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Forum on Medical and Public Health Preparedness for Catastrophic Events; Board on Health Sciences Policy; Institute of Medicine; Davis M, Reeve M, Altevogt B, editors. Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary. Washington (DC): National Academies Press (US); 2013 Dec 26.

Cover of Nationwide Response Issues After an Improvised Nuclear Device Attack

Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary.

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5Challenges to Command and Control

Key Points Made by Individual Speakers

  • The command and control framework using the Incident Command System and the National Incident Management System is sufficiently flexible to apply to the enormous challenges of an improvised nuclear device (IND) attack.
  • If the target area’s command and control infrastructure is rendered unusable, an incident command post from a neighboring jurisdiction needs to assume control. To facilitate the transfer, memoranda of understanding and delegation of authority to an alternate jurisdiction should be in place prior to an IND attack.
  • The integration of command and control systems among local, state, and federal agencies will be one of the foremost challenges in the event of an IND attack.
  • The factors crucial to the successful implementation of command and control are feasibility and flexibility, reliance on evidence-based practices, reliance on multiple-use technologies, and possessing a range of capabilities, including behavioral health, communication, and laboratory surge.
  • The establishment of command and control starts with developing specific plans and policies ahead of time, ensuring clarity in roles and responsibilities, and planning for complex commands throughout the affected region.
  • Command and control systems are uniquely compromised in IND incidents relative to other disasters because of the massive disruption of communications, transportation, and financial systems, the scarcity of resources, the inability to deploy first responders into the severe damage zone, and ethical dilemmas for triaging patients.

Another important issue identified by the ad hoc committee during the workshop planning process is the challenge of reconstituting command and control after an improvised nuclear device (IND) incident. To help address this, the Institute of Medicine commissioned a team at National Security Technologies, a contractor to the Department of Energy, to write a paper describing the needs and planning recommendations for jurisdictions to avoid a lack of infrastructure if the existing command and control system sustains damage. Following the presentation of the white paper, other command and control experts offered their challenges and solutions to reconstituting functional operations.

ESTABLISHING FUNCTIONS AFTER AN IND ATTACK

David Pasquale1 and Richard Hansen2 organized their presentation and their companion white paper (see Appendix H) around a series of questions regarding the complex problem of establishing effective command and control functions after an IND attack. This establishment starts with developing specific plans and policies ahead of time, ensuring clarity in roles and responsibilities, and planning for multiple levels of command throughout the affected region. The framework that ensues should be regarded as a collaborative effort among federal, state, and local jurisdictions. That collaborative effort entails sharing of plans before the incident and the sharing of situational awareness during the incident. Without rapid situational awareness, the effort cannot succeed, Pasquale said.

Changing Basic Framework

The first question the two speakers addressed was, Would the current command and control framework change in the face of an IND incident? They said that the command and control framework using the Incident Command System (ICS) and the National Incident Management System (NIMS) should not change. The framework of ICS and NIMS has been developed over decades, starting with a system for fighting fires, and it was embraced in 2004 by the Department of Homeland Security for responding to hazards of all types (FEMA, 2013a). The framework is known nationwide and has been adopted by responders at all different levels and by communities of different sizes. Importantly, Pasquale said, the framework has proved itself to be sufficiently flexible, scalable, and adaptable to be applicable to an IND attack.

Management of Operations

Their second question was, What would the management of operations look like as the event unfolded? Each jurisdiction needs to set up an incident command post (ICP) that has the legal authority to manage the incident, and an emergency operations center (EOC), which is a hub of communication and coordination serving the ICP. As quickly as possible, one or more ICPs should transition to an area-wide command, the purpose of which is to manage an integrated response by multiple ICPs. The area command should include representatives from all affected agencies, such as law enforcement, public health, fire, emergency medical services, public works, and mass transit and transportation. As the response grows and becomes more complex, one of the area commands should evolve into a unified command. A unified command helps to determine each jurisdiction’s complex needs, including the need for health care, mass evacuation, and medical equipment. Pasquale noted that one major purpose of a unified command is to manage each jurisdiction’s competition for resources, which in the event of an IND detonation are likely to be scarce. Because an IND attack affects a broad geographic area, there may be a need for more than one unified command. To better coordinate a unified command with several jurisdictions, many state and local authorities often utilize Web-accessible resources to assist in the setup and operation of an ICP or EOC during a response. These could also prove very useful in an IND attack response.

