MEDICAL EVACUATION IN OPERATIONS

By B. LAURS

CONTENTS CHAPTER ONE INTRODUCTION 1 BACKGROUND 1 RESEARCH OBJECTIVES AND THE INFLUENCE OF SEPTEMBER 11 2 RESEARCH METHODS 3 TERMINOLOGY 4 TERRORISM 4 CBRNE VERSUS WEAPONS OF MASS DESTRUCTION 4 HOW THIS REPORT IS ORGANIZED 5 CHAPTER TWO THE MILITARY HEALTH SYSTEM AND MILITARY SUPPORT TO CIVIL AUTHORITIES 7 THE TWO PRIMARY MISSIONS OF THE MILITARY HEALTH SYSTEM 7 THE MILITARY HEALTH SYSTEM MISSIONS SHARE RESOURCES 8 MILITARY MEDICAL ASSETS 9 MISSION MEDICAL ASSETS 10 INFRASTRUCTURE MEDICAL ASSETS 11 DOD ORGANIZATION GUIDANCE AND PLANNING 11 ORGANIZATION FOR MILITARY OPERATIONS 11 GUIDANCE 16 PLANNING 16 LIMITATIONS TO CONSIDER WHEN PLANNING FOR MILITARY ASSISTANCE 18 MILITARY ASSETS MAY BE ENGAGED IN OTHER MISSIONS 18 MILITARY ASSETS ARE MAINTAINED AT VARIOUS LEVELS OF READINESS BASED ON WARTIME REQUIREMENTS 18 CHAPTER THREE THE EVOLUTION OF STRUCTURES SYSTEMS AND PROCESSES FOR DOMESTIC PREPAREDNESS 19 RECOMMENDATIONS FROM NATIONAL COMMISSIONS 19 NEW PLAYERS AND NEW ROLES IN HOMELAND SECURITY 21 THE OFFICE OF HOMELAND SECURITY AND THE NATIONAL STRATEGY 21 THE DEPARTMENT OF HOMELAND SECURITY 22 HOMELAND SECURITY PRESIDENTIAL DIRECTIVE 5 22 THE NATIONAL RESPONSE PLAN 23 THE ROLE OF DOD IN RESPONSE AN OVERVIEW 24 THE NATIONAL DISASTER MEDICAL SYSTEM 24 OTHER DOD DIRECTIVES RELATED TO CIVIL SUPPORT 24 THE DIRECTOR OF MILITARY SUPPORT 25 THE ASSISTANT SECRETARY OF DEFENSE FOR HOMELAND DEFENSE 25 U S NORTHERN COMMAND 25 CHAPTER FOUR LEGAL AND OTHER BARRIERS TO MILITARY SUPPORT TO CIVIL AUTHORITIES 27 CONSTITUTIONAL AND HISTORICAL BASES FOR USE OF THE MILITARY DOMESTICALLY 27 STATUTORY AND REGULATORY AUTHORITIES ENABLING THE USE OF MILITARY ASSETS TO SUPPORT CIVIL AUTHORITIES 28 CONSTITUTIONAL AUTHORITY 28 CONGRESSIONAL AUTHORITY POSSE COMITATUS ACT AND ITS PROGENY 28 CONGRESSIONAL AUTHORITY CIVIL DISTURBANCE OR INSURRECTION STATUTES 29 CONGRESSIONAL AUTHORITY COUNTERDRUG AND RELATED STATUTES 30 CONGRESSIONAL AUTHORITY DISASTER RELIEF AND THE STAFFORD ACT 31 CONGRESSIONAL AUTHORITY COUNTERTERRORISM AND WEAPONS OF MASS DESTRUCTION 32 CONGRESSIONAL AUTHORITY QUARANTINES EVACUATIONS AND CURFEWS 33 CONGRESSIONAL AUTHORITY NEW AUTHORITY FOR USE OF THE RESERVE COMPONENTS 34 CONSTRAINTS ON THE EXERCISE OF EXPLICIT AUTHORITY 34 EXECUTIVE AUTHORITY THE PRESIDENT S RESIDUAL AUTHORITY 36 EXECUTIVE AUTHORITY MARTIAL LAW 37 EXECUTIVE