State-by-State Report on the Status of Emergency Medicine

As a nice complement to the "Ready or Not?" report released earlier this week, the American College of Emergency Physicians has published its annual "National Report Card on the State of Emergency Medicine," which examines emergency medicine on a state-by-state basis and concludes that:

The emergency care system in the United States remains in serious condition, with numerous states facing critical problems. That is the disturbing but unmistakable finding of the 2009 edition of "The National Report Card on the State of Emergency Medicine," a report designed to provide the American public with an objective assessment of the emergency care environment across the country.

Which is, of course, not a surprise. For years, hospital managers have applied "just-in-time" principles to their operations, in an attempt to hold down spiraling costs. They've trimmed as much fat as possible, leaving hospitals with little surge capacity.

Granted, we are stockpiling vaccines and other medications, which will help in the event of the inevitable health care crisis. (I'm less sanguine about our ability to deliver them in a timely, organized, effective manner; but that's another story.) Unless we re-build some excess capacity in our health care system, other necessities such as bed space, health care staff, respirators, etc., are simply not going to be there.

We pays our money, we takes our chances...

Worthwhile Reading: "Marrying Prevention and Resiliency"

There's some good food for thought in this occasional paper from RAND, which advocates a "hybrid" approach to prevention and mitigation:

Instead of seeing an either/or choice between traditional prevention and mitigation or resiliency measures, it is more productive to consider them together in an integrated way—as two complementary elements of a strategy aimed at lessening the consequences of successful terrorist attacks. Doing so essentially stretches the concept of prevention beyond the ideal of halting attacks before they happen to also include efforts to limit the human and economic costs of even successful attack operations.

It's not a terribly long read, and it's worth the time.

We still haven't found the right balance of prevention, mitigation, and response. The unfortunate political reality is: It's much too easy to allow preventive efforts to devolve into "security theater"; it's much to easy to give short-shrift to mitigation, despite the effectiveness of many mitigatory efforts, because mitigation almost always lacks sex appeal; and it's much too easy to overemphasize response, since everybody wants to take the credit for a successful response to the inevitable disasters and nobody wants to take the blame for an unsuccessful one.

Earthquakes in the Midwest: Who's Prepared?

Not good news:

Tennessee is the only one of eight states in the Central United States Earthquake Consortium to finish its revision to the Catastrophic Event Annex of our state's emergency-management plan.

Anyone in the Midwest who's unprepared for a major earthquake simply doesn't appreciate history. In 1811 and 1812, three enormous quakes in the New Madrid seismic zone devastated a wide area. Fortunately the population was very low at the time. But today? Memphis and St. Louis are both in the zone and could sustain major damage from a big quake.

Check out November's report by the Mid-America Earthquake Center, which said:

[T]he total economic impact of a series of New Madrid Seismic Zone (NMSZ) earthquakes is likely to constitute by far the highest economic loss due to a natural disaster in the USA.

An earthquake of magnitude 7, as has been predicted, or a recurrence of the 1811-1812 series could have devastating impacts on the region, with considerable national repercussions, as transportation routes, natural gas and oil transmission pipelines are broken and services are interrupted. Preliminary estimates, including those completed by the Mid-America Earthquake Center (MAEC), found that economic losses from a magnitude 7.7 (Mw7.7) event in the NMSZ could reach $50-$80 billion dollars in direct losses alone. Additionally, there could be thousands of fatalities, tens of thousands of injured victims, and even hundreds of thousands left without homes.

According to Hildenbrand et al. (1996), the chance of a magnitude 6 or 7 earthquake occurring within the next 50 years is roughly 90%.

1812 seems like a long time ago, but complacency is unforgivable.

Poughkeepsie Gets It

Good practice in Poughkeepsie:

When different police departments talk to each other, it's bad news for the bad guys.

The Field Intelligence Group is an unofficial association of about two dozen police officers, probation and parole officers and other law enforcement officials from the various departments in Dutchess and Ulster counties.