Jurisdictional Coordination with the State

The third question was, How do neighboring and affected jurisdictions coordinate with the state? The state needs to set up a state EOC, the purpose of which is to coordinate the activities of local EOCs and area commands (see Figure 5-1). Because an IND detonation will quickly become a regional, state, and national incident, the state EOC will be crucial in drawing resources from other states and from the federal government.

FIGURE 5-1. Organizational diagram for ICPs and EOCs at the local and state levels.

FIGURE 5-1

Organizational diagram for ICPs and EOCs at the local and state levels. NOTE: EOC = emergency operations center; ICP = incident command post. SOURCE: Pasquale, D. A., and R. G. Hansen. Implications of an Improvised Nuclear Device Explosion on Command (more...)

Assisting Disabled Infrastructure

The fourth question Pasquale and Hansen addressed was, If the target area’s command and control infrastructure is destroyed or disabled, how can neighboring jurisdictions assist with command and control of the targeted jurisdiction? An ICP/EOC from a neighboring jurisdiction will need to take over command and control functions in the event that a local ICP/EOC is unable to perform its duties. To facilitate the transfer of operations, preplanning must be undertaken to ensure that memoranda of understanding, joint power agreements, and delegation of authority documents are already in place prior to an IND attack. Without preexisting agreements, a neighboring jurisdiction cannot readily and efficiently assume command and control functions. A preexisting agreement can also cover an IND incident in which the city being targeted happens to be a state capital, such as Boston, Massachusetts.

Public Health and Medical Services

The fifth question is, How would public health and medical services fit into the command and control structure? No single public health agency will be able to manage mass casualties. Not even multiple public health agencies can handle the response, which will include medical care, population monitoring, triage, stabilization, transport, and decontamination. There will be a need to exploit surge health care capacity from nongovernmental organizations, disaster medical assistance teams, the military, and volunteers. Senior public health professionals should participate in the unified incident command structure and EOC. A new algorithm for uniform patient triage should be considered, justified by specific circumstances to focus more intently on the needs of the entire community as opposed to individual patient care (IOM, 2012). This algorithm includes the assessment of traumatic injuries, radiation dose, and availability and time to access definitive care (Casagrande et al., 2011; Coleman et al., 2011).

One of the most daunting tasks for command and control is the coordination of patient transfer and transport. No matter how many ambulances there are, there will probably not be enough. Even if there are enough ambulances, they will not have easy access to highways and transportation corridors because of the traffic congestion from people evacuating the area. Air transport, which must be included and coordinated, will be covered in more depth in Chapter 7. The participation of public health in the command and control structure is needed throughout the incident.

Influence of Preplanning on Response

The final question is, How can preplanning and common policies improve coordination and response effectiveness? Preplanning and preparation with partners throughout the region is critical to success, Pasquale said. Some of the thorniest regulatory discrepancies across different jurisdictions relate to personal protective equipment requirements and contamination levels for first responders. Consensus is needed in advance, Hansen said, to adopt a pragmatic policy of “clean enough for now.” Such a policy could maintain the flow of patients, commerce, and response. The magnitude of an IND attack will make it impossible to have the time and resources to clean everything down after each use. Without uniform standards for contamination, the whole response effort may falter. Currently, there is a group working on addressing uniform standards for contamination action levels sponsored by the Chemical, Biological, Radiological, Nuclear, and Explosives Branch at the Federal Emergency Management Agency (FEMA) and the Office of Infrastructure and Protection at the Department of Homeland Security. If the IND attack occurs before a variety of other regulatory discrepancies are remedied, help will be available through a federal advisory team dealing with the environment, food, and health. The advisory team can be contacted through a local or state EOC.