AUTHORITY EXECUTIVE ORDER 38 EXECUTIVE AUTHORITY DOD POLICY ON MILITARY ASSISTANCE IN CIVILIAN EMERGENCIES 38 LEGAL LIABILITIES IMPLICATED BY THE USE OF MILITARY MEDICAL ASSETS TO SUPPORT CIVIL AUTHORITIES 39 LIABILITY UNDER THE FEDERAL TORT CLAIMS ACT OF 1946 39 LIABILITY UNDER SECTION 1983 AND BIVENS FOR VIOLATIONS OF CONSTITUTIONAL RIGHTS 41 LIABILITY RELATED TO THE MANAGEMENT OF PROPERTY PEOPLE AND INFORMATION 42 DISTINGUISHING BETWEEN HOMELAND DEFENSE AND CIVIL SUPPORT 43 NONLEGAL CONSTRAINTS ON THE USE OF THE MILITARY 44 DIFFUSE NATURE OF AUTHORITY 44 RELUCTANCE TO SEEK FEDERAL ASSISTANCE 44 APPREHENSION ABOUT MILITARY ASSISTANCE 44 CULTURAL BARRIERS 45 CAPABILITIES 45 REQUIREMENTS IDENTIFICATION 45 CONCLUSIONS 45 RECOMMENDATION 46 CHAPTER FIVE MILITARY MEDICAL SUPPORT TO CIVIL AUTHORITIES HISTORICAL CASE STUDIES 47 DOD S ROLE IN MEDICAL RESPONSE 47 RESEARCH METHODS FOR CASE STUDIES 48 HURRICANE ANDREW BACKGROUND 49 GOVERNMENT AND MILITARY RESPONSE TO HURRICANE ANDREW 51 HURRICANE MARILYN BACKGROUND 55 GOVERNMENT AND MILITARY RESPONSE TO HURRICANE MARILYN 55 TROPICAL STORM ALLISON BACKGROUND 58 GOVERNMENT AND MILITARY RESPONSE TO TROPICAL STORM ALLISON 59 WHAT LESSONS CAN BE LEARNED FROM THESE CASE STUDIES 62 A CONCEPTUAL FRAMEWORK FOR RESPONSE 64 DECENTRALIZED VERSUS CENTRALIZED RESPONSE 64 CIVILIAN VERSUS MILITARY RESPONSE 66 CHAPTER SIX EXERCISE BASED STUDIES OF POTENTIAL MILITARY MEDICAL SUPPORT TO CIVIL AUTHORITIES 69 OBJECTIVE 69 EXERCISE METHODS 70 EXERCISES WERE BASED ON AN ESTABLISHED METHODOLOGY 70 THE ANALYTIC FRAMEWORK FOR THE EXERCISE 72 THE DESIGN AND TESTING PROCESS INCLUDED CONSIDERATION OF A MENU OF POTENTIAL ISSUES 73 TERRORIST ATTACK SCENARIOS 74 THE GEORGIA EXERCISE SMALLPOX ATTACK 75 BACKGROUND 75 GEORGIA EMERGENCY RESPONSE SERVICES 76 THE THREAT AND THE SCENARIO 76 THE EXERCISE 77 EXERCISE RESULTS ISSUES AND OBSERVATIONS 80 THE CALIFORNIA EXERCISE RADIOLOGICAL DISPERSION DEVICE ATTACK 83 BACKGROUND 83 CALIFORNIA EMERGENCY RESPONSE SERVICES 84 THE THREAT AND THE SCENARIO 85 THE EXERCISE 85 EXERCISE RESULTS ISSUES AND OBSERVATIONS 90 CONCLUSIONS 94 CHAPTER SEVEN CONCLUSIONS AND RECOMMENDATIONS 97 CONCLUSIONS 97 RECOMMENDATIONS 100 CHAPTER ONE INTRODUCTION TRIAGE NOUN 2 A SYSTEM USED TO ALLOCATE A SCARCE COMMODITY SUCH AS FOOD ONLY TO THOSE CAPABLE OF DERIVING THE GREATEST BENEFIT FROM IT 3 A PROCESS IN WHICH THINGS ARE RANKED