INTERHANDS IIIJune 2003Miami, FL

Initial Medical (Health) Assessment

INTERHANDS IIIJune 2003Miami, FL

Initial Medical (Health) Assessment

United States Southern Command United States Southern Command Col. Miguel A. Montalvo USAF MC FSCol. Miguel A. Montalvo USAF MC FS

Command SurgeonCommand Surgeon

United States Southern Command United States Southern Command Col. Miguel A. Montalvo USAF MC FSCol. Miguel A. Montalvo USAF MC FS

Command SurgeonCommand Surgeon

AssessmentsAssessments

(Defining How Bad Is Bad)Defining How Bad Is Bad)

When does the assessment When does the assessment process begin???process begin???

Right AwayRight Away

Disaster AssessmentsDisaster Assessments

Decision MakersDecision Makers• On-scene Military On-scene Military

CommanderCommander• U. S. AmbassadorU. S. Ambassador• Combatant CommanderCombatant Commander• National Command AuthorityNational Command Authority

ConsiderationsConsiderations• RequirementsRequirements• Resources AvailableResources Available• National InterestsNational Interests• Legal AuthorityLegal Authority• FundingFunding

Purpose: To provide decision makers the information Purpose: To provide decision makers the information they require to determine the appropriate USG responsethey require to determine the appropriate USG response

ObjectivesObjectives• Recognize the wide variety of resources

available to support assessments

• Understand the criticality of gathering political, economic, military, cultural, engineering, health and other essential information

• ID the capacity and status of the HN

• Everyone is responsible for gathering information

• Recognize the wide variety of resources available to support assessments

• Understand the criticality of gathering political, economic, military, cultural, engineering, health and other essential information

• ID the capacity and status of the HN

• Everyone is responsible for gathering information

United States AmbassadorUnited States AmbassadorRoles and ResponsibilitiesRoles and Responsibilities

ResponsibilitiesResponsibilities

• Declaration via Cable to DoSDeclaration via Cable to DoS

• Recommends appropriate Recommends appropriate USG responseUSG response

• Focal Point for USG agencies Focal Point for USG agencies responding to disasterresponding to disaster

ConsiderationsConsiderations• Country desires U.S. Country desires U.S.

assistanceassistance• Capability of the country Capability of the country

to respond is exceededto respond is exceeded• Impact of disasterImpact of disaster

Role: The U.S. Ambassador to the affected nation Role: The U.S. Ambassador to the affected nation is responsible for declaring the occurrence of a is responsible for declaring the occurrence of a disaster or emergency in a foreign country that disaster or emergency in a foreign country that requires U.S. foreign humanitarian assistance requires U.S. foreign humanitarian assistance support.support.

Combatant CommanderCombatant CommanderRoles and ResponsibilitiesRoles and Responsibilities

ResponsibilitiesResponsibilities• Transform policy and Transform policy and

guidance into operational guidance into operational plans and activitiesplans and activities

• Structures the force Structures the force necessary to conduct and necessary to conduct and sustain HA operationssustain HA operations

ConsiderationsConsiderations• Immediate employment Immediate employment

of intra-theater assetsof intra-theater assets• Mission and magnitude Mission and magnitude

of the responseof the response• Force ProtectionForce Protection• Logistical SupportLogistical Support

Role: The combatant commander establishes Role: The combatant commander establishes theater strategic objectives required to transform theater strategic objectives required to transform national strategic policy and guidance into national strategic policy and guidance into operational level activities.operational level activities.

On-Scene Military CommanderOn-Scene Military CommanderRoles and ResponsibilitiesRoles and Responsibilities

ResponsibilitiesResponsibilities• Report action at onceReport action at once• Request guidanceRequest guidance• Track costsTrack costs• Request reimbursement Request reimbursement

IAW DoDD 5100.46IAW DoDD 5100.46

ConsiderationsConsiderations• Immediate threat to lifeImmediate threat to life• U.S. Military response U.S. Military response

requiredrequired• Reimbursement not Reimbursement not

assuredassured

Role: A military commander at the immediate scene Role: A military commander at the immediate scene of a foreign disaster may undertake prompt relief of a foreign disaster may undertake prompt relief operations when time is of the essence and when operations when time is of the essence and when humanitarian considerations make it advisable to do humanitarian considerations make it advisable to do so.so.

