Put simply, emergency management deals with risk and risk avoidance.1 This simple phrase turns into a complex, comprehensive discipline and field of study considering all hazards, all phases, all impacts, and all stakeholders.2 All hazards include the many possible natural (earthquake, hurricane, tornado, flood, climate issues) or man-made (domestic/international terrorism, cyber) threats that create risk and vulnerability to an organization, community, or region. Using the phases of prevention, preparedness, mitigation, response and recovery, emergency management forms a management paradigm that prepares the organization to be disaster resistant and disaster resilient. All impacts include assessing the effects on population, human services, the economy, and infrastructures. Stakeholders include the individual, community, organization, business, hospital and the government as well as the collaboration between public, private, and governmental agencies. Emergency managers exist at all levels and function to coordinate and mobilize the right people, right agreements, and right policies and procedures when needed in an incident. The EMS physician is in a perfect position to assume a leadership or supportive role in many emergency management functions.
Define the role of emergency management organizations.
Discuss the relationship between emergency management and EMS, fire and law enforcement.
List the major communications modalities with advantages and disadvantages for each.
Define the roles of relevant Emergency Support Functions as well as the role the EM/EMS physician might play in each.
Discuss the role of EMS physicians as part of the Emergency Management system.
Emergency management is the coordination and integration of all activities necessary to build, sustain, and improve the capability to prepare for, protect against, respond to, recover from, or mitigate against threatened or actual natural disasters, acts of terrorism, or other manmade disasters. The US development of emergency management began as a reactive model to a New Hampshire town destroyed by fire in 1803 when the government authorized dollars to rebuild. Under Franklin Roosevelt in the 1930s, the Reconstruction Finance Corporation and the Bureau of Public Roads led the effort to rebuild public facilities after disasters through loans. Flooding was an issue evidenced by the Tennessee Valley Authority projects and the Flood Control Act of 1934 leading to increased use and authority of the US Army Corps of Engineers to design and build flood control projects. Beginning in the 1950s, the focus shifted to the potential effects of nuclear war and the Cold War era began. Civil Defense programs were in place in every community and the familiar “Duck and Cover” program was taught in the schools and fallout shelter signs were common. During this time emergency preparedness was embedded in the Office of Defense Mobilization before being combined with Civil Defense into to the Office of Civil Defense and Mobilization. Natural disaster events such as Hurricanes Hazel and Audrey were dealt with in the previous reactive model of post event funding for recovery of the affected regions.
President Kennedy changed the federal structure when he created the Office of Emergency Preparedness to deal with natural disaster events while maintaining the Office of Civil Defense in the Department of Defense to deal with Cold War issues. During the 1960s, many events occurred that caused tremendous damage and lives lost which, although handled in the reactive post event funding model, set the stage for changes in the 1970s. Over 100 different agencies had involvement in disaster preparedness and response, leading to confusion and fragmentation of services. Efforts began to grow to consolidate federal emergency management activities into a centralized agency and gained momentum after issues arose in the response to the Three Mile Island nuclear power plant accident in 1979. Under President Carter, Federal Emergency Management Agency (FEMA) was created merging many disaster-related functions under one structure. Under this new agency, an Integrated Emergency Management System was developed combining natural disasters and civil defense into an all hazards approach. The 1980s and early 1990s were turbulent, controversial times for FEMA based on poorly handled responses to events such as Hurricanes Hugo, Andrew and Iniki, the Loma Prieta earthquake, political issues and unpopular decisions until President Clinton appointed James Lee Witt as director in 1993.
Under Witt’s leadership, FEMA developed into a more functional and responsive agency with a new emphasis on disaster preparedness, mitigation, and customer service. As the first director with state emergency management experience, Witt was able to build relationships, focus on customer service, embed technology and build community disaster resilient programs. During Witt’s tenure as director many natural disaster incidents occurred as well as the Oklahoma City bombing. The success of FEMA’s response to all of these events created the platform for emergency management’s growth as a profession and as an international model of resilience, mitigation, and response. During this time the Federal Response Plan (FRP) was enacted to coordinate federal assistance and resources to states and local governments overwhelmed by a major disaster, supporting implementation of the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
After September 11, 2001 the attention turned to terrorism with the majority of resources being directed through the newly created small Office of Homeland Security which evolved within a year to the Department of Homeland Security. Combining 22 agencies, budgets, and personnel with the mission of protecting the nation, reducing the vulnerability to terrorist attacks, and reducing damages from all incidents man made or natural led to sweeping changes. With the focus on terrorism, less attention was spent on mitigation and preparedness of natural disasters until the impact of Hurricane Katrina was realized in 2005. Due to the inefficient response to Katrina, the Post Katrina Emergency Management Reform Act was passed in 2006, realigning functions within the Department of Homeland Security including elements of FEMA.
As a profession Emergency Management embraces the management principles necessary to build an effective organization—one that is able to build resilience based on the core principles of emergency management:
Comprehensive—Emergency managers consider and take into account all hazards, all phases, all stakeholders, and all impacts relevant to disasters.
Progressive—Emergency managers anticipate future disasters and take preventive and preparatory measures to build disaster-resistant and disaster-resilient communities.
Risk-driven—Emergency managers use sound risk management principles (hazard identification, risk analysis, and impact analysis) in assigning priorities and resources.