IN TERMS OF IMPORTANCE OR PRIORITY BACKGROUND EVEN BEFORE THE EVENTS OF SEPTEMBER 11 2001 THREAT ASSESSMENTS SUGGESTED THAT THE UNITED STATES SHOULD PREPARE TO RESPOND TO TERRORIST ATTACKS INSIDE ITS BORDERS THIS RESEARCH ON THE USE OF MILITARY MEDICAL ASSETS TO SUPPORT CIVIL AUTHORITIES IN THE EVENT OF A TERRORIST ATTACK IN SIDE THE UNITED STATES WAS BEGUN IN SPRING 2001 AND ORIGINALLY FOCUSED ON ONLY THE POTENTIAL CONSEQUENCES OF CHEMICAL OR BIOLOGICAL WEAPONS CBW ATTACKS IN THE UNITED STATES IT HAD ALREADY BEEN DOCUMENTED AT THAT TIME THAT SOME CIVILIAN MEDICAL ORGANIZATIONS AND FACILITIES WERE ILL PREPARED TO DEAL WITH A SITUATION INVOLVING LARGE NUMBERS OF CBW CASUALTIES 1 IN DEED THIS SITUATION SEEMS TO PERSIST TODAY 2 RECOGNIZING THAT CIVILIAN SYSTEMS COULD BE OVER WHELMED IN THE EVENT OF A TERRORIST ATTACK THE ADVANCED SYSTEMS AND CONCEPTS OFFICE ASCO OF THE DEFENSE THREAT REDUCTION AGENCY DTRA ASKED THE RAND CORPORATION TO CONDUCT THIS RESEARCH BASED ON THE PROBABILITY THAT DEPARTMENT OF DEFENSE DOD MEDICAL ASSETS WOULD BE CALLED UPON TO PROVIDE SUPPORT TO CIVIL AUTHORITIES IN THE AFTERMATH OF AN ATTACK DEALING WITH A CHEMICAL OR BIOLOGICAL THREAT IS NOT NEW TO DOD MILITARY MEDICAL UNITS ROUTINELY TRAIN TO MANAGE CBW CASUALTIES ON THE BATTLEFIELD ALTHOUGH SOME CIVILIAN ORGANIZATIONS SUCH AS HAZARDOUS MATERIAL RESPONSE UNITS AND PUBLIC HEALTH AGENCIES ALSO TRAIN TO RECOGNIZE AND TREAT CASUALTIES SIMILAR TO THOSE CAUSED BY CBW AGENTS IT IS POSSIBLE INDEED LIKELY THAT DOD WOULD BE CALLED UPON TO PROVIDE SUPPORT TO CIVIL AUTHORITIES IN THE EVENT OF AN ATTACK PORTIONS OF DOD S EXISTING RESOURCES PRINCIPALLY THOSE FROM THE MILITARY HEALTH SYSTEM MHS COULD BE EMPLOYED TO ASSIST CIVIL AUTHORITIES IN FACT DOD OFTEN ASSISTS IN NATURAL DISASTER RELIEF AND FOR YEARS HAS PROVIDED MEDICAL SUPPORT TO BOTH COALITION PARTNERS AND LOCAL POPULATIONS IN DEPLOYMENTS TO HAITI KOSOVO AND SOMALIA FOR EXAMPLE THESE MISSIONS SHARE MANY CHARACTERISTICS THAT MAY ALSO BE ENCOUNTERED FOLLOWING A CBW ATTACK 1 MCINTYRE A G ET AL WEAPONS OF MASS DESTRUCTION EVENTS WITH CONTAMINATED CASUALTIES EFFECTIVE PLANNING FOR HEALTH CARE FACILITIES JAMA VOL 283 2000 PP 242 249 2 U S GENERAL ACCOUNTING OFFICE GAO HOSPITAL PREPAREDNESS MOST URBAN HOSPITALS HAVE EMERGENCY PLANS BUT LACK CER TAIN CAPACITIES FOR BIOTERRORISM RESPONSE WASHINGTON D C U S GENERAL ACCOUNTING OFFICE GAO 03 924 2003A 1