Spectrum of HA OperationsSpectrum of HA Operations

Types of MissionsTypes of Missions• Immediate disaster assistanceImmediate disaster assistance• Dislocated civilian supportDislocated civilian support• Security missionsSecurity missions• Technical assistance and Technical assistance and

support support • Consequence managementConsequence management

Types of Aid ProvidedTypes of Aid Provided

• Immediate response to save Immediate response to save life/prevent destructionlife/prevent destruction

• Shelter, clothing, beddingShelter, clothing, bedding

• Food and waterFood and water

• Medical care, sanitation Medical care, sanitation

• Transportation, Transportation, communicationscommunications

Natural Disasters: hurricanes, floods, earthquakes, Natural Disasters: hurricanes, floods, earthquakes, volcanic eruptions, drought, firevolcanic eruptions, drought, fire

Man-made Disasters: civil violence, CBRNE Man-made Disasters: civil violence, CBRNE incidents and accidentsincidents and accidents

Initial AssessmentInitial AssessmentWhat Happened? What Does it Mean?What Happened? What Does it Mean?

Magnitude of the eventMagnitude of the event• Area affectedArea affected• Number of people affectedNumber of people affected• Damage to infrastructureDamage to infrastructure

Impact of the eventImpact of the event• Baseline capabilitiesBaseline capabilities• Remaining capabilitiesRemaining capabilities• Response of other Response of other

nations, IOs, NGOsnations, IOs, NGOs

Immediate NeedsImmediate Needs• Most vulnerable populationMost vulnerable population• Emergent requirementsEmergent requirements• Chronic vs. acute needsChronic vs. acute needs

Other ConsiderationsOther Considerations• EthnicEthnic• ReligiousReligious• PoliticalPolitical• EconomicEconomic

Description of the event: type of incident, location, Description of the event: type of incident, location, time, cause, casualties, ongoing threattime, cause, casualties, ongoing threat

Initial AssessmentInitial AssessmentPlanning ConsiderationsPlanning Considerations

Force DeploymentForce Deployment• Available food, water, Available food, water,

sanitationsanitation• Displaced civilian population Displaced civilian population

and locationand location• Disease risk assessmentDisease risk assessment• Local medical capabilitiesLocal medical capabilities• Status of roads and bridgesStatus of roads and bridges• Available logistic facilities for Available logistic facilities for

air and sea-liftair and sea-lift• Threat and security Threat and security

requirementsrequirements

CoordinationCoordination• Status of host nation Status of host nation

government government • Host nation relief effortsHost nation relief efforts• Outside relief effortsOutside relief efforts• Points of contact Points of contact • Continuously update as Continuously update as

situation and information situation and information requirements changerequirements change

Intelligence and Information GatheringIntelligence and Information Gathering

Intelligence and Intelligence and Information Gathering in Information Gathering in

Foreign Humanitarian Foreign Humanitarian Assistance OperationsAssistance Operations

ReligionReligionReligionReligion

PoliticsPoliticsPoliticsPolitics

MilitaryMilitaryMilitaryMilitary

BusinessBusinessBusinessBusiness

EconomicEconomicEconomicEconomic CriminalCriminalCriminalCriminal

Medical Medical Medical Medical InfrastructureInfrastructureInfrastructureInfrastructure

EnvironmentalEnvironmentalEnvironmentalEnvironmental

EthnicEthnicEthnicEthnic

How do YOU define “BAD”????

Baseline DataBaseline Data

• PopulationPopulation• InfrastructureInfrastructure

• WaterWater• Electric PowerElectric Power• CommunicationsCommunications• RoadsRoads• BridgesBridges

• FoodFood• Health StatisticsHealth Statistics

Baseline DataBaseline Data

• AssetsAssets• PublicPublic• PrivatePrivate

• Distribution capabilitiesDistribution capabilities• AgricultureAgriculture• IndustriesIndustries• PortsPorts• TransportationTransportation

• AssetsAssets• PublicPublic• PrivatePrivate

• Distribution capabilitiesDistribution capabilities• AgricultureAgriculture• IndustriesIndustries• PortsPorts• TransportationTransportation

• ClimateClimate• TerrainTerrain• Natural HazardsNatural Hazards• Environmental Environmental

issuesissues• GovernmentGovernment

• TypeType• LeadersLeaders• MinistriesMinistries• RelationshipsRelationships

Baseline DataBaseline Data

• EconomyEconomy• CommunicationsCommunications

• TelephoneTelephone• CellularCellular• RadioRadio• TVTV• Internet Service Internet Service

ProvidersProviders

• EconomyEconomy• CommunicationsCommunications

• TelephoneTelephone• CellularCellular• RadioRadio• TVTV• Internet Service Internet Service

ProvidersProviders

Where do I find the Where do I find the information I need?information I need?

