# Presentation: 804980

## 2004 Hurricane AAR’s 

- NDMS Conference

- May 3, 2005
- William L. Devir, EMT-P, BA, MIM

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## AP Photo/USGS, John Pallister 

- AP Photo/USGS, John Pallister

**Notes:**
This photo released by the U.S. Geological Survey (USGS ) shows smoke and ash rising from the crater of Mount St. Helens on Oct 1, 2004. The volcano belched steam thousands of feet above its crater Monday, Oct. 4, 2004, apparently the largest burst yet as days of tremors and low-level earthquakes have raised fears the volcano will blow at any moment. 

## Slide 8

## AAR 2004 Hurricanes – the Process

- AAR’s submitted to Program Managers and EOC
- MWG submitted proposal to Jack Beall that they analyze and present findings at conference
- AAR’s collected by John Gaffney and placed in MWG mailbox
- Pubs & Docs Working Group converted to standard format
- John Burgard performed this tedious task
- Management Working Group combined 21 Hurricane and   NSSE reports for presentation in two presentations

## AAR

- © AP/WWP

## AAR 2004 Hurricanes

-   Teams treated a total of 9,653 patients during the four hurricanes, including:
- 3,872 patients treated during Hurricane Charley
- 1,461 patients treated during Hurricane Frances
- 3,330 patients treated during Hurricane Ivan
- 961 patients treated during Hurricane Jeanne

**Notes:**
Source of info:

Statement of Under Secretary Michael D. Brown
2004 International Association of Emergency Managers
52nd Annual ConferenceDallas, TexasMonday, November 8, 2004

## AAR 2004 Hurricanes

- Comments divided according to Working Groups for follow-up
- 		Management Working Group
- 		Training Working Group
- 		Publications & Documentation Working Group
- 		Operations Working Group
- 		Logistics Working Group
- 		Finance/Admin Issues

## AAR 2004 Hurricanes

- Issues grouped by Keywords
- 		Team Size			Cadre Management
- 		Staging			Communication
- 		Basic Load			Pharmacy
- 		Re-supply			Transportation
- 		Shelter Operations		Safety
- 		Advance Team		Local Medical

## AAR 2004 Hurricanes

- Issues grouped by Keywords
- 		ICS				Accountability
- 		Mental Health		PIO
- 		Fuel				LNO
- 		JMT 				Billeting
- 		Team-owned Equipment	Personnel
- 		Identification

## AAR – Alert Pre-deployment

**Cadre Management**
- Personnel deployed in position description were later refused by Cadre Management for same position assignment
- Problems assigning a Paramedic in a Communications position, despite qualifications and previous deployment in Communications
- Inexperienced augmentation personnel were utilized to fill positions which could have been filled by team personnel
- Cadre Management needs to defer to personal knowledge of team command regarding capabilities of team personnel

## AAR - Safety

- Deployment to an austere environment needs to include planning for potable water for team members
- Logistics personnel were tasked to work extended shifts.  Drivers who picked up personnel from the airport were unrested causing unsafe conditions.
- Team members experienced heat-related illness.  Consider better physical conditioning prior to deployment.
- Team was ordered to travel through remnants of Frances in “unsafe” conditions to stage.

**Notes:**
Water Issue   Frances OH-5
Extended shifts  Charley  MST
Physical conditioning  Frances NC-1
Driving through storm  NM-1 Frances

## AAR - Safety

- Recommendation that teams establish safety precautions for vehicle operations:
- Spotters for backing
- Convoy operations
- Complete set of paperwork for each vehicle
- Establish minimum rest period before driving
- Team deployed in rental vehicles with inadequate rest

**Notes:**
Vehicle operations  Frances OH-5
Minimum rest period  Ivan CA-1

## AAR - Safety

- Safety Issue Should Never Be Ignored
- Complaint by one team that their policy of two drivers per truck for safety was ignored, and team was instructed to move trucks with one driver per vehicle.  This occurred after specific objection by team Commander.

**Notes:**
Ivan MA-2

## AAR – Team Size

- Recommendation to change team size to 40 in order to cover 24 hour operations

**Notes:**
Charley AL-3
Charley FL-5

## AAR – Staging

- Recommendation that deployment teams be flown to staging area to avoid fatigue prior to mission
- Staged teams need to be briefed on a frequent  basis – 3 times per day was found to be good for one team
- Team was staged in urban hotel with no place to park team trucks, presenting security and response issues
- Need to consider composition of team during pre-deployment.  Some teams have long response times to assemble team at point of departure

**Notes:**
Fly to staging  Frances MI-1
Regular briefing  Frances MI-1
Urban hotel Frances NC-1
Team travel distance  Frances NM-1

## AAR – Communication

- Communications issues with JMT and OSC – no answer on phones and radio.
- Command Trailers recommended for deployed teams.
- Investigate deployment of Nextel Tower.
- Asked to communicate daily patient info.  Unable to contact 12 Sept – found out after the fact that JMT had moved.
- Dependence on Nextel a problem when local service not available.
- Austere environment not always compatible with Communication needs – no fax, no Quicktime, etc.