Integrated—Emergency managers ensure unity of effort among all levels of government and all elements of a community.
Collaborative—Emergency managers create and sustain broad and sincere relationships among individuals and organizations to encourage trust, advocate a team atmosphere, build consensus, and facilitate communication.
Coordinated—Emergency managers synchronize the activities of all relevant stakeholders to achieve a common purpose.
Flexible—Emergency managers use creative and innovative approaches in solving disaster challenges.
Professional—Emergency managers value a science and knowledge-based approach based on education, training, experience, ethical practice, public stewardship, and continuous improvement.2
The current US model, the National Response Framework, was created out of the earlier models to guide the interagency response of communities, tribes, States, the Federal government, private, and nongovernmental partners in a coordinated national response. It defines the principles, roles, and structure that organize how the response to any event is organized into an effective approach using best practices. Coming out of the Homeland Security Act of 2003, Homeland Security Presidential Directives 5, 7, and 8 strengthened US preparation for domestic incident response, including incidents from terrorism, pandemics, to natural disasters. Built on the concepts of engagement and collaboration, tiered response, a scalable, flexible, and adaptable capability, and unity of command all support a readiness to act from the individual or community level all the way to the federal government.
National Incident Management System (NIMS) is the country’s process for organizing disaster management. It is a comprehensive, multiagency plan to improve communications, coordination, command, and control across all elements involved in a systematic response.3 Using a common framework provides for a standardized but flexible response that every responding agency can apply with an understandable structure and terminology. The Incident Command System (ICS) is the most visible aspect of NIMS, developed out of the need to add organization to events where multiple people and groups come together to deal with a disaster situation. These situations most often call for response services from multiple jurisdictions and types of response agencies to converge on a specific location to address incident needs. Bringing responders together that have different internal command structures, protocols, communication systems, and expectations usually resulted in chaos. Firefighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE) developed from the California wildfire experience and created the Incident Command System management model to begin to organize command, control and communications across multiple organizations platforms.
Organization can occur across responding units by building a common structure of responsibilities and reporting. Functionality can be capitalized upon to provide an organized response to the event. Using common language and reporting structures allows responding units to avoid interpretation errors and to be placed in settings to perform the needed tasks. Using this command management system every day, paid and volunteer staff become acclimated to the structure, command and control, reporting mechanisms, and paperwork. The ICS structure has five primary components: command, operations, planning, logistics, and finance/administration. Additional elements are incorporated based on the situation and technical expertise necessary.
The concept of unified command speaks to the way different jurisdictional response agencies relate to each other, respecting the integrity of each agency’s internal chain of command while creating a mechanism of coordination across jurisdictions.4 With the goal of organizing and maximizing the skills of each agency and still having an effective command structure, unified command brings this expertise into a single command function.5,6 In this function a single set of incident objectives and collaborative strategies are created. Duplication of resources is minimized and communications enhanced.
Communication is often the Achilles heel of disaster response. Plans often foolishly assume that normal modalities will work in all situations. For many reasons, that will not be the case in a disaster. Infrastructure damage may limit some modalities. Sheer volume may overwhelm others. One goal of NIMS is to ensure that the systems necessary for emergency management are in place. Time should not be lost devising a plan to deal with a failure that could have been avoided. Poor interoperability may make it impossible for one responding agency to communicate with another. The keys to communications success are preparation and redundancy.
In addition to the hardware listed below, the word “communications” also refers to interpersonal dialogue. Planning and mitigation involve discussion among key stakeholders. The hospital EOP, for example, should be the product of all those from whom buy-in is required. That includes not only those who directly provide health care, but also ancillary services, facilities management, human resources, and others. Many hospital EMCs wisely ask guidance from local EMS representatives. It is also critical to remember that the media will be the major entity getting information to the public. Emergency management officials need to speak with the media and must name and train a Public Information Officer (PIO). That role is critical. The PIO is part of the Command Staff. (See Chapter 74 for a more thorough description of this ICS position.)
There is no doubt that the cell phone—especially the “smart phone”—is the most popular and arguably the most useful communication device in the setting of a disaster. The device is ubiquitous in the US. It is so popular that the landline phone industry has declined significantly. Many individuals no longer own a land line phone. Most cellular carriers scale operations to handle only a fraction of system capacity. In a disaster cellular use increases markedly, sometimes enough to overwhelm capacity. During the August 2011 east coast 5.8 Richter earthquake that caused no real damage and generated no injuries, most could not use their cell phones for several hours. There are ways, however, for providers to increase capacity. Carriers can send trailers into the congested area with antennas, repeaters, generators. Additionally, some carriers can provide predesignated emergency workers priority, though there is no legal requirement that they do so.7 That does not guarantee that a call will go through, but makes it more likely that the worker will get a connection. Additionally, most phones have the capacity to send text messages. Thankfully, the texting function works even when cellular capacity is overwhelmed. Finally, the Department of Homeland Security allows key disaster responders to obtain an enhanced cellular signal using the National Communications System “Government Emergency Telecommunications Service” or GETS card. The license is usually given to a facility or service which then requests a specific number of GETS cards. That card must be surrendered when an individual leaves the facility or the emergency management service position within that facility.
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