They meet weekly and stay in contact constantly, using text messaging and e-mail to alert each other of crimes and trends and work together on cases that cross jurisdictions.

Information they share include descriptions of suspects or crimes. These days it does not take long to distribute surveillance video to all the police agencies in the area.

"You'd be surprised how many times we get video of something and we send it out, and you'll get three or four calls within a few hours ... saying, 'Hey, I know him,' " said Detective Erik Lindmark, field intelligence officer for the Town of Poughkeepsie Police Department.

Dutchess' Field Intelligence Group was born out of tragedy. After Sept. 11, 2001, a lack of communication between different federal agencies was blamed for not preventing the attacks. A lack of communication between the New York City police and fire departments was blamed for further loss of life that day.

Deputy Sheriff Stephen Reverri, the field intelligence officer representing the Dutchess County Sheriff's Office, said Sept. 11 shed light on the importance of communication on the local level, as well.

"Information wasn't being shared, and we saw it on a local level dealing with common criminals," Reverri said.

Share information. Preserve civil liberties. Protect the public. It works. And ... it's free!

The group has no budget; it relies on individual agencies allowing their officers the time to participate.

Quickly Noted: Annual "Ready or Not?" Report Published

The Trust for America's Health has released its annual "Ready or Not?" report, analyzing the readiness of the U.S. public health system for a major biological disaster. The report includes state-by-state rankings and always makes for interesting, if somewhat depressing, reading.

Here's the press release and summary of key findings. Here's the full report (pdf, 2.6MB).

Lessons Learned: Only Our Own?

It's probably a universal human trait: We're very adept at changing our ways based on what's in the rear-view mirror. But only our own, not someone else's.

That's why it's so vital to share information and learn from others' experiences. For example:

CHARLESTON, W.Va. -- Kanawha County officials have changed an emergency response plan more than three months after a deadly explosion at the Bayer CropScience plant in Institute.

Depending upon the severity of an event, Emergency Services Director Dale Petry says the county will issue an automatic shelter-in place during a chemical emergency if officials can't get clear information about the incident within 10 minutes.

Emergency services officials have criticized Bayer CropScience for failing to provide timely information following the Aug. 28 incident in which two people died. The incident remains under federal, state and local investigation.

Has Kanawha County's experience caused any other local government officials, anywhere else in the United States, to re-consider their own emergency response plan?

There are 15,000 hazardous chemical facilities in the United States. 7000 of them could affect more than 1000 people in the local area in the event of an accident or intentional release. 123 of them could affect more than 1 million people (source). When is the last time the communities near those chemical facilities examined their emergency response plans?

LA Re-thinks Emergency Management

The Mayor's office in Los Angeles has released a new emergency management initiative.

This initiative ... involves several components to enhance the City’s planning and preparedness efforts, train city employees in disaster response, better prepare the community in disaster preparedness, and modernize the City’s antiquated emergency management structure.

Here's one thing I find interesting. To describe the current state of preparedness, the city uses measures such as staffing levels, training exercises, programs and strategies. For example:

[T]he City Council recently approved the Mayor’s request to add three new positions to EMD to work on planning and preparedness activities, emergency operations, and public information. In addition, through the leadership of General Manager Jim Featherstone, a former Captain in the LAFD’s Planning and Tactical Training Division, EMD is modernizing its operations, procedures, and principles to reflect a contemporary emergency management approach to the numerous dangers the City faces.

But that's not the best measure of preparedness. Real preparedness has to be measured in terms of capabilities. It's not just how many training exercises you have, the size of your staff, or the strategies and tactics you employ. Those are necessary, yes. But they're not sufficient. If you're going to assess your state of preparedness, you need to be able to declare with some confidence what your capabilities are.

Planning for a Pandemic? Meh.

In direct contrast to the immediately previous blog entry, and a week after the NYT's Freakonomics blog asked, "Why do voters reward poor disaster preparedness?" a story comes out of Georgia about some local elected officials who haven't even shown up to the meeting to prepare for a pandemic flu:

Jones County’s biggest problem with a pandemic flu occurrence may be the perceived apathy demonstrated in planning for the event by local elected officials.