SSOOUURRCCEE

SSOOUURRCCEE

Needs AssessmentNeeds Assessment • IdentifiesIdentifies resources and services for immediate resources and services for immediate

emergency measures to save and sustain the lives of emergency measures to save and sustain the lives of the affected populationthe affected population. It is conducted at the site of a . It is conducted at the site of a disaster or at the location of a displaced population. disaster or at the location of a displaced population.

• Quick response based on this information should help Quick response based on this information should help reduce excessive death rates, and stabilize the reduce excessive death rates, and stabilize the nutritional, health, and living conditions among the nutritional, health, and living conditions among the population at risk. population at risk.

• A quick response to urgent needs must never be A quick response to urgent needs must never be

delayed because a comprehensive assessment has delayed because a comprehensive assessment has not yet been completed. not yet been completed.

AssessmentAssessment Goals Goals

• Provide timely and comprehensive information Provide timely and comprehensive information on the scope and impacts of a disaster on the scope and impacts of a disaster

• Support effective emergency decision making Support effective emergency decision making at local, state and federal levels at local, state and federal levels

• Keep the public accurately informed Keep the public accurately informed

• Develop and support requests for disaster Develop and support requests for disaster resources and recovery assistance resources and recovery assistance

• Impact a disaster has had on a society and its ability Impact a disaster has had on a society and its ability to copeto cope

• Most vulnerable populations that need to be targeted Most vulnerable populations that need to be targeted for assistancefor assistance

• Most urgent requirementsMost urgent requirements

• Levels of response by affected country (by other Levels of response by affected country (by other players)players)

• Make recommendationsMake recommendations

Provide information so that timely Provide information so that timely

decisions can be madedecisions can be made

Provide information so that timely Provide information so that timely

decisions can be madedecisions can be made

Keys to a Successful Keys to a Successful AssessmentAssessment

• Identify who needs your dataIdentify who needs your data• Potential users will specify their data requirementPotential users will specify their data requirement

• Identify the information needed to plan specific Identify the information needed to plan specific actionaction• What information is vitalWhat information is vital• Best method for collectingBest method for collecting• How detailed does the information have to be usefulHow detailed does the information have to be useful• What is your mission, task (implied or specified) What is your mission, task (implied or specified)

Keys to a Successful Keys to a Successful AssessmentAssessment

• Consider the TimingConsider the Timing• May effect the accuracy since situation and needs May effect the accuracy since situation and needs

can change dramatically from day to daycan change dramatically from day to day

• Determine the best place to get accurate Determine the best place to get accurate informationinformation

• Distinguish between emergence needs and Distinguish between emergence needs and Chronic needsChronic needs

Situation/Disaster Situation/Disaster AssessmentAssessment

• ID areas affected (size/location)ID areas affected (size/location)

• Numbers affected by the disasterNumbers affected by the disaster

• Mortality / Morbidity rateMortality / Morbidity rate

• Characteristics and condition of the affected Characteristics and condition of the affected

populationpopulation

• Emergency Emergency

• Medical / Health / Nutrition / Water / Sanitation Medical / Health / Nutrition / Water / Sanitation

• Levels of continued / emerging threats Levels of continued / emerging threats (natural and human)(natural and human)

Priority Health StatusPriority Health Status Assessment Assessment

• How many How many deathsdeaths have occurred have occurred• From the DisasterFrom the Disaster• From DiseasesFrom Diseases• Children/Adults/Gender/Age Children/Adults/Gender/Age • Main cause of death for each group.Main cause of death for each group.

• Vaccinations (measles) have been or will be Vaccinations (measles) have been or will be provided Determine the incidence of diarrhea provided Determine the incidence of diarrhea among adults and children.among adults and children.

• Determine the most common diseases among Determine the most common diseases among children and adults.children and adults.