**Notes:**
Comm issues Charley AL-3
Command Trailers Charley AL-3
Nextel tower Charley FL-1
JMT moved without telling team Frances NM-1
Dependence on Nextel a problem Ivan JMT

## AAR – Communication

- Inadequate Communications resources – team members used personal cell phones for team business without reimbursement.
- Cell phones for deployed teams need to be part of cache
- Team depended on personal cell phones for communication due to lack of radios.  No reimbursement.  Other FEMA personnel seemed to have access to Nextel equipment, why not DMAT’s?
- Inadequate Comm assets for mission.  Use of personal cell phones at personal expense. Request to use FRS.

**Notes:**
Ivan MA-1
Frances MI-1
No cell phones Frances NM-1
Use of personal cell phones OH-1
Use of personal cell phones, can we use FRS  Ivan CA-1

## AAR – Communication

- Phones re-issued to incoming personnel – personnel still attempting to reach previous personnel all hours of day and night – reissue by position assignment?
- Clear instructions – mixed signals:  there to treat patients or there to treat Federal personnel only?
- Include team commanders on daily conference calls to improve understanding of mission.
- FEMA ADD used by commander –system is not user friendly and at least one person was missed who had deployed

**Notes:**
Reissue phones Charley MST
Mission assignment Frances NC-1 Mental Health
Include commanders on calls Frances NC-1
FEMA ADD not user friendly Frances OH-1

## AAR – Communication

- Provide written directions/maps to local pharmacies, hospitals, labs, etc., to incoming DMAT
- Provide written instructions to teams on logistics issues
- Hotel check-in/payment
- Per diem information
- Laundry instructions

## AAR – Communication

- Hospitals discharged patients to shelters when nursing homes were unavailable.  Better coordination needed to project nursing resources needed when this occurs.

**Notes:**
No nursing home  Frances MI-1

## Charley, Punta Gorda, FL, Aug. 16, 2004 

- Charley, Punta Gorda, FL, Aug. 16, 2004

## AAR – Basic Load

- Requests for cache improvement:  RSI Kit, Crash Cart, Privacy Screen, Prescription Pads, Dry Erase Boards
- Request Basic Load be evaluated for basic dental, ENT and Ophthalmology needs not currently addressed
- Team-owned hard hats used on deployment – none available in load
- Deployed with incomplete cache.  Regular Inventory updates provided to Logistics, but no re-supply. Team sent to field with incomplete cache.

**Notes:**
Cache improvement  Charley AL-3
Special dental/ENT  Frances NC-1
Hard hats  Frances NC-1
Incomplete Cache Frances NC-1 and OH-5

## AAR – Basic Load

- Basic Load Rev 20 has issues – some boxes too heavy
- Team met a cache which was not theirs and was missing items
- Team required to fax daily reports – No fax machine in load?
- Deployed with another team – cache became intermingled.
- Consider flexibility to accomplish mission relative to team-owned supplies.  Had two air-conditioned trailers which could have improved team conditions had their use been allowed.
- Request addition of X-ray equipment
- Add hand sanitizer to load for austere environment

**Notes:**
Rev 20 issues Frances NM-1
Incomplete cache Frances NM-1
No Fax in load NC-1
Flexibility  Charley FL-1
Add X-ray Charley FL-1
Hand Sanitizer Frances OH-5

Load intermingled Frances OH-1

## AAR – Basic Load

- Patient needs were met with team-owned supplies
- Medical strike team had no inventory for Thomas Pack – missing IV fluids and critical items for mission.  IV fluids out of date.  Missing laceration supplies, eye cleaning supplies, hand sanitizer.
- Team deployed without load due to distance – Logistics slow to supply water food and cache.
- Truck load dependent on mission.
- Team-owned assets need to be segregated if team to leave cache behind

**Notes:**
Team-owned Charley FL-5 no details
Missing items Charley MST
No cache Frances NM-1
Truck loading OH-5
Team-owned equipment OH-5

## Slide 30

## AAR – Basic Load

- Need Crash Cart for resuscitations
- Shelter Operations not addressed with basic load
- O2 Cascade System needed
- Elderly and bed-ridden need pads if cots are used
- All caches received from FEMA were incomplete.  This was provided as an example of why regional cache concept is NOT a good idea.

