Medical Response Capabilities Research Articles

Surgeons' Roles and Responsibilities in Disaster and Public Health Emergency Management-A Transition from Multitasking Surgeons to a Collaborative Surgical Approach.

Surgeons have historically played critical roles in disaster management, particularly as military and trauma specialists. However, the role of surgeons in disasters has changed over time, with advancements in medical knowledge and disaster response capabilities. Recent public health emergencies and global events have signaled a paradigm shift, emphasizing the necessity of cross-disciplinary, transdisciplinary, and multidisciplinary approaches. This shift calls for revisiting and reevaluating surgeons' roles and responsibilities. In this narrative review, the literature concerning the roles and responsibilities of surgeons during disasters and public health emergencies was systematically searched and mapped. This streamlined process aimed to gather high-quality information typically found in a systematic review but within a shorter timeframe. The goal was to expedite the discovery of insights that could inform policy decisions or address urgent matters related to the study's topic. Furthermore, action research was performed to strengthen the paper's methodology, capture essential literature, and avoid missing important data. The results indicate a change in surgical specialty and a shift in the paradigm from multitasking surgeons to a multidisciplinary approach in surgical disaster management. Current educational initiatives are insufficient, and training opportunities are lacking, indicating the need for novel educational initiatives, simulation training, a collaborative surgical approach, and a reevaluation of the current curriculum. The study outcomes aim to guide future policy development and facilitate the creation of practical guidelines for disaster and public health emergency planners at local, regional, national, and international levels. Surgeons' future roles in disaster and public health emergency management will be characterized by innovation, collaboration, and a commitment to improving outcomes for affected populations, addressing the unique challenges of disasters, and strengthening healthcare systems globally.

EMT2-ITA Regione Piemonte Greening Initiatives for Building Climate Resilient Field Hospital

Background/Introduction:The World Health Organization (WHO) declared climate change a defining issue in the 21st century with more intense heatwaves, higher risks of flooding and damaging storms, and a changing pattern of emerging infectious diseases. In this scenario, the response of Emergency Medical Teams (EMTs) to disasters represents a fundamental resource.Objectives:To expand EMT2-ITA-Regione Piemonte operational independence and to minimize its environmental footprint.Method/Description:A multiphasic and prospective project is planned in order to:(1) Reduce water consumption: use of a sterilizer designed with a set of high-efficiency heat exchangers enabling a substantial saving in water consumption by the vacuum pump and a significant reduction of total water usage through a recirculation system.(2) Reduce demand for diesel: photovoltaic (PV) system to integrate the current energy production system based on diesel generators.(3) Reduce paper consumption: use of sterilization management and traceability system and computerized medical record in order to be paperless.(4) Improve staff awareness and education on greening practices: educational program for the staff focused on waste segregation/management and energy and water saving both in the hospital and in the Base of Operation (BoO).Results/Outcomes:EMT2-ITA-Regione Piemonte aims to reduce energy and water consumption by 30% and to become paperless.Conclusion:Advances in greening initiatives offer to EMT2-ITA-Regione Piemonte the potential to improve its disaster medical response capabilities and to reduce its ecological footprint.

Policy disparities in response to the first wave of COVID-19 between China and Germany

ObjectiveOur research summarized policy disparities in response to the first wave of COVID-19 between China and Germany. We look forward to providing policy experience for other countries still in severe epidemics.MethodsWe analyzed data provided by National Health Commission of the People’s Republic of China and Johns Hopkins University Coronavirus Resource Center for the period 10 January 2020 to 25 May 252,020. We used generalized linear model to evaluate the associations between the main control policies and the number of confirmed cases and the policy disparities in response to the first wave of COVID-19 between China and Germany.ResultsThe generalized linear models show that the following factors influence the cumulative number of confirmed cases in China: the Joint Prevention and Control Mechanism; locking down the worst-hit areas; the highest level response to public health emergencies; the expansion of medical insurance coverage to suspected patients; makeshift hospitals; residential closed management; counterpart assistance. The following factors influence the cumulative number of confirmed cases in Germany: the Novel Coronavirus Crisis Command; large gathering cancelled; real-time COVID-19 risk assessment; the medical emergency plan; schools closure; restrictions on the import of overseas epidemics; the no-contact protocol.ConclusionsThere are two differences between China and Germany in non-pharmaceutical interventions: China adopted the blocking strategy, and Germany adopted the first mitigation and then blocking strategy; China’s goal is to eliminate the virus, and Germany’s goal is to protect high-risk groups to reduce losses. At the same time, the policies implemented by the two countries have similarities: strict blockade is a key measure to control the source of infection, and improving medical response capabilities is an important way to reduce mortality.