Jones County’s pandemic flu preparedness committee met July 17 at the Emergency Management office and has the task of educating the public to the reality of having to be self-sufficient if the disease hits. In the case of a pandemic, communities cannot be dependent on federal or even state assistance.

City and county elected officials were conspicuous by their absence at the meeting with Probate Judge Mike Greene the sole representative.

They also didn't show up to a table-top exercise in February:

An after-action report by the North Central Health District Office about Jones County’s Feb. 20 table top exercise stated, “The fact that no elected officials or business leaders were present at the exercise lends itself to the belief that the leadership of Jones County does not seem to have bought into this concept.”

Any local official who isn't involved in this type of planning is doing their community a great disservice. A pandemic is not a question of if, but when. And every community will be affected.

I've bolded the key concept in red. Every local official needs to realize that in the event of a major pandemic, local communities are going to be largely on their own. Local planning is essential.

Preparation In the Absence of Press

The threat of pandemic flu has gotten a lot less press lately, mostly because the incidence of avian flu seems to have plateaued somewhat (though Indonesia is still being really tight-lipped about what's going on there, so who really knows?)

But even though the issue is getting less attention in the media, some communities are continuing to do the smart thing and developing plans to address a pandemic flu. It's worth remembering that there's no guarantee that the source of the next human pandemic will be avian flu. It could come from another source, and it could conceivably come out of nowhere and surprise us.

So it's good to see local communities, like these in South Dakota, working together to develop plans to deal with the threat, which in its severest instances (e.g., an event comparable to the 1918 Spanish Flu outbreak) could have more widespread impacts than almost any other catastrophic event:

After more than a year of work, the members of a local planning committee will present their pandemic influenza response plan to the public.

The 131-page plan was developed by committees from Aurora, Davison and Hanson counties and it provides guidelines on how to deal with a pandemic flu outbreak that many medical professionals believe is inevitable.

[The plan] provides action checklists to help schools, businesses and other community organizations develop a coping plan, in the event of a flu outbreak.

A family preparedness kit will ... demonstrate what items should be on hand in the event of an epidemic. Such preparedness will be important in the event of a flu outbreak.

While the Centers For Disease Control and the state Health Department will monitor and report on all flu outbreaks, said Assistant Mitchell Fire Chief Steve Willis, local jurisdictions will largely be on their own.

Apathy is the greatest danger when it comes to planning for a dangerous flu outbreak, says Jim Montgomery, Davison County Emergency Management director.

Mr. Montgomery is absolutely right - the best community-based plan will be useless unless individual citizens, businesses and other entities such as churches and community groups do their part to prepare.

In my humble opinion, the effort to create the plan ought to be dwarfed by the effort to distribute it, publicize it, and follow up to ensure that people are prepared. According to the Red Cross, more than 90 percent of Americans are not prepared for a major disaster. In Mitchell, only about 40 people (in a population of 15,000) showed up at the meeting to learn about the pandemic flu plan. But as the dedicated John Solomon regularly and diligently reminds us (because repetition makes a message stick) citizen preparedness is vital.

The Holy Grail of preparedness is getting more individuals to prepare on their own. Every citizen that's adequately prepared will help the system - not only by being better off themselves, but also by reducing the strain on community services, improving the situation for their neighbors as well.

A Sensible Decision

An update on this story:

Prosecutors have dropped the "weapons of mass destruction" charge in the case of the South Carolina teenager who allegedly planned to bomb his school.

The teenager who allegedly planned to destroy his high school with explosives will not face a WMD charge at his anticipated trial, the Associated Press reported yesterday.

Ryan Schallenberger, 18, had been charged with attempting to use a weapon of mass destruction in connection with his suspected plot against Chesterfield High School. Federal prosecutors dropped the charge without explanation in May.

The WMD charge never made sense. He had enough ammonium nitrate to take out a classroom or two, but that's a far cry from a weapon of mass destruction.

