Domestic Response Systems

Military medicine has had a fundamental role in the development of domestic DR strategies, especially in the United States. The military’s influence on civilian disaster management can be broadly categorized into operational systems and clinical care. Key among the systems contributions are the Incident Command System (ICS) and principles of high-reliability organizations (HROs). The ICS is an all-hazards incident management approach for the command, control, and coordination of emergency responses. The ICS is based upon limited span of control and is a fundamental tenet of DR. The ICS concept, initially proposed in 1970 by California fire chiefs as a strategy for coordinated battling of forest fires, was based on the U.S. Navy hierarchical chain of command. In the past 45 years the ICS emerged as the key operational paradigm for prehospital, health care facility, and governmental response to crisis. Both in the prehospital environment and in health care facilities (e.g., hospital ICS) the ICS system is used to standardize the management of complex, interagency, or interdepartmental responses. Briefly, the ICS system creates flexibility of action, clear accountability, and clear operational span of control. ICS mirrors the military command system by identifying and empowering an incident command (e.g., commanding officer), operations officer (e.g., staff 3 [S3]), planning officer (e.g., staff 5 [S5]), logistics officer (e.g., staff 4 [S4]), finance and administration officer (e.g., staff 1 [S1]), and information officer (e.g., staff 6 [S6]). The ICS principles are discussed at length in Chapter 38 .

During the past 5 years, disaster management practitioners have gained increased awareness of the principles of HROs. The theory of HROs began in the 1970s but gained traction with the study of the aircraft carrier USS Carl Vinson and Capt. Thomas Mercer. The study examined the notion that “accidents” in high-risk environments were considered normal. Capt. Mercer and his team faced highly complex operational environments, uncertain threats, frequent turnover of staff, and catastrophic consequences for failure. Their approach embodied the principles of HROs, leading to fewer significant adverse outcomes and improved safety. An in-depth discussion of HROs is beyond the scope of this chapter; however, the five core concepts of HROs include the following :

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  Sensitivity to operations: Constant awareness by leaders, practitioners, and staff about the state of the systems and key processes that affect patient care. Accidents are rarely the result of a single error by a single person, but rather errors “latent in the system.”

  
  
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  Reluctance to simplify: Clinical and response operations are inherently complex. Development of simple processes can reduce error, but oversimplification of the root cause of errors is dangerous. Categorizing challenges is unavoidable, but should not constrain skepticism or investigations.

  
  
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  Preoccupation with failure: Constant vigilance about viewing near misses within the system as early signs of failure. This is not a preoccupation with avoiding failure. Rather, this acknowledges that errors will happen and focuses attention on avoiding complacency and limiting adverse outcomes.

  
  
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  Deference to expertise: Willingness of leaders and managers to listen and respond to the expertise of front-line staff. Expertise is not based on position, but rather knowledge, experience, and credibility.

  
  
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  Commitment to resilience: Organizations must maintain function during periods of high demand or system failures and grow from prior episodes.

These HRO principles are applied in intensive care units (ICUs), emergency medical service (EMS) agencies, EDs, and DR. They have also become a component of the Agency for Healthcare Research and Quality (AHRQ) standards for achieving clinical quality, safety, and efficiency.

Clinical Care Advances

The practice of military medicine has advanced tremendously in the past decade. The GWOT has provided a generation of military medical providers with expeditionary experience. During this period, the military often looked to civilian HA/DR providers for lessons learned, best practices, and gap analysis. However, where civilian practice is frequently limited by lack of funding, the GWOT provided the unique opportunity to align defense funding and training requirements with these identified gaps, therefore accelerating the advancement of medical care delivery in austere or high threat environments, both military and civilian.

In the prehospital environment the influential example is the creation of the Tactical Combat Casualty Care (TCCC) guidelines. TCCC stems from efforts by U.S. Special Operations units in the 1990s to adapt prehospital care techniques to the battlefield environment where disciplined adherence to tactics often determines mission success versus failure. The TCCC guidelines were the first modern medical guidelines to align medical care and operational constraints—in this case the tactical combat scenario—to address potentially preventable causes of death. The tiered application of TCCC guidelines to nonmedical personnel, medics, and physicians resulted in the lowest case fatality rate in modern combat history. Over the past decade the TCCC Guidelines expanded beyond point-of-injury care to address issues related to standardized field surgical care, analgesia, damage control resuscitation, and tiered hemorrhage control. The CoTCCC also drove initiatives, such as the DoD implementation of tourniquets, hypothermia prevention, expanded use of tranexamic acid (TXA), and utilization of intranasal ketamine for analgesia.

The military experience has clear and direct application to mass casualty incidents (MCIs), acts of terrorism, and management of complex polytrauma in the civilian setting. The civilian Committee for Tactical Emergency Casualty Care (C-TECC) was established in the United States to serve as a best practice development group for translating combat lessons learned to civilian response to high threat prehospital care. The C-TECC guidelines emphasize an integrated, threat-based response to prehospital care with emphasis on threat mitigation, early hemorrhage control (e.g., aggressive tourniquet application), rapid extraction, and tiered initiation of damage control resuscitation principles. The TECC guidelines represent a critical paradigm shift in civilian care, especially in regards to aggressive tourniquet use, which had been considered an anathema in trauma care. Multiple studies have demonstrated the efficacy and safety of properly applied tourniquets, leading to more widespread adoption as part of MCI plans. Since, organizations such as the American College of Surgeons have looked with increasing frequency to the military to provide lessons learned on management of traumatic MCI events. The 2013 Boston Marathon Bombing illustrated the critical importance of proper, aggressive tourniquet application—a key lesson learned from combat experience and articulated in TECC.

