5.6 Illustrative Example

The following example demonstrates how the concepts presented in this chapter may be applied during an actual incident response. The various phases of response (as described in Chapter 1) highlight when critical actions should occur; however, the example extends only as far as incident operations, as this is the focus of the MSCC Management System.

Background and Incident Description

State Alpha is a southern State on the U.S. coast.
A large Category 4 hurricane has struck the State, devastating multiple jurisdictions along the coast with extensive structural damage and flooding.
In at least three separate low-lying jurisdictions with high population densities, HCOs have had their normal operations disrupted due to flooding.

In this scenario, the early stages of response unfold well before the event occurs:

Incident recognition occurs several days prior to landfall when the National Weather Service issues a hurricane warning for the coast of State Alpha.
Notification/activation occurs when the State EMA notifies State emergency response agencies, private response assets (e.g., HCOs), and the general public, and issues practical preparedness recommendations.
Mobilization of State emergency/disaster services is characterized by the following steps:
- The primary ICP is established in the facilities that house the State's EOC. State-level incident comand is now co-located with, but physically separate from, its emergency management operations support at the EOC.
- A UC team composed of representatives from the primary response disciplines is established at the ICP. A senior health officer from the State's Department of Health (DoH) serves on the UC to represent public health and medical issues.
- The State ensures that weather-resistant communications are operating between the ICP/EOC and jurisdictional EOCs. The State issues short-term preparedness recommendations for State- level response agencies, and calls on jurisdictions directly in the storm's path to provide immediate post-landfall situation and resource status reports. Instruction is given on what to include in reports, where they should be sent, and how to format the information.

Incident operations are initially characterized by full evacuations of coastal areas and the pre-positioning of State response resources. State-level incident command works closely with Federal authorities to coordinate pre-positioning of Federal response assets. State action plans are issued for the two 24-hour operational periods preceding landfall. As the storm approaches, State Alpha switches to 12-hour planning cycles and fully staffs its ICP/EOC.

In the aftermath of the hurricane, affected areas report on storm-related injuries and physical/structural damage. It is quickly recognized that regular and emergency medical care has been compromised at multiple hospitals in several jurisdictions. The State UC assumes a primary incident command role and establishes overarching control objectives, operational period objective and response strategies. The State incident action plan (IAP) is developed and shared with affected jurisdictions, with other States (Tier 5), and with the Federal assistance liaison (Tier 6). This promotes the "common operating picture" described in NIMS. A key component of the State IAP is a public health and medical section that includes the following:

Public health and medical situation assessments and resource status reports from data collected daily by affected jurisdictions; the assessments capture the number and types of victims directly affected by the event, as well as the medical special needs populations in the jurisdictions;
Input into the safety message that includes public information messages to address such issues as displaced populations of wildlife and the handling of water in affected areas.

Based on initial reports, the State UC anticipates that local jurisdictions will need support and thus offers medical and public health resources to assist with unmet needs. State medical assets are provided to support the incident response being managed in the most heavily affected jurisdictions. This includes a State-sponsored Disaster Medical Assistance Team (DMAT). In addition, evacuation planning for some severely impacted HCOs is undertaken in conjunction with Federal partners (Tier 6) and State medical and health personnel are deployed to support locally affected health departments. The latter integrate through the jurisdictional (Tier 3) Logistics function and are assigned to the appropriate Operations Section positions in the jurisdictional ICS.

State Alpha's Governor and State health officer temporarily suspend, through emergency declarations, selected State health regulations. This action allows for:

Relaxation of restrictions on hospital bed capacity in the most heavily affected jurisdictions so facilities that are still operational can "legally" care for more victims than their State license stipulates.
Temporary changes to State licensing and certification regulations for healthcare professionals. The emergency regulations, developed during preparedness planning, permit HCOs to accept evidence of licensure from other States and allows medications to be dispensed by healthcare personnel other than physicians, nurses, or pharmacists.
Establishment of several convenient locations where out-of-State healthcare personnel who want to volunteer in the response can report for screening, examination of their professional credentials, and granting of temporary credentials from State Alpha. This removes the credentialing burden from local jurisdictions and local HCOs.

One jurisdiction that was not fully evacuated has temporarily lost use of its primary outpatient and inpatient dialysis centers. Mutual aid is requested to provide dialysis services using resources from an unaffected jurisdiction elsewhere in the State. The State MAC Group (Agency Executive directors convened to address strategic and policy issues in the response) addresses the financial issues involved in meeting this request. The MACC (i.e., State EOC) implements the MAC Group decisions and addresses the issues that allow the dialysis mutual aid to be arranged and executed. Logistical issues involve transportation to move personnel and equipment, public works to arrange for a clean water source for the dialysis machines, and other details. The State also provides a financial guarantee to the assisting jurisdiction, as well as reporting guidelines so Federal reimbursement may be obtained.

The State facilitates coordination between affected local jurisdictions (Tier 3). Situation assessment and resource status reports are collected from affected jurisdictions and collated to provide summary health and medical information for the State. These aggregate data are included in the State IAP. State public health authorities provide case definitions for reporting storm-related injuries or illnesses. Included in this message is guidance for reporting gastrointestinal complaints. This becomes critical later to counter rumors about the outbreak of infectious disease.

Lastly, State Alpha coordinates with other nearby States (Tier 5) and with Federal agencies (Tier 6). Jurisdictional public health and medical needs that cannot be met through local resources or tactical mutual aid are reported to the State EOC. The State rapidly evaluates the requests and attempts to meet them using assets within State Alpha. For requests that cannot be met by the State, the MACC (i.e., State EOC) inquires from its regional partners (Tier 5) and/or forwards a request for assistance to Federal authorities. For example, when all three affected jurisdictions request medical teams to provide out-of-hospital patient evaluation and medical care, the State-sponsored DMAT can only fill one jurisdiction's request. Additional resources are requested from Federal agencies (Tier 6), but will take time to arrive. The appropriate assignment of the State DMAT may be determined by the MAC Group, or through the MACC using a pre-developed decision support tool for determining the best use of the DMAT asset.

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