**Notes:**
Crash Cart  Frances OH-5
Shelter Ops Frances OH-5
Incomplete FEMA cache Ivan CA-1
No cache with team Ivan JMT

## AAR – Basic Load

- Issues related to transporting team separately from their cache – this needs to be revisited.
- Comm personnel monitored weather and briefed Commander on risks or possible evacuation need.  Equipment needs to be part of basic load
- Last team out careful to clean and pack cache for team who left it behind

## Slide 33

## AAR – Pharmacy

- Need for ACLS Drugs and team-care drugs maintained by team – issues with pharmacy arriving separately
- Insufficient pharmacy for mission:  need more pain medication, tetanus, antibiotic and IV fluids
- Request Pharmacy travel with team – not meet team
- Pharmacy driver needs detailed inventory of Pharmacy
- Two teams forced to split pharmacy load – shorted both teams
- Team received Pharmacy load with no tetanus

**Notes:**
ACLS drugs Charley FL-5
Insufficient pharmacy Charley FL-5
Pharmacy travel with team Charley FL-1
Pharmacy list Charley FL-1
Split pharmacy  Charley FL-1 and FL-5
No tetanus  Frances NM-1

## AAR – Pharmacy

- Operational DMAT was told not to open Pharmacy Cache – had to borrow supplies from hospital
- Need FEMA Rx pads with area to print provider’s name and team ID

**Notes:**
“Don’t open” pharmacy Frances NC-1
Rx Pad Charley AL-3 and Frances NC-1

## AAR – Re-supply

- Food and Water did not arrive when needed from Logistics.  Lack of Water was a Safety Issue.
- Fuel re-supply although contracted, arrived dangerously late.
- A decision was made to deploy NM-1 without its cache.  This caused multiple problems when the team arrived with no cache, co-located with a team which had a cache.
- Need Procurement Officer with authority to purchase to support each MST.  USAR can’t deploy with lumber needed, but can’t wait once on scene for days if lives are to be saved.
- THIS ISSUE CAME UP MULTIPLE TIMES AND CONTRIBUTED DIRECTLY TO LOGISTICS SUPPLY ISSUES

**Notes:**
Food and Water  NM-1
Late fuel re-supply Jeanne FL-1
Deploy without cache NM-1
Need procurement officer MST

## Slide 37

**Notes:**
Hurricane Ivan  checkpoint

## AAR – Transportation

- Having vans or SUV’s on scene to move personnel was considered optimal (sub-compacts not practical with personnel and gear)
- Rental Company requested large personal deposit on vehicles.  Renting authority needs to address this up front to avoid delays.
- Arrangements to deploy team were disjointed – not made as a team.
- Lack of fuel cards was an issue
- Issue with flight having inadequate freight capacity to move load with team.  Members left behind to escort gear.

**Notes:**
sub compact no good for gear and personnel MST -Frances
Vans ideal instead of busses to move personnel  Frances MI-1 and Frances OH-1
Request for deposit  CA-1 Ivan
Logistics needs to look at operations issues of renting trucks 2 hours away when local trucks are available Frances NC-1
Inadequate air freight Ivan CA-1
Travel disjointed Frances NM-1
No fuel cards Frances NM-1
Need convoy guideline and markings/lights. Frances OH-1

## AAR – Transportation

- Guideline for convoy needed.  Markings/flashing beacons for convoy recommended.
- Traveler was ready to travel, but early flight was not “FEMA approved.”  Hurricane cancelled later flights, and traveler forced to travel by rental vehicle, which provided later logistical issues on return of rental.  Flexibility on flight could have avoided delay and costs.
- FEMA policy to transport patients across street to hospital by ambulance caused patients to be charged for ambulance transport.

**Notes:**
JMT Ivan
ambulance transport Charley FL-5

## Slide 40

**Notes:**
Orlando shelter

## Slide 41

**Notes:**
Orlando, FL, September 12, 2004-- Members of the FEMA Disaster Medical Assistance Teams prepare to assist people who are arriving at the Orange County Convention Center where a DMAT has been deployed. FEMA Photo/Jocelyn Augustino 

## AAR –  Shelter Operations

- Staffing a shelter presents different mission load requirements.  Recommend participants develop a list to include: sufficient wheel chairs, O2 regulators and Concentrators, safe power supply, etc.
- O2 delivery was an issue – need to anticipate Special Needs population requirements.
- Need to review DMAT role at shelter vs. local health care and supplemental nursing.  Identify ratio of care-givers/aides to patients in special needs shelter
- Some pre-planning on how to co-mingle special needs patients with family members/care-givers.

