APHJ – Emergency Preparedness with Jane Braun and Jim Harris

In the wake of the September 11th attacks and the subsequent anthrax scare, a great deal of time and resources were rapidly invested in the public health system to respond to this crisis In the process of preparing to respond to bioterrorism, we discovered that the skills we learned were useful in many emergency and disaster situations We also learned that being prepared for terrorism or other disasters, is not a one-time thing It has evolved from being an acute problem into more of a chronic issue that needs to be addressed on a long-term basis The question is, how do we incorporate planning for emergencies into a sustainable public health framework? We’ll try to answer that question on today’s episode of “A Public Health Journal” (male narrator) Welcome to “A Public Health Journal”, a program that explores public health issues facing our society today and tomorrow The host of the show is Dr. Ed Ehlinger, Commissioner of Health for the state of Minnesota “A Public Health Journal” is sponsored by the Minnesota Department of Health, and the Hennepin County Human Services and Public Health Department; all working together towards the goal of healthy people living in healthy communities Welcome to “A Public Health Journal” Today we’re going to look at the issue of emergency preparedness, that is, how do we develop emergency response plans at the federal, state, and local levels, and how do we train the people to respond in an effective way and maintain their level of experience We’ll be talking about that with a couple of experts in the field of emergency preparedness, but first we’ll start with a recent news report provided to us courtesy of KSTP Channel 5 It was a field hospital, set up at the Minneapolis Convention Center today Medical professionals from across the state were triaging patients It was all a training mission so that crews can be ready to roll when a disaster strikes 5 Eye Witness News reporter Jessica Miles has the story Is everybody ready for Scenario Number Two? (Jessica) It’s the first time all of this equipment has been in the same place at the same time (woman) Is it getting better? Seems to be getting better (Jessica) This vehicle is basically a hospital on wheels Medical teams are training how to use it The goal is to have this unit set up at the site of a disaster within 36 hours One thing we worry about a lot is tornadoes We saw in Joplin, Missouri, a tornado can hit a hospital and a community can lose their medical care (Jessica) Over here, the ambulance strike team that can deploy multiple ambulances and crews anywhere in the state to take over 911 systems, help with evacuations or shelter We have systems built in place that can be deployed quickly, efficiently, and timely (Jessica) Lanenberg says this huge coordinated effort can be set up anywhere in the state in a day This tent right here can be used as shelter, as a hospital, as an operations center It can sustain 75 mile-per-hour winds, it has its own electrical, heat and air, and it can pop up in less than two hours Large buses can become human transporters One was used back in 2009 when the Red River flooded in Fargo We moved roughly about 180 patients in just under 6 to 7 hours, once we got onsite (Jessica) This training will help communities across the state Drills like this keep us very proficient and ready to go in a moment’s notice (Jessica) But it’s not only Minnesota that benefits We have been told several times that we have probably helped more states out than any other state in the country, as far as our response capabilities In Minneapolis, Jessica Miles, 5 Eye Witness News The mobile medical teams consist of two different groups One is based right here in the Twin Cities area, the other is in St. Cloud Each group has more than 30 members These are volunteers who all have day jobs Their employers work with them to let them go on a moment’s notice if they’re needed at a disaster Joining us now to discuss the emergency preparedness are Jane Braun, the Director of Emergency Preparedness for the Minnesota Department of Health, and Dr. Jim Harris, an Emergency Physician, and Director of Emergency Services at Riverwood Healthcare Center in Aitkin, Minnesota, and Medical Advisor for the Mobile Medical Unit and the Mobile Medical Team Project Jane, Jim, welcome to our program Thanks Ed And it’s nice having you on after this event that you had, this training program that KSTP kinda filmed Jane, you’ve been in, you know, emergency preparedness for a while Could we have done that kind of thing 12, 13 years ago, the kind of get together that you had of all of those people and all of that equipment and all of this planning? Absolutely not; things have really evolved over the last 10 to 12 years, where we have built the partnerships, we’ve built the teamwork, as well as obtained the equipment and the types of resources we need and the training And a lot of it we’ve been working on lately is the coordination How do we know who’s role is what? How do we bring in the things we need? And that exercise actually was the first time that we’ve ever had all of our mobile assets in one place to practice statewide with a lot of different teams So, so how did this come about? I know we had, the September 11th attacks, and we got resources to do that And how did the planning actually happen, to say what do we need to do this, to make this actually come together? Yeah, shortly after September 11th, there was a realization