FEMA PERSPECTIVE

Robert Farmer, again speaking for FEMA as the director of the operations division, opened his presentation by saying that after an IND attack or similarly catastrophic event, FEMA will immediately start sending resources to the affected area without waiting for a formal declaration of a state of emergency under the Stafford Act, the federal law designed to marshal an orderly flow of federal disaster assistance to state and local governments. A proactive stance by FEMA can save lives, he said. In terms of command and control functions, FEMA’s successful response to Hurricane Sandy in 2012 showed that it can manage a complex disaster across multiple states, which in that case included Connecticut, Massachusetts, New Jersey, and New York. The command and control function remained intact throughout all phases of the response.

Command and control is predicated on a communications infrastructure. In the event that communications are destroyed by an IND attack, FEMA, the military, and the private sector have vehicles specially equipped to set up cell towers for emergency communications. Farmer also suggested that the Federal Bureau of Investigation (FBI) will play a leading role after an IND attack because the site of the attack is also a crime scene. The FBI will be investigating who is responsible for the attack and how to respond appropriately.

STATE INVOLVEMENT

Jonathan Monken presented his perspective as the Illinois state director of emergency management on the IND exercise he participated in, sponsored through FEMA. Through the experience he ascertained that command and control was the foremost function to protect after an IND attack. One of the greatest challenges for command and control, he said, was to coordinate the local, state, and federal assets flowing into the affected area. In the IND scenario, the city’s main government buildings were destroyed, with significant loss of local leadership, and the state of Illinois immediately moved to assume command and control functions over the city and region. One significant downside of locating command and control so far from the site was the loss of situational awareness. Because of this, the State of Illinois and FEMA developed a plan to preposition five potential sites for command and control closer to the site of detonation. The choice of alternative sites was based on their proximity to the city and airports but also on having sufficient distance from the site to avoid fallout and loss of communications, water, electricity, and road access.

Monken said that his experience with the recent North Atlantic Treaty Organization summit held in Chicago was also instructive in anticipating the consequences of an IND attack. The summit was an international, multijurisdictional coordinated event with significant security presence. Twenty-six emergency operations centers were set up in and around Chicago, which led to a duplication of effort that Monken and colleagues realized should be avoided in future planning. Still, he said, the experience was instructive in demonstrating that civilian and military resources could be successfully co-located and combined.

Monken affirmed the importance of having plans in place in the event of an IND attack. He said that preplanning gave him a good idea of what resources exist through the mutual aid system both within and outside of his state. The state of Illinois, for example, has 1,150 fire departments and 1,100 police agencies. If more assistance is needed, Illinois has plans in place to draw from nearby states and the federal government. One specific plan covers the loss of command and control by his state agency. Through the planning process Monken also discovered that the Department of Defense (DOD) has plans in place for deploying to Illinois a homeland response force from nearby Ohio. One problem with the DOD plan is that it situates its forces in the same facility that the state plans to reserve for the Illinois National Guard. This is one reason why a major challenge of command and control among local, state, and federal agencies is integration. Monken also would like to see command and control plans integrated with the business community in his state. He learned that a business emergency operations center exists at both the city and state level in Illinois. He would like all private and public agencies to have access to the same information in order to make more efficient use of resources and to ensure the protection of command and control systems.

PERSPECTIVE FROM THE OFFICE OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE

Dr. John Koerner of the Office of the Assistant Secretary for Preparedness and Response (ASPR) began his presentation by emphasizing that command and control systems are uniquely compromised in IND incidents relative to other disasters. What makes them uniquely compromised is the massive disruption of communications, transportation, and financial systems; the scarcity of resources; the inability to deploy first responders into the severe damage zone; and ethical dilemmas for triaging patients. Conversely, he emphasized that the factors leading to the successful implementation of command and control include feasibility and flexibility, reliance on evidence-based practices, reliance on multiple-use technologies, and possessing a range of capabilities that include behavioral health, communication, and laboratory surge.

ASPR has developed numerous so-called playbooks to help implement the role of the Department of Health and Human Services (HHS) as the lead agency for public health and medical services under FEMA’s 2008 National Response Framework (Murrain-Hill et al., 2011). The purpose of the playbooks is to provide strategic guidance for command and control and other types of decision making under a distinct set of disaster scenarios. The playbooks highlight key decision points, actions, capabilities, and assets that may be needed to respond to a disaster. The playbooks contain a concept of operations that delineates the phases of the response and identifies specific action steps for each phase. ASPR has developed playbooks supporting several scenarios, including attacks with a radiological dispersal device as well as an IND, all available on its website (ASPR, 2012).