Calling something "WMD" when it's not only confuses and dilutes the meaning of the term.

For What It's Worth

One time I recall hearing someone quip that to understand what's meant by the word "expert," you just have to analyze its two syllables. When you do this, you realize that an "ex" is a has-been and a "spurt" is a drip under pressure.

So then.

A group of homeland security experts have spoken:

Book Hill Partners and the Homeland Defense Journal released the results of a survey of 122 homeland security experts on priorities for the next administration in protecting the American people and homeland.

Key findings of the survey include:

• Over 83 percent of experts surveyed expected a major disaster of some kind in the United States within the next four years, within the term of the next president.
• Roughly 58 percent of respondents said that the most probable scenario for a major disaster was a natural disaster. More surprisingly almost 22 percent of experts said that the most probable scenario for a major disaster was a terrorist attack with a weapon of mass destruction (chemical, biological, radiological or nuclear specifically).
• Almost 72 percent of respondents expect major changes if Sen. Obama is the next president. In contrast, over 80 percent of respondents believed that homeland security policies under a McCain administration would be largely unchanged from those under the Bush administration.
• The next administration's top four homeland security priorities should be border security, emergency response, development of medical counter-measures to weapons of mass destruction, and port security.

Prognostication is always a nice safe business. Even if you're wrong, it was just an educated guess anyway. But I am curious as to how anyone could predict a "major natural disaster" within a given timeframe. You can lay odds on it, sure, but to expect that one will happen? Hmm...

Terrorists and the Energy Infrastructure: What's the Risk?

In a brief paper published under the auspices of the Naval Postgraduate School, Dr. Michael Mihalka and Dr. David Anderson analyze the risk of catastrophic terrorism targeting the energy infrastructure. They argue that the risk is relatively slight when compared to other threats:

The threat from and effect of transnational terrorism [to the energy sector] is much less than many pundits have argued. In essence, the transnational terrorism poses a challenge well within the parameters of natural events and the ability of the current security system to handle.

Well, we must remember that the prime threat to the security of supply in the short-term perspective is not terrorism, or even politics. It's Mother Nature.

It's certainly true that a terrorist group would really have to "go big" to replicate the kind of disruption to the energy sector that Hurricanes Katrina and Rita caused.

Energy is one sector in which the ability to respond and recover can be a real deterrent. A primary goal of any direct attack on energy infrastructure would be economic. But if the economic damage is mitigated by resiliency in the sector, then there's less rationale for the attack.

Cool Tool For Tracking Disease Outbreaks

Healthmap

(h/t Effect Measure)

How Do They Do It? ... Volume! Volume! Volume!

State, local, and tribal governments will soon be able to leverage the federal government's buying power to purchase homeland-security related items:

The U.S. General Services Administration received new authority to help state and local governments in purchasing homeland security equipment and services under the Local Preparedness Acquisitions Act (HB 3179) signed by President Bush last week. The new law authorizes the GSA Administrator to allow state, local, and tribal governments to buy homeland security goods and services through the cooperative purchasing program. Officials will be able to use GSA's Schedule 84 to buy items such as alarm systems, facility management systems, firefighting and rescue equipment, law enforcement and security equipment, and marine craft.

Federal Acquisition Service Commissioner Jim Williams said, "GSA's ability to leverage the federal government's enormous buying power enables us to provide goods and services at best value and pass the savings on to our client agencies. Now we can pass these discounts on to state and local governments ...

Using your organization's buying power to get discounts is, of course, a no-brainer.

At the same time, state, local and tribal governments have to maintain strategic discipline and avoid slipping into the tempting but faulty line of thinking that homeland security means the opportunity to buy more stuff (!)

Material purchases should always support the state and local homeland security strategy. If they don't, the money is probably better spent elsewhere, even if the new stuff looks great and provides local politicians with some really nice publicity shots.