that there was a real lack of coordination of efforts, and incapacity to surge the healthcare system and the public health systems And so the federal government did give large grants to states at that time to start building this capacity and capability And so we worked very hard to determine what the needs were and then to work on building on systems and resources and partnerships to take care of those needs Now, and this all came about because of September 11th, but I have a slide here that shows you know, what happened just recently up in Moose Lake, where we have a, the Moose Lake Elementary School underwater Uh, this is an example Jim, what are some of the things, you know, this is, we’re not just talking bioterrorism, you know, nuclear disaster, we’re talking what happens in your local community (Jim Harris) Absolutely, yeah, there’s uh, you know, obviously we see flooding in our state, we see tornadoes, there’s plenty of natural disasters that can do this, and put communities or healthcare at risk But there are other more uh, more mundane things, you know One example would be if a, a say part of a hospital or a rural health clinic had a sprinkler malfunction, and they lost a lot of their bioelectronics, lost part of their facility, that could put them at risk as well, to be able to care for their community’s healthcare needs Yeah, so, so preparedness is not just preparing for this major disaster It’s preparing for something that happens probably every day somewhere in Minnesota, somewhere in the United States (Jim Harris) Absolutely, yeah Now I’ve got another slide, ’cause Jane talked about all of the resources coming together So I’ve got a slide here that says alright we’ve got Public Health as their role, and you got Emergency Management and Healthcare; how do these all come together? Explain what’s going on with the thinking behind this kind of Venn diagram (Jane Braun) What we’re really looking at is what we call an all-hazards approach, that it’s not about a tornado specifically, or about bioterrorism specifically, it’s what do we need to do in the system working with our different partners to be able to deal with any type of hazard that might occur? And as the slide shows, we’re really trying to coordinate the things between Public Health, Healthcare and Emergency Management We need to understand each other’s roles, we need to use each other’s assets, we need to have common language, we need to make sure that we know, have compatible equipment All of those kinds of things And so the federal government, has separate grants to these different disciplines, but they have things that are called the capabilities, and some of those themes are common among the different programs And so we work very hard to work on certain things, like for example, communications is one of them, things like surveillance and epidemiology, mass care, all kinds of those things are parts of each of our responsibilities So we work very hard not only with different geographic areas, but with different disciplines of professional expertise to bring one system together where we understand the big framework and we know our roles and work together Now Jim, you know, those of us in public health, we, collaboration is part of our DNA and we work with partners, ’cause that’s sort of what Public Health does But you come more from an individual patient perspective as an ER doc, you know, you take care of individuals How, what kind of mind set change do you have to have to actually say, “Oh yeah, we’ve got lots of partners in here, “we need partners, we need systems, we need collaboration?” It must have been sort of a culture change It’s, yeah, a little different way of looking at things You know, fortunately for me I do some, I do disaster medicine for the federal government under DMAT, NDMS System And so I kinda learned the way of working together there, but yeah, partnerships are very important, I think for physicians one of the hard things is when you work in the Emergency Department, you’re generally in charge at least of that area, and getting used to the idea of letting go of that and working under the instant command system, letting other people deal with um, the command and control and really focusing on patient care and what you need to do for that particular mission to take care of people Giving up control is always hard isn’t it? [laughter] I want to talk about different roles, but first we need to take a little break, so we’ll be back right after this message (woman) What if a disaster strikes without warning? What if life as you know it has completely turned on its head? What if everything familiar, becomes anything but? Before a disaster turns you family’s world upside down, its up to you to be ready Get a kit Make a plan Be informed today Learn how at WWW.READY.Gov Welcome back, we’re talking about emergency preparedness with Jane Braun, Director of Emergency Preparedness at the Minnesota Department of Health, and Dr. Jim Harris, an Emergency Physician who’s also been

engaged in a lot of planning for emergency preparedness Jane you talked a little bit about roles, that came about, you know the feds said we need to do something I want to go through; what is the federal role, what is the state role, what is the local community role in all of this? So let’s start with the feds Where do they play, what role do they play in overall preparedness? Well the federal government really sets the overall direction They provide the structure, the scope, you know, what pieces should we be working on, what are outside of our scope And then they have secured a lot of the funding, actually 97% of our Public Health emergency preparedness in the state, at the state level, is federal money So they do a lot of the big picture, the vision of where we are, how the structure is run, what we’re working on At the state level, we work on kind of more of an assurance role ‘Cause a lot of this work needs to be done locally, we make sure that the local departments are doing the assessments that they need, that they understand what the priorities of the state are and how we want to be moving forward over the next several years, and monitoring and also providing a lot of guidance and coordination And