One of the other critical military care advancements with direct application in the civilian DR community is the conceptualization and development of damage control resuscitation (DCR) strategies. DCR emerged in the early years of the U.S. conflict in Afghanistan as forward-deployed surgical units began to manage large volumes of complex, polytrauma patients in resource-poor environments. The principles of DCR include early hemorrhage control, permissive hypotension, prevention of acidosis and hypothermia, and early damage control surgery (DCS). The apparent reductions in mortality noted by implementation of DCR and DCS principles in combat led to the widespread adoption of these techniques in civilian trauma centers, especially as part of MCI and disaster plans. Though DCR principles continue to be fine tuned, they certainly have a role in the provision of high-quality care in austere, resource-challenged, and crisis situations.

Humanitarian Assistance

The U.S. DoD has a long history of conducting and supporting HA missions. The DoD provides much of its routine humanitarian aid through the Overseas Humanitarian, Disaster and Civic Action (OHDACA) account. Outside of overt war zones, these DoD operations are generally conducted in “semi-permissive” environments defined by elevated threat scenarios but not outright combat operations. Academic, operational, and policy stakeholders actively debate the impact, consequences, and implications of the “militarization” of HA missions. However, there are clear lessons learned from military operations that inform modern and future civilian HA missions.

Operations Management and System Design

The DoD is a clear global leader in logistics and mission support. Frequently, components of the U.S. military must work with other branches of the U.S. Armed Forces, USG civilian agencies, foreign governments, nonstate responders, and IOs to achieve mission success. In response, the DoD creates various interagency task forces and provides guidance on roles, responsibilities, and operational span of control. Clear chains of command, effective communication, and cooperation are critical to success. This mission profile mirrors that of the HA community during large-scale response operations. The largely ineffective U.N. cluster system was and is an attempt to provide a similar coordination infrastructure by identifying key stakeholders within each sector and identifying sector “leads.” Limitations to the U.N. cluster system include a lack of regulatory and command authority. In Jordan the U.N. High Commissioner for Refugees (UNHCR) has begun to implement, with some success, issue-specific task forces, innovation and problem solving teams (similar to Red Cell teams in the military), and contracted lead agencies with execution authority within specific areas of operation.

The U.S. military is also an expert at the development and deployment of trauma systems in crisis zones. In Iraq and Afghanistan the U.S. military has created an integrated, tiered trauma system that provides exceptional care from point of wounding through evacuation to the United States. The DoD system combined trauma training for nonmedical personnel, rapid evacuation using various modalities (e.g., trucks, helicopters, and fixed-wing aircraft), far-forward deployment of surgeons and critical care staff, mobile ICUs, modern information management systems, and a properly resourced logistics and support system to reduce combat mortality to the lowest rate in modern combat history. The system design focused around the critical issues of prolonged evacuation time and resource limitation. In particular the ability to provide critical care in austere environments was a major advance in combat, and thus HA medicine. These principles focused on diligent resource management, aggressive infection control, practiced interdisciplinary team care, and leveraging of air-evacuation platforms. In disaster zones from postearthquake Haiti to posttyphoon Philippines these lessons are critical for success and should be closely studied by HA leaders.

Innovation and Technology

Plato wrote, “Necessity, the mother of invention.” Jonathan Schattke expanded on Plato, writing that “Necessity, it is true, but its father is creativity, and knowledge is the midwife.” The September 11, 2001, attacks drew into the military some of the most creative, knowledgeable, and motivated individuals in the United States. The subsequent decade of complex urban operations, counterinsurgency, and mixed national policy goals demanded from leaders at all levels the rapid development of expertise and application of creativity in order to both achieve mission success and to survive.

Reliable energy is critical to effective HA mission execution. Often-times HA/DR operations occur in remote regions or areas where the energy infrastructure has been destroyed. The U.S. military faced a similar challenge in Afghanistan, where the logistical system required to provide power to forward-operating bases was expensive, deadly, and unreliable. In 2009 the Pentagon estimated the average cost to provide one gallon of fuel to a vehicle in Afghanistan was $400/gallon. The officials also estimated that one casualty was sustained every 24 missions. So pressing is the issue that the Defense Advanced Research Projects Agency (DARPA) is developing a mobile integrated sustainable energy recovery (MISER) system. The applications in HA missions is direct and obvious. Unfortunately, the cost of large-scale solar projects and antiquated funding mechanisms have prevented the large-scale deployment of renewable energy solutions beyond solar lamps, solar water heaters, and the occasional solar street lamp. For example, during 2014, UNHCR spent an estimated $700,000 USD on electricity for the Za’atari refugee camp in northern Jordan. Jordan has an abundance of solar energy with average annual daily solar irradiance ranges from 5 to 7 kWh/m ² . The scenario is primed for widespread application of clean energy technology, such as solar and wind. The increased interest from the U.S. military is driving research and development, creating a private sector market for mobile renewable energy and providing case studies for application in austere environments.

In HA/DR missions one of the most significant challenges is tracking refugees, casualties, and at-risk populations. In Haiti the Operational Medicine Institute (OMI) identified a critical gap in the interagency/U.N. cluster system capacity to track volunteers, patients, and displaced populations. As a result, the OMI developed an iPhone-based tracking application that gained widespread utilization. However, the issue of accountability repeated itself in the Philippines, South Sudan, and countries responding to the massive Syrian refugee crisis. In 2013 the HA community again looked to the military for a solution. During the conflicts in Iraq and Afghanistan, the U.S. military deployed portable biometric identification devices to identify criminals, track insurgents, and vet potential political allies. Again this drove development and technology transfer to the civilian sector. In Jordan the UNHCR contracted with Iris Guard to provide biometric registration of refugees, allowing greater situational awareness, the efficient deployment of cash and food voucher systems, and the identification of potential security threats from insurgents posing as refugees.