Priority Health StatusPriority Health Status Assessment Assessment

• Affected Country(s)Affected Country(s)• Population at riskPopulation at risk• Health InfrastructureHealth Infrastructure

• Clinics, Dispensaries, HospitalsClinics, Dispensaries, Hospitals• Supportive: Roads, Shelter, Water, Food Supportive: Roads, Shelter, Water, Food

SanitationSanitation• MedicinesMedicines• Health Care Workers Health Care Workers

Providing Providing WaterWater

• Information you might Information you might needneed

What is the demandWhat is the demand

What are the sourcesWhat are the sources

Road network likeRoad network like

Transportation availabilityTransportation availability

FuelFuel

StorageStorage

Tools of the TradeTools of the Trade

• Field Operations GuideField Operations Guide

• CamcorderCamcorder

• Digital CameraDigital Camera

• CameraCamera

• Access to a computerAccess to a computer

• MapsMaps

Main PointsMain Points

• Only a “snapshot in time”Only a “snapshot in time”

• Information changes over timeInformation changes over time

• The significance of the information changes The significance of the information changes over timeover time

• What you can’t see is often more important What you can’t see is often more important than what you can seethan what you can see

• Goal: Goal: to save and sustain the lives of to save and sustain the lives of the affected populationthe affected population

Main PointsMain Points

• Vital to use the first assessment to establish Vital to use the first assessment to establish an ongoing data collection and analysis an ongoing data collection and analysis systemsystem

• The initial assessment should provide The initial assessment should provide information that feeds directly into the information that feeds directly into the program planning processprogram planning process

• Timing is vital – without a point of reference Timing is vital – without a point of reference most assessments data is of little valuemost assessments data is of little value

• Disasters are traumatic events to individuals – Disasters are traumatic events to individuals – Mental Health intervention will be neededMental Health intervention will be needed

Eastern

Tegucigalpa

THE MOST DEVASTATING STORM TO HIT CENTRAL AMERICA IN OVER 200 YEARS.THE MOST DEVASTATING STORM TO HIT CENTRAL AMERICA IN OVER 200 YEARS.

Hurricane Mitch - Overview

Dead: 8,209

Missing: 9,397

Displaced-Homeless: 2,747,640

Bridges Damaged: 356

Dead: 8,209

Missing: 9,397

Displaced-Homeless: 2,747,640

Bridges Damaged: 356

Managua

San Salvador

GuatemalaCity

Life saving missions and emergency delivery of relief supplies and medical assistance

Managua

Guatemala City

San Pedro Sula La Ceiba

Phase I - Emergency

Soto Cano

$42,500,000 $42,500,000

26-Nov-98

Lives Saved 1,052 Lives Saved 1,052 Food Distributed 3,245,100 LbsFood Distributed 3,245,100 LbsMedical Supplies Distributed 131,000 Lbs Medical Supplies Distributed 131,000 Lbs Water Distributed 120,000 Water Distributed 120,000 GalsGals

Lives Saved 1,052 Lives Saved 1,052 Food Distributed 3,245,100 LbsFood Distributed 3,245,100 LbsMedical Supplies Distributed 131,000 Lbs Medical Supplies Distributed 131,000 Lbs Water Distributed 120,000 Water Distributed 120,000 GalsGals

39 A/C 440 Sorties1686 hrs

6 A/C200 Sorties 385 hrs

2,102

Phase II - Rehabilitation

Bridges

Power

Roads

Structures

Medical

Wells

Managua

Guatemala City

Comalapa

San Pedro Sula La Ceiba

Repairs to infrastructure required to reestablish national capabilities to provide for health

and basic welfare of the populace5,400 +

10

53

11

219(Sorties)

Soto Cano

4 $112,500,000 $112,500,000

Schools

RoadsBypasses and Bridges

Phase III - Restoration

Long term effort to permanently repair infrastructure, rebuild economies and fully mitigate storm damage.