Sensible Medicine

The Florida legislature recently passed a law that makes sense. It will allow people to refill prescriptions in an emergency, even if their insurer says they're not yet due for a refill:

Recently, the Legislature passed the Emergency Prescription Refill bill (Florida Statute 252.358 and 462.0275). This law requires all insurers and managed-care organizations to suspend refill-too-soon restrictions when a patient seeks a refill in a county that:

• Is currently under a hurricane warning issued by the National Weather Service
• Is declared to be under a state of emergency in an executive order issued by the governor
• Has activated its emergency operations center and its emergency management plan

This law also allows patients outside of these areas to get an emergency 72-hour refill if the pharmacist is unable to readily obtain refill authorization from the doctor.

In certain cases, simply telling people to "be prepared" is not enough. Sometimes you've got to remove obstacles for them. This law is a good example of that.

FEMA: The Iceman Will No Longer Cometh

Catching up on this one:

FEMA Administrator R. David Paulison said in April his agency will only distribute ice for medical emergencies or life-threatening situations following a disaster. Since its inception, FEMA has provided ice to disaster victims, especially in areas where power outages occur.

“We’re not in the ice business anymore,” Paulison said, and that it is not a “life-saving commodity” for most people. “It takes a tremendous amount of resources, and it really doesn't accomplish much, other than making people feel good because they have a bag of ice," Paulison added. “Ice is more of a comfort thing.”

“My response is that during July, August and September in South Mississippi, ice is not necessarily used to cool water to drink,” said Don McKinnon, director of the Jones County Emergency Operations Center (EOC). “During emergencies, it is used for medical purposes to keep specific medications cool, to help keep food good in refrigerators until power can be restored, and for cooling people off. It is a necessity here."

With the current situation (FEMA out of the ice business), McKinnon said the “state is trying to take up the slack. They (state emergency agencies) have limited resources, and can’t do it quite as effectively as FEMA did. Our pockets aren’t that deep. Locally, we hope we keep water pressure and generators to try to provide ice. Large chicken plants produce large amounts of ice and they have been kind enough to share it with the citizens of Jones County. After Katrina, they provided several thousands of pounds of ice.

“Who will distribute the ice?,” McKinnon asked. “We don’t have the manpower or resources to do that, or don’t have funds to buy ice and give to people. It’s a big void in our plan right now; we don’t know what we’re going to do. If we’re able to get any ice at all, it will probably be from the state if local providers are down. We will definitely focus on medical needs, and the elderly and young to keep them cool to prevent heat stroke and deaths."

This needs to get worked out. Your bottled water may not need ice, but your food and medicine do. The big question: How does FEMA define a "medical emergency" or "life-threatening siutation"?

Here's what's puzzling to me: It's fine if FEMA doesn't deliver the ice themselves - they have already vowed to get out of the logistics and transportation business, leaving that work to contractors. But with their buying power and their network of suppliers, they ought to be able to facilitate the supply of necessary ice during an emergency.

This also seems to show a disconnect between state and local homeland security and DHS/FEMA. Did FEMA get local input before making this decision?

Priorities?

Forgive me, it's Friday and I couldn't resist posting this:

Delivery boys across America, beware: Zach Phillips was arrested by Homeland Security Thursday afternoon in Kansas City—for delivering a pizza. Phillips parked his car in front of the KCMO Federal Courthouse to deliver lunch to a few judges and on his way out, he was approached by several Homeland Security officers. When questioned, Phillips forked over his I.D. to the inquisitive officers. According to Phillips, the officers then shoved him up against their S.U.V., cuffed him, and escorted him down the block to the county jail. His crime? An outstanding warrant for a minor, non-moving traffic violation. "They were real rough with me, throwing me up against their car," Phillips told CMJ.

"[Kansas City police officers] couldn't believe [Homeland Security] arrested me," Phillips said. "[KCPD] actually apologized to me. They were like 'We like you! Don't spit in our pizza!'" Phillips had a hard time believing it himself. "I was like, shouldn't you be looking for Osama Bin Laden?" said Phillips.