National Health Preparedness and Response Centers: Revisiting the Increasingly Critical Need to Expand Cooperative Emergency Response Capabilities in the United States.

In 1999, a robust National Health Preparedness and Response Center was conceptualized and piloted, but never fully operationalized. This study revisits the expansive, coordinated efforts invested in this concept, considered an overdue remedy for persistent shortfalls in medical Chemical, Biological, Radiological, Nuclear, and High Yield Explosives training, proficiency, and preparation. The concept defined a robust mission for longstanding, proven programs for prepositioning equipment and associated training of personnel. This study explores the reasons that ended military and governmental support, attendant funding, and operations of the created Joint/Interagency Civil Support Center, which ceased on September 30, 2006. Unfortunately, the concept remains relevant. Major gaps in disaster medical response capabilities have been recognized for decades. Experts from the Institute of Medicine, United States Northern Command, and multiple academic centers and professional organizations have identified these shortcomings, but the national response posture remains disjointed, under-resourced, and based upon obsolete planning premises. Given increasing threats, the authors recommend revisiting the collaboration of military, civilian, academic, and governmental resources that once established the Joint/Interagency Civil Support Center as a multidisciplinary and trans-disciplinary model for a new National Health Preparedness and Response Center coordinated framework for enhanced resilience and operational response capabilities on a national level.

National Institutes of Health (NIH) Executive Meeting Summary: Developing Medical Countermeasures to Rescue Opioid-Induced Respiratory Depression (a Trans-Agency Scientific Meeting)-August 6/7, 2019.

On August 6th, 2019, a two-day trans-agency scientific meeting was convened by the United States (U.S.) National Institute of Allergy and Infectious Diseases (NIAID/NIH) on the research and development of medical countermeasures (MCMs) and treatment strategies to mitigate synthetic opioid-induced toxicities. This trans-agency meeting was an initiative of the Chemical Countermeasures Research Program (CCRP) and organized by the NIAID in collaboration with the National Institute of Drug Abuse (NIDA), the Biomedical Advanced Research and Development Authority (BARDA), the Food and Drug Administration (FDA), and the Defense Threat Reduction Agency (DTRA). The CCRP is part of the larger NIH biodefense research program coordinated by NIAID, which also includes MCM research and development programs against biological, radiological, and nuclear threats. Its overarching goal is to integrate cutting-edge research and technological advances in science and medicine to enhance the nation's medical response capabilities during and after a public health emergency involving the deliberate or accidental release of toxic chemicals. The potential of a mass casualty public health event involving synthetic opioids is a rapidly growing concern. As such, the overall goals of this trans-agency meeting are to better understand opioid-induced toxicities and advance the development of MCMs to mitigate and reverse opioid-induced respiratory depression (OIRD) to prevent consequential mortality. The primary objectives of the meeting were (1) highlight the latest research on mechanisms of OIRD and related toxicities, animal models, diagnostics, delivery technologies, and emerging new treatment options to prevent lethality; (2) identify current knowledge gaps to advance medical countermeasure development; (3) hear from the U.S. FDA on regulatory considerations to support new technology and treatment approaches; and (4) provide a forum for networking and collaborative partnerships. To accomplish this, a diverse group of almost 200 US domestic and international subject matter experts spanning fundamental and translational research from academia, industry, and government came together in-person to share their collective expertise and experience in this important field. This report briefly summarizes the information presented throughout the meeting, which was also webcast live in its entirety to registered remote attendees.

Special issue: modeling and simulation technologies to enhance and optimize the Department of Defense’s medical readiness and response capabilities

Special issue: modeling and simulation technologies to enhance and optimize the Department of Defense’s medical readiness and response capabilities

Integration of energy analytics and smart energy microgrid into mobile medicine operations for the 2012 Democratic National Convention.