then at the local level, that’s really where the work is done There’s the phrase, all disasters are local And so they are doing a local assessment Emergency Management, Healthcare, and Public Health have all done assessments in the last couple years What are our risks here? What are the places where we’re most vulnerable? Where do we want to focus our resources? And then that’s where they build those local partnerships, because these are not things you can start up in an instant You have to have the structures in place, you have to think about, what are fact sheets, what is our recommendation for if you’re flooded? You know, we know you can use the paper products, but what about the cans and the bottles? All those kinds of things are very hard to do just in time And so we work on having the pieces in place, so that when something happens and there’s the expectation of Minnesotans that we’re able to respond, to provide them information, provide them with help that those systems are in place And Jim, how does the local voice get elevated into this conversation? You know, the local providers, the local ER doc, the local ambulance crew, the local community How do you say, these are our needs and we have to get these addressed? Well um, you know, it happens again at the local level, and so most of us, because we work for healthcare organizations, we get involved with the emergency planning or business continuity planning for those organizations And then usually with that, you’re partnering with your, your county government and uh, county emergency managers And then you kinda partner with them and, and come up with a joint plan And then if there’s anything you need beyond that, then you’ll push that up to the state So you had mentioned, you know, giving up control of things And how do we determine who actually is in control? We have, you know, let’s say we had a nuclear spill or we had a public health emergency with, you know, an outbreak of infectious disease, or you’ve got a tornado or you’ve got, uh, Jane how do you determine who sort of takes the command in these situations? Well there’s a couple of structures The first one is that you handle it at the lowest level you can And so locally, generally the first person of authority on scene begins We have what’s called the Incident Command System, which outlines roles for people, makes it clear who reports to whom, who communicates in which direction, who has which piece, how often do you report in, you have briefings, those kinds of things And then at the state level there’s what’s called the Minnesota Emergency Operations Plan, or the MEOP And that outlines the role of every state agency Do have the lead role, or are they a support role? And so we have these structures we’ve been building over the years where we understand who’s got which piece, who communicates, how do we come together, how are decisions made? Do we have one person in charge or in a larger incident there’s a thing called Unified Command, where a lot of people have a big role And so they have to do the command as a group So it’s systems we’ve been practicing over the last many years, that are used to quickly get a handle on the situation, and they’re scalable up and down as the situation changes So Jim, in your training as a physician and an emergency room doc, do you get training in disaster preparedness, emergency preparedness, and do you know when to sort of call for help? Um, you know, there’s, I think, you know, I’ve been in this for a little while so my answer for my training would be no But I know that the programs now are including it, it is part of the training that newer physicians are getting The Instant Command System is really the, the key Understanding that and knowing, and again, that kind of guides you on, on who to call, and when to do it, so if anything, we could kinda bring out, it’s using Instant Command; that really helps keep you on track and on target And I know recent, relatively recent, we had the 35W Bridge collapse, which was, certainly Emergency Medicine really needed to be involved and Public Safety And how did that play out, how did it come up that our, let’s mobilize the resources? Could you kinda walk through the, the framework,

the scenario of that? And again, it, it starts out with the first on scene and they’re doing an assessment, and then they’re reporting up to their structures And then they quickly determine what the scope is It’s, you know we have situational awareness, we have a size-up of the situation And so they start saying what other assets are needed here, be they for water rescue or for all different kinds of things How many ambulances might we need? All the issues they had there with um, problems of not being able to get across the river or access And how do we determine who comes in from what side, which jurisdiction, who, how are we communicating, all those kinds of things, and what are the roles for public health in there a little bit farther down the road? For example, they had a huge component with that, on what we call behavioral health The traumatic effects to both those affected, their families, and the responders and, who has these roles on helping these families while they’re waiting to hear about their loved ones, getting information on status of those who have been taken to a hospital or those who are still missing All of those kinds of pieces, we bring the system together, we know our roles ahead of time because we’ve practiced, we’ve trained, we know what we’re doing ahead of time, so that the system can work smoothly and efficiently And Jim, you know, you have a practice, you’re a practicing physician, so you’re, and, work for an organization that you have a job to do, that’s part of your daily routine How do you build this in and how does, how does your organization that you work for say, you know, I’m going to give some time