**Notes:**
Shelter ops  Frances MI-1
Special needs Frances MN-1
Role at shelter and pre-planning for family  Frances OH-5

## Slide 43

**Notes:**
Hurricane Frances  DMAT OH-5 in special needs shelter, Port St. Lucie

## AAR –  Advance Team

- Use advance team to verify mission – don’t engage entire team until confirmed
- Assessment teams should be pre-positioned on events of this magnitude to improve responsiveness.
- Recommendation to use a Medical Liaison Officer to review new mission to verify appropriate response
- Use advance teams.  Try to include staged teams in briefings and any SitReps.

**Notes:**
Verify mission  Charley FL-1
Pre-position assessment team Ivan DMORT 4
Use medical liaison officer  Ivan JMT
Included staged teams  Charley AL-3

## Stuart, FL, September 6, 2004 – DMAT NM-1 at 

- Stuart, FL, September 6, 2004 – DMAT NM-1 at
- Martin Memorial Hospital South following Hurricane Frances

## AAR –  Local Medical

- Need improved Medical Intel going in.  Available beds, pharmacies open, lab support, etc.
- Outreach to local Fire, EMS, Hospitals, Pharmacies and Red Cross worked well.
- Attempt to merge with hospital operations improved relationship with staff
- Great attitude by Holmes Regional Hospital.  Combined daily senior staff briefings seemed have positive effect.
- Early Command interface with hospital administration made for smooth transition and teamwork.

**Notes:**
Medical intel Charley AL-3
Outreach  Frances MI-1
Merge operations Charley FL-1
Attitude and briefings Frances NC-1
Early command interface Frances NM-1

## AAR –  ICS

- Several DMAT’s working together on same mission.  Command staff consulted each other on decisions, but one person had ICS assignment.
- When teams are combined, Command staff from each team should participate in Unified Command.
- One local provider was disruptive to team operations, but had inordinate influence with local law enforcement joint command.
- Medical Officer, Chief Nurse and Commander should be involved in site selection.  Team set up tents when hardened structure with power and AC was available one block away.

**Notes:**
Several DMAT’s  Frances MI-1
Local provider issue  Frances DMAT OH-5
Involve team command  Frances DMAT NC-1
Branch director  Charley MST

## AAR –  ICS

- Single branch director supervising Supervising Medical Officer, supervising LNO, supervising Team Commander.
- Perception that NDMS was not with the program relative to ICS.  Wanted to do things the “NDMS” way.  Perception that NDMS needs to mold itself to the FEMA/USAR model.
- Drivers for cache were re-routed to a location separate from the team.  Drivers had dual role as medical providers, and team Admin supplies were separated from the team.  Team Command was never consulted on this decision, which impacted operational readiness.

## AAR – Accountability

- FEMA ADD was used by team Commander.  System is not user friendly.  At least one deployed member was missed.
- Personnel were on scene, working the incident, who were not officially on any personnel list.
- Constant buddy-system and training reinforcement made for heightened awareness and good personnel accountability during deployment.

**Notes:**
OH-1
Personnel not on list  Charley MST
Buddy System  Frances DMAT OH-5

## AAR –  Mental Health

- Mental Health important for patients and their families.  Need Mental Health on team to treat patients.
- NDMS supports Federal teams.  SAMHSA supports civilians. NDMS assets could have positive impact on civilian victims.
- Recommend that mental health be represented on JMT.
- Need standard reporting format for Mental Health contacts on deployment
- Need better liaison and familiarity with Mental Health Assets. Presence at daily briefings.  Collateral materials like laminated wallet cards.

**Notes:**
CISM important NC-1 Frances
Mental health JMT Ivan IL-2
MH reporting  Ivan IL-2
MH familiarity Charley IL-2
NDMS treat civilians? Ivan IL-2

## Under Secretary Mike Brown speaks with John Caprio 

- Hurricane Charley Punta Gorda, FL, August 17, 2004
- Under Secretary Mike Brown speaks with John Caprio

## AAR – PIO

- Local Pharmacies would not accept federal PA scripts.  Need to have info for Pharmacies and local health care that outlines nature and authority of NDMS medical mission.  Provide sample of FEMA script pad to local pharmacies.
- Team Commander should _always_ have the authority to speak to the media, especially where it pertains to a mission assignment.
- Conflicting information on who can give an interview to the press.
- Would be nice to have signs for back-drop at interviews or photo ops.