Disasters create major strain on energy infrastructure in affected communities. Advances in microgrid technology offer the potential to improve "off-grid" mobile disaster medical response capabilities beyond traditional diesel generation. The Carolinas Medical Center's mobile emergency medical unit (MED-1) Green Project (M1G) is a multi-phase project designed to demonstrate the benefits of integrating distributive generation (DG), high-efficiency batteries, and "smart" energy utilization in support of major out-of-hospital medical response operations. Carolinas MED-1 is a mobile medical facility composed of a fleet of vehicles and trailers that provides comprehensive medical care capacities to support disaster response and special-event operations. The M1G project partnered with local energy companies to deploy energy analytics and an energy microgrid in support of mobile clinical operations for the 2012 Democratic National Convention (DNC) in Charlotte, North Carolina (USA). Energy use data recorded throughout the DNC were analyzed to create energy utilization models that integrate advanced battery technology, solar photovoltaic (PV), and energy conservation measures (ECM) to improve future disaster response operations. The generators that supply power for MED-1 have a minimum loading ratio (MLR) of 30 kVA. This means that loads below 30 kW lead to diesel fuel consumption at the same rate as a 30 kW load. Data gathered from the two DNC training and support deployments showed the maximum load of MED-1 to be around 20 kW. This discrepancy in MLR versus actual load leads to significant energy waste. The lack of an energy storage system reduces generator efficiency and limits integration of alternative energy generation strategies. A storage system would also allow for alternative generation sources, such as PV, to be incorporated. Modeling with a 450 kWh battery bank and 13.5 kW PV array showed a 2-fold increase in potential deployment times using the same amount of fuel versus the current conventional system. The M1G Project demonstrated that the incorporation of a microgrid energy management system and a modern battery system maximize the MED-1 generators' output. Using a 450 kWh battery bank and 13.5 kW PV array, deployment operations time could be more than doubled before refueling. This marks a dramatic increase in patient care capabilities and has significant public health implications. The results highlight the value of smart-microgrid technology in developing energy independent mobile medical capabilities and expanding cost-effective, high-quality medical response.

Contributions of academia to public health preparedness research.

The 2006 Pandemic and All-Hazards Preparedness Act (PAHPA) resulted in the development of several major program areas designed to respond to its legislation, “to improve the nation's public health and medical preparedness and response capabilities for emergencies, whether deliberate, accidental, or natural.”1 In 2008, the Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response (OPHPR) created seven Preparedness and Emergency Response Research Centers (PERRCs) in an effort to support the goals of PAHPA. The program expanded to nine centers in 2009. PERRCs, located at Council on Education for Public Health (CEPH)-accredited schools of public health, were tasked to improve “public health practice for preparedness and emergency response planning and policies at the local, state, federal, and tribal level.”2 CEPH is an independent agency certified by the U.S. Department of Education that accredits schools and programs of public health to assure compliance with well-defined standards. CDC established a cooperative agreement in 2008 with the Association of Schools of Public Health (ASPH), now known as the Association of Schools and Programs of Public Health (ASPPH), to provide programmatic support to the PERRCs (“Year Four: ASPH Continuation Application,” application by CDC, June 2008). As the voice of accredited public health education, ASPPH works to transform public health by strengthening and promoting the education, research, service, and practice activities of CEPH-accredited schools and programs of public health and by advocating for the investments in science that will advance population health. A commitment to advocating for evidence-based public health policies and programs lies at the core of the ASPPH mission (Unpublished document, ASPPH Strategic Framework, ASPPH, 2013). PERRCs conduct research that can be used to enhance public health preparedness (PHP) policies, planning, and response.2 Most health departments lack the resources to test new theories or concepts, but the federal funding allocated for these centers allows researchers to be more innovative in their work.3 The PERRCs have formed numerous collaborations with community partners and performed extensive outreach, including to disciplines not traditionally engaged in public health activities, such as engineering, law, and public policy. Involving stakeholders is a crucial component of translational research.4 As a result, those working with communities can feel confident that their activities and trainings are rooted in evidence.

Time for a revolution: smart energy and microgrid use in disaster response.

Modern health care and disaster response are inextricably linked to high volume, reliable, quality power. Disasters place major strain on energy infrastructure in affected communities. Advances in renewable energy and microgrid technology offer the potential to improve mobile disaster medical response capabilities. However, very little is known about the energy requirements of and alternative power sources in disaster response. A gap analysis of the energy components of modern disaster response reveals multiple deficiencies. The MED-1 Green Project has been executed as a multiphase project designed to identify energy utilization inefficiencies, decrease demands on diesel generators, and employ modern energy management strategies to expand operational independence. This approach, in turn, allows for longer deployments in potentially more austere environments and minimizes the unit's environmental footprint. The ultimate goal is to serve as a proof of concept for other mobile medical units to create strategies for energy independence.