available to do some of this coordination for things that, don’t happen every day, that are sort of beyond the scope of what our responsibility is It must take some commitment and some recognition that there is, needs to be a community effort Yeah, there definitely is and there’s, there’s time carved out for myself as well as a lot of other people on our administrative team, our emergency management side The, one of the organizations that uh, involved with credentialing hospitals, JCAHO, kind of mandates some of this stuff, so there is kind of a framework there that’s laid out and, so to meet those guidelines that they lay out we budget time and, and work towards those goals I’m going to talk about what you called some of the assets, some of the equipment that you got in the last segment, so that people know what’s available in the state if they need some needs, but we need to take another break We’ll be back right after this message [wind and thunder roar] Did you find that flashlight and the batteries? Yes Did you make sure we’re not missing anything in the first-aid kit? Yup Did you go through the plan with the kids again? Yes (man) The more you prepare today, the more you’ll be able to reduce the devastating events of a tornado, an earthquake, a power outage or any other disaster Get the kit Make a plan Be informed Visit READY.GOV Welcome back; we’re talking about emergency preparedness with Jane Braun from the Minnesota Department of Health, and uh, Jim Harris, an emergency room physician who is actively involved in disaster and emergency planning When we started the program, we had a little clip from KSTP and it showed, the you know, kind of getting together of all of the assets and all of the equipment and things And I think people may not be aware of all of the things that go into this and I just want to go through fairly quickly what these things are I know that you have a casualty bus, a multiple casualty bus, why do you need that and how does that play into your disaster planning? Well there’s actually two of them, and uh, the importance of them is to be able to transport larger amounts, numbers of patients quickly and possibly for greater distances The one bus can do 12 patients, lying down, 10 patients sitting; the other I believe can do 16 or 20 laying down, 16 sitting up roughly They can take critical care patients so they can take patients that are on ventilators, so they’re really key if you ever had a mass casualty incident, where you needed to transport a lot of patients, if you had to evacuate a hospital, nursing home, they can move large amounts of patients relatively easily And as we go through these things, are they available statewide? I mean I know they have to be located someplace, but can they be mobilized and moved to various places throughout the state? All these assets that we’ll be talking about are state assets They are managed and coordinated by various jurisdictions, but through the State Duty Officer, it’s kind of a one call, that if somebody needs these, we’ll talk to them quickly, see what assets are the correct fit, and they are available for anywhere in the state that they’re needed Right, what about the Mobile Medical Unit? I know this is like a, kind of a mobile hospital, right? It is; the Mobile Medical Unit is basically a 53-foot semi

that is an 8 bed hospital inside the semi Kind of equate it to an emergency department or an urgent care, in general, that type of thing, but we have a lot of capacity there, being close to being a regular emergency department And that’s something that would be real useful, for example, the instance that Jim gave earlier about if a sprinkler ruined part of a we could temporarily serve hospital, that purpose in that area, or if a tornado hit a small hospital or an emergency department, serve as that function We occasionally, for training purposes, we’ll do a large event, really to help practice with the staff, but it’s an asset that provides a level of care that’s beyond what one would expect normally in a mobile area Yeah, I would expect that would actually be very cool at one of these large outdoor concert things where you have hundreds of thousands of people and in heat and it would be a good thing to have available And then I know that, we have to also worry about alternate care sites, and what are the assets that we have, when something closes down, you’ve got the Mobile Medical Unit, but you also need alternate care kind of sites What do you use to do that? Well there’s um, there’s two mobile medical teams in the state right now, one in the Central Region, one in the Metro Region, and they both are capable of setting up alternate care sites Generally the alternate care sites are 25-bed increments, and they can provide critical care if needed, they can do ventilators, just like the MMU would be able to But they can set those up in gymnasiums, school One of the advantages of the Mobile Medical Team’s alternate care site is really timing If you look at the Mobile Medical Unit, it takes a little time to set up, it’s granted it’s very cool, it brings its own lab, its own pharmacy Again, pretty much an emergency department with a, short of the CAT scanner But the Mobile Medical Teams are a little bit more nimble They can get out a little bit quicker, get ahead of things a little bit We talked about the MCI buses One of the advantage to them, is they can usually go out really quick and so again, it’s kind of the what do you need and when you need it kind of uh And I assume all of the planning takes into account Minnesota weather, particularly our winters and cold? You can operate all of these things in 20 below zero? Yeah, we do have, fortunately for example, on the Mobile Medical Unit, we have an enormous generator on there that can provide power to some of the other assets But you know, the Minnesota Ambulance Strike Team, also has