ASPR’s emergency management group (EMG) is the command and control hub for HHS, with direct communications to the White House’s Disaster Resiliency Group. The EMG is a high-level decision-making body that deals with situational awareness and responds to requests emanating from EOCs at the state and local level. The EMG makes decisions about the range of resources that HHS can deploy, including disaster medical assistance teams and the U.S. Public Health Service’s Commissioned Corps. The EMG interfaces with HHS’s regional emergency coordinators through an entity known as the incident response coordination team, which controls activity on the ground. To ensure continuity of operations in the event that HHS itself is among the sites of an IND attack, command and control activities devolve to the Centers for Disease Control and Prevention or to an undisclosed location.

Situational awareness on the ground is indispensable for command and control functions, Koerner emphasized. MedMap is currently one of the foremost tools for gaining real-time situational awareness. It is an interactive geographic information system (GIS)-based electronic mapping application that relies on data from numerous sources during a public health emergency. It combines data from multiple agencies at the federal (e.g., modeling of the zones by Department of Energy’s national laboratories), state, and local levels into a single visual environment. MedMap is designed to display the three damage-level zones, the dangerous fallout zone, medical care sites, assembly centers, evacuation routes and evacuation centers, and other important information. Figure 5-2 displays a hypothetical MedMap that overlays the sites used for the RTR (Radiation-specific TRiage, TReatment, and TRansport) system (Hrdina et al., 2009). MedMap was first used after the earthquake in Haiti, Koerner said. Once satellite photos were updated, responders on the ground had a better sense of which structures had collapsed and which were still standing. Analysts marked the location of health care facilities that were known to be there before the earthquake and then tried to reconcile that knowledge with observations on the ground.

FIGURE 5-2. Example of a MedMap.

FIGURE 5-2

Example of a MedMap. NOTE: AC, assembly center; EC, evacuation center; MC, medical care; RTR, Radiation Triage, Treatment, and Transport system. SOURCE: http://www.remm.nlm.gov/RTR.htm (accessed June 10, 2013).

Finally, command and control surrounding the movement of patients to care is one of the critical functions that HHS coordinates with FEMA and DOD. Koerner explained that strategic command and control decisions are jointly made as to who gets moved, how they are moved (e.g., ground transportation via ambulance, air evacuation), and to which location in the network of 17,000 National Disaster Medical System receiving facilities.

SUMMARY

Command and control systems are uniquely compromised in IND incidents relative to other disasters because of the massive disruption of communications, transportation, and financial systems; the scarcity of resources; the inability to deploy first responders into the severe damage zone; and ethical dilemmas for triaging patients. Still, speakers noted the command and control framework using ICS and NIMS should be retained. It affords sufficient flexibility and adaptability to be used. The establishment of command and control starts with developing specific plans and policies ahead of time, ensuring clarity in roles and responsibilities, and planning for complex commands throughout the affected region. To facilitate the transfer of command and control from the target city to an outlying community, documents should be in place in advance of an IND attack. During or following an attack, each jurisdiction needs to set up an ICP, which has the legal authority to manage the incident, and an EOC (a hub of communication and coordination serving the ICP). As more and more jurisdictions become involved, a uniform command, with participation by public health, transportation, law enforcement, and other agencies, should assume control and should interact with state and federal authorities. It is also important to remember that the FBI will be playing a leading role in command and control, as they will be trying to ascertain the source and intelligence behind the incident. Command and control must possess situational awareness, which can be provided in part by MedMap. MedMap is a GIS-based electronic mapping application that displays key features such as location of area commands, emergency operations centers, damage zones, and sites for triage and evacuation.

Footnotes

1

Former fire department chief officer, Raton, New Mexico, and president of the New Mexico Fire Chiefs Association.

2

Resident scientist for Counter-Terrorism Operations Support (CTOS) Research, Analysis, and Development Department and team leader for the development of Department of Homeland Security (DHS)/Federal Emergency Management Agency (FEMA) training program.

Copyright 2014 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK184319

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