Preparedness in America’s prime danger zone and at the Boston Marathon bombing site

The area between Newark and Elizabeth, NJ, contains major transportation hubs, chemical plants, and a dense population. This makes it "the most dangerous two miles in America," according to counterterrorism officials at the Federal Bureau of Investigation. This study compares medical response capabilities for terror and disaster in Newark, New Jersey's largest city, with those in Boston in view of that city's favorable response to the Marathon bombings in April 2013. Boston's numerous world-class medical facilities offer advantages unavailable in Newark and most other metropolitan locations. Thus, preparedness in Newark, despite its prime-danger designation, can also be instructive for many communities with similar medical resources. Three categories of response capabilities are assessed: hospital resources, relevant personnel, and symposia/exercises. Data were derived from hospital Web sites, the New Jersey and Massachusetts Hospital Asso-ciations, communications with emergency response personnel, and interviews with spokespersons for hospitals. Boston's population (618,000) is more than twice Newark's (278,000), and the number of hospitals and hospital beds in each city reflects that proportion. However, Boston's seven general adult hospitals include five level 1 trauma centers (which can provide comprehensive trauma care), whereas Newark's four hospitals include only one such center.Beds per 1,000 people are similarly disparate in those trauma centers: five in Boston, 1.5 in Newark. Emergency Medical Services (EMS) personnel based in Boston and Newark are comparable in numbers, though full-time hospital physicians/dentists and nurses are not. The number of doctors at Boston's five level 1 centers is more than triple that at all four of Newark's hospitals (5,284 vs 1,494). The disparity between nurses at the two sites is even greater (6,784 vs 1,566).There is greater equivalency between the two cities both in content and frequency of symposia/exercises. Hospitals in each city have conducted numerous tabletop and action exercises including on communications efficiency, power outages, and dealing with a bombing or active shooter. Hospitals in each city also have participated in citywide drills with EMS, police, fire, and other responders. Commonalities in Newark and Boston's exercise approaches suggest that Boston's successful response at the Marathon might be replicated at least in part if the Newark area were similarly challenged. Whether Newark and similarly enabled communities would respond with comparable efficiency remains conjectural. Still, maintaining rigorous preparedness efforts seems a self-evident imperative, especially in an area deemed among the country's most inviting terrorist targets.

Foreign Medical Teams: What Role Can They Play in Response to a Catastrophic Disaster in the US?

Hurricane Katrina demonstrated that a catastrophic event in the continental United States (US) can overwhelm domestic medical response capabilities. The recent focus on response planning for a catastrophic earthquake in the New Madrid Seismic Zone and the detonation of an improvised nuclear device also underscore the need for improved plans. The purpose of this analysis is to identify the potential role of foreign medical teams (FMTs) in providing medical response to a catastrophic event in the US. We reviewed existing policies and frameworks that address medical response to catastrophic events and humanitarian emergencies and assess current response capabilities by a variety of FMTs. While several policies and plans outline the role of the US in providing medical assistance during foreign disasters, further planning is necessary to identify how the US will integrate foreign medical assistance during a domestic catastrophic event. We provide an overview of considerations related to federal roles and responsibilities for managing and integrating FMTs into the overarching domestic medical response to a catastrophic disaster occurring in the continental US.

Medical Response Capabilities to a Catastrophic Disaster: "House" or House of Cards?

Abstract Planning for a disaster is often influenced by the dual factors of perception of probabilities and current technology. Response design is built upon assumptions on the size, scope, and severity of the catastrophe. Yet, history documents myriad disasters that far surpassed even the direst predictions. Similarly, response mechanisms build upon what is in use at the time in terms of equipment, transportation, and employment. Current planning factors may prove inadequate to address a disaster of historical proportion. The authors offer a review of significant disasters as a measure of the potential scope of needed medical response and the inherent shortcomings therein. They call for a more comprehensive approach to medical response planning.