their tents with generator capacity and heating and air conditioning And we did actually deploy the Mobile Medical Unit, in 2009, and we were in Moorhead and it was down to 16 degrees We had a snowstorm; we deployed in a blizzard, and learned that Dr. Harris actually designed a drill where we practiced opening and closing the doors and seeing if we could keep the temperature comfortable in there, and we could And so all of these various assets, are big parts of the whole, and they all can operate in a wide variety of temperature ranges and other conditions And then lastly among the things is the, the portable mortuary I don’t think people actually think through, I mean the general population, that you need to, in fact, if some people die, you need to have a plan for how to deal with, with the bodies Yeah, for a mass fatality situation, again, that’s one you don’t like to think about, but there’s really no excuse for not having a plan And so there, it’s a system of 6 trailers that we have, that are stored in St. Paul currently, but can be deployed anywhere in the state and, with the right facilities, say an armory or some type of thing, we can set up a very large mortuary there to deal with all the kinds of things that need to be done around identification of remains, all kinds of things like that And then we’re working on some software systems too, on family reunification, notification, all those kinds of things And so, it’s, it’s not something people like to think about, but we do have that capacity and capability in Minnesota too, for if we were to have some sort of a mass fatality situation And where do you get the people to do this? I mean we only have a limited number of emergency room docs, and who are the people that come and volunteer their time or work on these disasters in the emergency preparedness? Well, we kinda draw from a, a large pool and again, it’s kind of based a little bit around timing One of the things is the Mobile Medical Teams, and these are teams that are preformed, they’re dedicated to doing this, and they’re able to deploy relatively quickly Um, our goal with them is to probably use them in that first 24 to 72 hours as an event is kind of unfolding Then we can pull from the Minnesota Response Medical Reserve Corps and use volunteers from across the state to kind of fill in and our goal is to eventually work towards using local staff to staff some of these resources But you need to give communities time to, to take care of their own, their own houses, their own families, before you

can allow them to come back and start, start working And we’ve only got about a minute left, but I know with tight budgets, is there concern that this training that really has been ongoing over the last 10 to 12 years, which has brought us up to a really good level, can this be sustained? And how much resources do we need to make sure that it’s always there? We are struggling with that quite a bit right now These Mobile Medical Teams that we’ve been talking about, we have developed under a Homeland Security grant that is running out this year, so our ability to keep training and recruiting more is going to be compromised With the, with the Medical Reserve Corps again, a lot of that is done locally, but the grants that we pass along to the locals, as we get cut, we’re cutting what’s there So it is a difficult thing to sustain this, which is really a shame, because we’ve built a system that I think people expect to be there, and it’s jeopardized right now Yeah, and we know that disasters will occur, events will occur, weather, traumatic things occur, so we have to be prepared Well, thanks, this has been very helpful, so thanks for being with us Thank you And I’ll be back with a closing comment, right after this message [lively flute, strings and piano play] ♪ ♪ The difference between medical care and public health has been characterized over the years in many dichotomous ways like treatment or prevention, individual or population, short term or long term But as a society we tend to lean more towards the treatment, the needs of the individual, and the short term But as we learn more about protecting, promoting, and improving health, we begin to understand the need to think more about prevention, the needs of the community, and our long-term health, if we are to achieve our personal and societal health goals We need to think about the structure on which our health system stands It’s sort of like building a house You need both a strong and firm foundation on which to build an attractive and functional structure If you put all your resources into decorating your house and skimp on the foundation, you will not have a house that’ll meet your needs for the long term Conversely, if you spend all your resources on the foundation, you will not have enough to put up a structure that is comfortable and enjoyable A balance is needed, but that balance needs to start with making sure the foundation is adequate So it is with planning for emergencies We need a preparedness foundation to protect our health We need the capacity and the ability to respond to the needs that arise in the community from situations that are out of our control We need a strong public health infrastructure on which to build that response capability Too often, we’ve delayed investing resources in our public health infrastructure with the mistaken notion or hope that nothing bad will happen The reality is that disasters and emergencies are going to be with us for a long time So we need to rethink and rebuild a balance between treatment and prevention, between individual needs and the community needs, in between the short term and the long term Only when we have an appropriate balance will we have a long-term security and better health That’s all for today, thanks for watching I hope you can join us again next time on “A Public Health Journal.”