**Notes:**
Need info for local medical community Charley MST
Commander should speak  Charley FL-5
Conflicting info  Charley AL-3
Background for photo ops  Frances NC-1

## AAR –  Fuel

- Use of team credit card facilitated purchase of fuel for deployment.  Need to investigate cash, due to lack of power and credit card access in some deployments.
- Team fuel cards were especially important for refueling rental vehicles.
- Team did not have credit cards to charge fuel – this was an issue.

**Notes:**
Fuel cards  Frances OH-1
Team credit cards  Frances OH-5
Needed fuel credit cards  Frances NM-1

## Slide 54

## AAR – LNO

- LNO should support team, not attempt to manage team.
- Group Supervisor was Team Commander with knowledge of NDMS and mission.  Very helpful as result of experience.  This position should always have medical experience.
- LNO worked with only one of two Commanders on mission.
- LNO led convoy at unsafe speed for conditions.
- LNO needs to take supportive role toward team, not supervisory.  In no case should a LNO pass info or orders directly to team members.  Always go through Commander.
- Team had 7 LNO’s in 14 day deployment.

**Notes:**
Support team Charley FL-5
Recommend med experience Frances NC-1
Worked with one Commander Frances NM-1
Unsafe speed Frances NM-1
Supportive role  Frances CA-1
7 LNO’s Frances CA-1

## AAR –  JMT

- JMT should be more supportive of teams needs, less directional.
- NDMS Chain of Command needs to interface to JMT.  Comm/IT equipment pulled for another mission, disabling JMT operation.
- Recommend that personnel experienced in NDMS be included in JMT planning section when mission has medical component.
- Not apparent that all JMT staff are accustomed to using ICS- could be a training issue

**Notes:**
JMT role Charley FL-5
Interface Charley JMT
Included NDMS  Ivan JMT
ICS Charley JMT

## AAR –  Team-owned Equipment

- At end of deployment team-owned equipment had to be returned in truck rented by sponsor.
- Consider flexibility in response.  Team had 2 AC’d trailers which could have been used for patient care or team support.

**Notes:**
Team owned equipment Frances NC-1
AC trailers Charley FL-1

## AAR –  Personnel

- Need for Medical Logistics Officer.  This position was not always staffed when Medical Liaison was in the field.
- Nurses from team assigned to another location.  Request augmentation teams support this requirement to keep team assets intact.
- Difficult to integrate Physicians and nurses who have not previously worked or trained together.  Try to avoid deploying partial teams.

**Notes:**
Med Log Off  Ivan  JMT
Split team  Charley FL-1
Team experience  Frances AL-3

## AAR –  Identification

- NDMS uniforms confused with law enforcement.  Suggest signage clearly indicate medical care available.

**Notes:**
ID  Charley JMT

## AAR –  Billeting

- Team was scheduled to be housed in hotel with no power, when hotel with power was available.  Team comfort and morale should be considered where possible.
- Need for team travel cards.  Issues with centrally booked rooms which were billed to travelers personal credit cards by mistake.

**Notes:**
No power Frances NC-1
Charges to personal cards. Frances OH-5

## Hurricane Charley

- AL-1, AL-3, CA-3, ERT, FL-1, FL-2, FL-3, FL-4, FL-5, FL-6, GA-3, IL-2, KY-1, MI-1, NDMS-1, OK-1, PA-1, PA-3, RI-1, TN-1, VMAT-3

## Hurricane Frances

**Notes:**
Hurricane Frances  DMAT OH-5 in Port St. Lucie special needs shelter 

## Hurricane Ivan

- AR-1, CA-1, CA-3, CA-9, DMORT-4, ERT, FL-3, FL-4, GA-3, GA-4, IL-2, MA-2, MO-1,
- NDMS-1, NJ-1,
- OK-1, OR-2, SC-1, TN-1, TX-3, TX-4

**Notes:**
Hurricane Ivan USAR

## Hurricane Jeanne

- ERT, FL-1, FL-5, GA-4, KY-1, NDMS-1, TN-1

**Notes:**
Hurricane Jeanne

## VMAT Response

**Notes:**
Hurricane Charley, US Mike Brown with VMAT

## USAR Response

**Notes:**
Hurricane Ivan  USAR response

## Invitation to Participate ...

- NDMS at-large members wishing to serve on a  specific WG:
- Submit names with a short resume to their Team Commander for approval
- Forward list to MWG liaison
- Selection according to current needs
-  Criteria for assignment may include: Region, team type, specific skill set

## Contact: 

- William.Devir@dhs.gov

## Slide 69

**Notes:**
Hurricane Frances DMAT OH-5

## Slide 70