Clinics and Medical Outreach

12 / 39

33

Wells

$70,000,000 $70,000,000

90 km / 26 / 2

27

Medical Priorities in Phase IMedical Priorities in Phase I

• Safety of rescuersSafety of rescuers• Saving of lifeSaving of life• Distribution of water & foodDistribution of water & food

Medical Priorities in Phase IIMedical Priorities in Phase II

• Force health protectionForce health protection• Controlling disease outbreaksControlling disease outbreaks• Vector control consultationVector control consultation• Food and water suretyFood and water surety• Sanitation consultationSanitation consultation• Restoration of general public health measuresRestoration of general public health measures• Consultation on the disposal of remainsConsultation on the disposal of remains• Epidemiological surveillance Epidemiological surveillance • Functional HN medical infrastructureFunctional HN medical infrastructure

Lessons LearnedLessons LearnedLessons LearnedLessons Learned

• Early and accurate assessments a must:Early and accurate assessments a must:• Infrastructure needsInfrastructure needs

• Size and type of unitsSize and type of units

• Deployment prioritiesDeployment priorities

• Regional disaster office overwhelmed Regional disaster office overwhelmed • Disaster relief often creates competing prioritiesDisaster relief often creates competing priorities• Military Support to Civil Authorities is a different Military Support to Civil Authorities is a different

animal--Training a must…animal--Training a must…• SOUTHCOM both a supported and supporting CommandSOUTHCOM both a supported and supporting Command• Knowledge of ground rules-- Imperative!!! Knowledge of ground rules-- Imperative!!!

Balanced Surge Capacity Scale

Finding a Balance

Efficient Effective

Rhode Island Nightclub FireRhode Island Nightclub FireThe FactsThe Facts

• 20 Feb 03, West Warwick, RI20 Feb 03, West Warwick, RI• ““The Station” nightclub The Station” nightclub

caught fire with 250-300 caught fire with 250-300 people insidepeople inside

• Results:Results:• 99 dead99 dead• 150+ injured150+ injured

• Deadliest U.S. nightclub fire Deadliest U.S. nightclub fire since 1977since 1977

Rhode Island Nightclub FireRhode Island Nightclub FireMedical ResponseMedical Response

• Burn patients sent to 11 Burn patients sent to 11 regional hospitals includingregional hospitals including• Rhode Island Hospital, RIRhode Island Hospital, RI• Kent Co. Memorial Hospital, RIKent Co. Memorial Hospital, RI• Mass. General Hospital, MAMass. General Hospital, MA

• Response teams delivered Response teams delivered on scene medical careon scene medical care• EMTEMT• FireFire• Off-duty doctors/nursesOff-duty doctors/nurses

Rhode Island Nightclub FireRhode Island Nightclub Fire

• Validated theory of “Surge Capacity”Validated theory of “Surge Capacity”• Local hospitals overwhelmedLocal hospitals overwhelmed• Patients sent to other states for carePatients sent to other states for care

• Tested response plans to possible Tested response plans to possible terrorists attacksterrorists attacks

Source: Boston Globe, The Phoenix

Rhode Island Nightclub FireRhode Island Nightclub FireLessons LearnedLessons Learned

• Patient surge must be addressed!Patient surge must be addressed!• Can happen in peace timeCan happen in peace time• Terrorist attack is not only causeTerrorist attack is not only cause

• Use of all available resources is a must!Use of all available resources is a must!• Hospital bedsHospital beds• Response personnelResponse personnel

• Bottom Line: We must prepare for all Bottom Line: We must prepare for all possible disasters. We should organize, possible disasters. We should organize, train, and equip to meet the surge dilemma train, and equip to meet the surge dilemma in any crisis!in any crisis!

The Dilemma!The Dilemma!

• No solution currently exists to meet a surge No solution currently exists to meet a surge in patients during crisis!in patients during crisis!• 2001 Presidential Inauguration -- 7 ICU beds in DC2001 Presidential Inauguration -- 7 ICU beds in DC• Demolition of Mile High Stadium Exercise -- 7 ICU Demolition of Mile High Stadium Exercise -- 7 ICU

beds in Denverbeds in Denver• 2002 weekend in Dayton and Cincinnati -- 1 ICU 2002 weekend in Dayton and Cincinnati -- 1 ICU

bed in areabed in area• Hospitals face fiscal constraints in national crisisHospitals face fiscal constraints in national crisis

• Limited resources and manpowerLimited resources and manpower• Fear factorFear factor

• Who will arrive for second shift once bio/chem has Who will arrive for second shift once bio/chem has been detected?been detected?

Preparation for the NationMaking the Pieces Fit

First PreparersGeneral Population

City Planners

Disaster Planners

National PlannersFP

FRd

First RespondersPolice

Fire

EMS

City and County Health Officials

FR

First Receivers

Hospitals

Clinics

Health Facilities

Source: Dr. Paul K. Carlton

QUESTIONS?QUESTIONS?