Hmm ... sounds like there are a couple of disconnects here: One between DHS and KCPD, and the other between DHS and its priorities.

A Useful Terrorist Profile

There still isn't one.

A new joint security alert from the Department of Homeland Security and the FBI warns that terrorists are increasingly turning to women and teenagers to carry out suicide bombings.

The bulletin, obtained by CBS News, says “Female suicide bombers conducted more than twice as many attacks in Iraq in the first six months of 2008 than in all of 2007”.

US intelligence analysts also say Islamic radicals are enlisting greater numbers of teenagers for their deadliest missions.

It's not who they are; it's what they do.

DHS Targets Chemical Facilities

DHS has set its sights on U.S. businesses that manufacture, process, and store large amounts of chemicals, pointing out that such operations could be targets for terrorists (not to mention accidents):

The federal government will tell 7,000 businesses next week that they are considered high risk-terrorist targets because they house large amounts of chemicals.

The sites — which range from major chemical plants to universities, food processing centers and hospitals — will need to complete a vulnerability assessment so the government can decide how to regulate their security measures in the future.

U.S. intelligence officials say terrorist organizations, including al-Qaida, favor chemical attack methods because of the severe consequences they can inflict.

"This is never going to be an impregnable target set, but I want to introduce enough complexity into the mix that al-Qaida's going to go somewhere else," said Bob Stephan, assistant secretary of infrastructure protection at the Homeland Security Department.

As the department considers these 7,000 sites, it also will look at physical security; cyber security; insider threat potential; how hazardous a chemical release could be to the nearby communities; how dangerous the chemicals are if they are mixed with water; and whether the chemicals could be easily stolen from the sites and used to kill.

Sounds like purely protective intervention - harden the most potentially dangerous sites, thereby force the potential adversary to seek a softer target.

I like the move, because I've never been convinced that chemical facilities have been secured in proportion to the potential threat. The same goes for chemicals in transport via train and truck.

At the same time, it's important to contextualize this sort of action. No one should heave a sigh of relief, thinking that the possibility of a terrorist attack involving chemicals has just become vanishingly small. It remains necessary to fight terrorism at the source by complicating the efforts of potential terrorists to recruit, train, raise funds, organize into operational cells, and plan attacks. That sort of activity will do more to prevent a terrorist attack - via any attack mode - than any protection regime.

One point of fact in correction of the above: Historically, terrorist organizations have not favored chemical attacks. The overwhelming choice of attack is with conventional explosives. For a while in early 2007, al Qaeda in Iraq experimented with combining conventional explosives and chemicals (usually chlorine but also nitric acid in at least one instance), but that attack mode didn't seem to be much more deadly than the conventional explosives alone.

Disaster Preparedness: Status Update

Shameless linking:

HSToday does a good job summarizing a number of recent reviews of the federal disaster preparedness system.

Shameless quoting of a few key points:

DHS “needs to better integrate stakeholders in its revision of key policy documents, particularly the National Response Framework,” stated William O. Jenkins, Jr., director of GAO homeland security and justice issues.

[In] the National Pandemic Strategy and Implementation Plan, [GAO] found that there are numerous shared leadership roles and responsibilities, leaving uncertainty about how the federal government would lead preparations for and response to a pandemic.

[G]iven what a good many authorities – including federal preparedness insiders – have told HSToday.us about preparedness problems throughout the federal government (see HSToday.us’s reporting on emergency medical care, pandemic planning, and FEMA disaster preparedness), the ability of the federal government to adequately respond to a major and catastrophic disaster or crisis clearly is in doubt - despite the fact that the government's readiness today is clearly far, far better than it was just a few years ago.

"There is a real concern among the state homeland security directors around the country that there are people in the federal government who want to put the interests of the accountants ahead of the interests of our citizens. That would be a grave mistake," the subcommittee was told by Alabama Department of Homeland Security Director, James M. Walker, Jr.

It's not all bad news, though it may seem so from the excerpts above. DHS is moving forward slowly, slowly...