we have so many teams, we can actually field a very substantial health care work force in the event of a disaster. But we're talking now about a disaster that's in a localized area, not a disaster that is covering essentially all of the country at the same time where they are equal health care burden -- I hope time hasn't run out just because my watch has fallen -- health care burdens around the country, and they represent a variety of medical skills. They're locally sponsored teams. They're available to the states if states have a need for them, and they are community based.

Now, just to give you an idea of the extent of these teams, we have 27 primary care teams that can respond within a 12 to 24 hour. There are three teams on the West Coast and three on the East Coast that are on call at any one time. We have four national medical response teams, one located here in Washington, one in Winston-Salem, one in Denver, and one in Los Angeles, that can respond to the unique requirements of a chemical or biological weapons attack. We have burn teams which are essential, particularly in these kinds of scenarios, if we would, for example, have a mustard gas attack, because of the extensive burn treatments that would be required, and we have disaster mortuary teams, which are teams located around the country that can assist in meeting the extraordinary burden of fatality management in a mass casualty situation. This gives you an idea of the distribution of the team just to show you how broad an asset this is and yet locally based around the country, little known, but extraordinarily important.

Last year these teams were deployed in the field for 340 response days. Two hundred and twenty-five days of the year they were out in the field at least responding to one or up to four different disasters at the same time.
Now, the lead responsibility for definitive medical care rests with the Departments of Defense and Veterans Affairs. these resources are among existing hospitals that volunteer to participate in the national disaster medical system, and there are 2,000 such hospitals around the country offering as many as 100,000 beds in the system ranging everywhere from specialty beds to general medical-surgical beds. These are coordinated from 60 or 70 coordinating centers around the country, and it means that at any one time within a 24-hour notice we could move patients from one part of the country to another part of the country into beds that are committed in this system. To give you an idea of where these coordinating centers are located, you can see they are in all of the population concentrations in the United States, including Alaska and Hawaii.

Now, during the change of millennium and during the exercise that I think many of you are familiar with called top off, it became patently clear that we truly have a capacity problem in terms of being able to take care of mass casualties in the United States. This has been said very directly and alluded to on multiple occasions now throughout this conference, and in particular by some of my colleagues who spoke before me.

And I want to really express my great appreciation both to the center and to the American Hospital Association for their efforts to try to join with us in addressing some of these critical needs that we have. For example, during top off, an exercise that was held just a few months ago both in New Hampshire and in Colorado, it became clear that very rapidly should any kind of significant biological weapons release occur, that we would overwhelm the local hospital system. The demand that would be placed on that hospital system in that local area would be so substantial that it would essentially paralyze the ability of that locality to be able to offer health care services.

Now, recently there have -- well, not so recently. Over the last few years, there have been several studies that have been published, and I'm extrapolating from a study that was published by Kaufman and Meltzer, and I'd be glad to give you the reference if you'd like or the address on the Web, to be able to reference some of the projections of requirements that would exist for the health care delivery system should we be faced, for example, with an anthrax attack. And we've extrapolated the data from that study and said if you were a metropolis of about 500,000 people like Washington, D.C. is and you had about 3,000 hospital beds available, which is about what we have on the average in cities of this size around the country, the number of potential cases from the release of a line source of anthrax could be as much as 250,000 casualties or people exposed, and out of that, we might have as many as 150,000 potential casualties or deaths occurring from the release of that anthrax. Now, if that should occur, just imagine the demand, the immediate demand that's going to be placed on the health care delivery system that will be so overwhelming that it will paralyze that system.

Now, what we are trying to do is look at the options that are available for the health care systems to be able to respond, and part of that work is being done through what I will describe in a moment, which is our metropolitan medical response system planning efforts around the country and in the largest metropolitan areas.

But there are fundamentally three basic options of being able to expand capacity, and you can talk about a lot of different scenarios, and you can talk about a lot of different details, but when you boil them down, there are basically three ways of being able to approach these problems. One is to expand local capacity through the addition of alternate sites for care. Normally as an adjunct to an existing hospital so that the patterns of referral can be maintained, but as was cited earlier, the major problem, as Jim Bentley mentioned, is going to be the work force. It's not just going to be the facilities and the equipment. It's also going to be the work force.

Our second major alternative is home care, and this is something that really has to be looked at very seriously: how we might be able to adapt to a home care scenario in the event that we had mass casualties of the kinds that we're talking about with a bioweapons attack.

And the third is evacuating patients. Now, this has been a solution that works well when you have an isolated disaster and you can move people from a place of relative scarcity of resources to a place of plenty, but the challenge, again, in all of these instances is going to be adequate numbers of health professionals.

Now, one of the things that's happened to us is that in our exercises, and I'm going to just put on a few more slides, is that we have concluded all of our major national exercises within a couple of days after the release of one of these weapons so that it never has really demonstrated the stress that's going to be placed on our health care delivery system, overwhelming it and potentially paralyzing it. So one of the things that we're doing now is we are working with cities around the country to develop metropolitan medical response systems. It's not just cities. It's the surrounding counties and jurisdictions that can join together and develop a plan locally for being able to deal with the health care consequences of the release of a chemical or biological weapon. And to give you an idea of the breadth of the approaches that have been taken is this is a representation of the cities and metropolitan areas around the country we're hoping eventually that we can get to 200 cities. If we get to a little over 100 cities, we will have covered a population of about 150 million Americans. If we can go to 200 cities, we will have covered the vast majority of Americans, except those living in essentially rural areas. And what we expect will happen, what we are really trying to accomplish with this effort through our office and the national disaster medical system is to be able to bring communities together at the local level, parts of the local governance structure that haven't worked together before, and that is to really bring together our first responders, our law enforcement communities, our emergency management communities, our public health communities, and our medical and mental health service communities, to sit together and plan how a comprehensive response to one of these attacks might actually be organized and occur and how the extraordinary health care demands might be able to be met if one of these events ever should occur.

Thank you very much.
(Applause.)