Why the Prominent Improvement in Prehospital Medical Response in Iran Couldn’t Decrease the Number of Death Related Road Traffic Injuries

Copyright: © 2012 Khankeh HR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Road Traffic Injuries (RTIs) are still a major public health problem especially in lowand middle-income countries [1]. It caused more than 1.27 million deaths and almost 50 million injuries every year worldwide. For reduction of their consequences it required concerned efforts both for crash prevention and improvement in post crash management [2,3]. Iran ranks as one of the highest mortality rates of RTIs in middle-income countries. Focusing on post crash event, studies in Iran have shown that about 60% of the deaths use to be occurred at the crash scene or during transporting to hospital [2], but the pattern was changed in recent year and about 40% of the deaths occur in the pre-hospital phase. Changing in this pattern may because of pre-hospital medical response capabilities in recent years and a dramatically improvement in this area including staff training and their skill as well as ambulance number and ambulance dispatch sites and their equipments [4]. Despite these efforts, mortality and morbidity of RTIs has not shown a noticeable decrease [2].

Geographical Maldistribution of Pediatric Medical Resources in Seattle-King County

Seattle-King County (SKC) Washington is at risk for regional disasters, especially earthquakes. Of 1.8 million residents, >400,000 (22%) are children, a proportion similar to that of the population of the State of Washington (24%) and of the United States (24%). The county's large area of 2,134 square miles (5,527 km2) is connected through major transportation routes that cross numerous waterways; sub-county zones may become isolated in the wake of a major earthquake. Therefore, each of SKC's three subcounty emergency response zones must have ample pediatric medical response capabilities. To date, total quantities and distribution of crucial hospital resources (available in SKC) to manage pediatric victims of a medical disaster are unknown. This study assessed whether geographical distribution of hospital pediatric resources corresponds to the pediatric population distribution in SKC. Surveys were delivered electronically to all eight acute care hospitals in SKC that admit pediatric patients. Quantities and categories of pediatric resources, including inpatient treatment space, staff, and equipment, were queried and verified via site visits. Within the seven responding hospitals of eight queried, the following were identified: 477 formal pediatric bed spaces (pediatric intensive care unit, neo-natal intensive care unit, general wards, and emergency department), 43 informal pediatric bed spaces (operating room and post-anesthesia care unit), 1,217 pediatric nurses, 554 pediatric physicians, and 252 infant/pediatric-adaptable ventilators. The City of Seattle emergency response zone contains 82.1% of bed spaces, 83.5% of nurses, and 95.8% of physicians, yet only 22.8% of all SKC children live in that zone. The majority of hospital pediatric resources are located in the SKC sub-region with the fewest children. These resources are potentially inaccessible and unable to be redistributed by ground transportation in the event of a significant regional disaster. Future planning for pediatric care in the event of a medical disaster in SKC must address this vulnerability.

The CounterACT Research Network: Basic Mechanisms and Practical Applications

The National Institutes of Health has developed a comprehensive research program that includes research centers of excellence, individual research projects, small business projects, contracts, and interagency agreements to conduct basic, translational, and clinical research aimed at the discovery and/or identification of better medical countermeasures against chemical threat agents. Chemical threats include chemical warfare agents, toxic industrial and agricultural chemicals, and toxins and other chemicals that could be used intentionally as an act of terror or by large-scale accidents or natural disasters. The overarching goal of this research program is to enhance our medical response capabilities during an emergency. The program is named Countermeasures Against Chemical Threats (CounterACT). It supports translational research, applying ideas, insights, and discoveries generated through basic scientific inquiry to the treatment or prevention of mortality and morbidity caused by chemical threat agents. The categories of research supported under this program include creation and development of screening assays and animal models for therapy development, identification of candidate therapeutics, obtaining preliminary proof-of-principle data on the efficacy of candidate therapeutics, advanced efficacy and preclinical safety studies with appropriate animal models using Good Laboratory Practices (GLP), and clinical studies, including clinical trials with new drugs. Special consideration is given to research relevant to people who are particularly vulnerable, including the young, the elderly, and individuals with pre-existing medical conditions.

Role of Information Technology in Disaster Medical Response

This article addresses the importance of information technology (IT) in support of disaster medical response and provides a framework for the use of IT in response to natural disasters or terrorist activities. The appropriate use of IT enhances the effectiveness of the disaster response system, thereby safeguarding the population and the community infrastructure. This study found that most US hospitals have wireless local area networks (LANs) with disaster medical response capabilities. The data indicate that combined with the wireless LAN, many hospitals have acquired personal digital assistants, tablets, and handheld personal computers, which are important disaster medical response resources. This research shows that the wireless LAN networks and remote input devices are in place to ensure a timely medical response to disasters within many US communities.

The role of emergency medical planning in disaster response

This paper addresses the importance of emergency medical planning in disaster response and highlights the need for cooperation among community, governmental and private organisations. Research on emergency medical disaster planning will provide a framework for community leaders, elected officials and healthcare providers to analyse data to support evidence-based decision making in natural disasters or terrorist incidents. Such decisions increase the effectiveness of the disaster response system, thereby safeguarding the population and the community infrastructure. This study found that approximately 79% of rural communities in the USA have hospital emergency rooms with medical disaster response capabilities. Unfortunately, the data demonstrate that 21% of rural communities lack emergency rooms, which are important disaster medical response resources. As a result, rural populations could be at risk during disasters. It also emphasises the importance of building partnerships among local, state and national organisations to ensure a timely medical response to disasters.

Vulnerability of populations and the urban health care systems to nuclear weapon attack – examples from four American cities

BackgroundThe threat posed by the use of weapons of mass destruction (WMD) within the United States has grown significantly in recent years, focusing attention on the medical and public health disaster capabilities of the nation in a large scale crisis. While the hundreds of thousands or millions of casualties resulting from a nuclear weapon would, in and of itself, overwhelm our current medical response capabilities, the response dilemma is further exacerbated in that these resources themselves would be significantly at risk. There are many limitations on the resources needed for mass casualty management, such as access to sufficient hospital beds including specialized beds for burn victims, respiration and supportive therapy, pharmaceutical intervention, and mass decontamination.ResultsThe effects of 20 kiloton and 550 kiloton nuclear detonations on high priority target cities are presented for New York City, Chicago, Washington D.C. and Atlanta. Thermal, blast and radiation effects are described, and affected populations are calculated using 2000 block level census data. Weapons of 100 Kts and up are primarily incendiary or radiation weapons, able to cause burns and start fires at distances greater than they can significantly damage buildings, and to poison populations through radiation injuries well downwind in the case of surface detonations. With weapons below 100 Kts, blast effects tend to be stronger than primary thermal effects from surface bursts. From the point of view of medical casualty treatment and administrative response, there is an ominous pattern where these fatalities and casualties geographically fall in relation to the location of hospital and administrative facilities. It is demonstrated that a staggering number of the main hospitals, trauma centers, and other medical assets are likely to be in the fatality plume, rendering them essentially inoperable in a crisis.ConclusionAmong the consequences of this outcome would be the probable loss of command-and-control, mass casualties that will have to be treated in an unorganized response by hospitals on the periphery, as well as other expected chaotic outcomes from inadequate administration in a crisis. Vigorous, creative, and accelerated training and coordination among the federal agencies tasked for WMD response, military resources, academic institutions, and local responders will be critical for large-scale WMD events involving mass casualties.

The growing importance of disaster medical response

This paper addresses the importance of disaster medical response from a public administration perspective and highlights the importance of cooperation among community, governmental and private organisations. Research in disaster medical response will provide a framework for community leaders, elected officials and healthcare providers to collect and analyse data to support evidence-based decision making in response to natural disasters or terrorist activities. Such decisions increase the efficiency and effectiveness of the disaster response system thereby safeguarding the population and the community infrastructure. This study found that disaster medical response capabilities are greater in urban communities, while rural communities have less disaster medical response capabilities. This would support the premise that disaster medical response resources have been allocated in a manner to provide the greatest good to the greatest population.

Physicians and Disaster Preparedness

To the Editor. —I was delighted to see the focus on national planning for medical response to major disasters and emergencies. 1 However, in reading the article, I was disappointed to discover that Drs Pretto and Safar failed to recognize the important distinction between traditional, everyday emergency medical services (EMS) response and catastrophic mass casualty response. In fact, they completely ignored the National Disaster Medical System (NDMS), its current operational plans and arrangements, and its rapidly increasing medical response capabilities. Although EMS deal with everyday emergencies, a disaster, by definition, is an occurrence that overwhelms available personnel and other resources. To assume that concentrations of personnel and technology will occur rapidly following an incident producing tens of thousands of seriously injured or ill victims is impractical and unrealistic and creates false expections. Given the vast geographic area of our nation, the multiple major metropolitan concentrations of our population, the wide