Understanding the Chain of Communication During a Disaster

Understanding the Chain of Communication During a Disaster Blackwell Malden, Perspectives PPC © 0031-5990 January 1ORIGINAL 43 Blackwell 2007 USA Publishing in Publishing ARTICLE Psychiatric IncLtd. Care 2007

Heather Shover, MD, MPH

TOPIC.

Every disaster begins on a local level and

may, depending on size, evolve to a state of federal disaster response. Understanding California’s State Disaster Plan and the importance of the chain of communication is a first step to understanding the Federal Disaster Response

Heather Shover, MD, MPH, is a practicing physician, the director of urgent care at Beaver Medical Group, and a Clinical Instructor at Loma Linda School of Medicine in San Bernardino, CA. This report is part of her master’s thesis: San Bernardino County Surge Capacity: An Evaluation of the Emergency Medical Response in the Old Waterman Fire October 25–November 4, 2003. Dr Shover received her MPH from Loma Linda University and her MD from the University of California, Los Angeles.

system. The chain of command is critical to making sure services and resources are utilized in

S

disaster preparedness must incorporate training

ince September 11, 2001, Americans have had to confront their false sense of security, while our government grapples to realign and redefine the priorities on emergency preparedness. Up until that horrific day, the American people felt sovereign in a secure homeland. The world is different now, with nuances of vulnerabilities that can no longer tolerate placing emergency medical preparedness as a trivial frill. In the past, medical emergencies have been managed by the 911 system, first responders, and a receiving hospital. On September 11, 3,000 people died within 2 hrs, many of them our first responders. That incident was unique, in that there were very few survivors under the million pounds of rubble from the World Trade Center. If we placate ourselves in the midst of terrorist threats, then our next disaster surely will bring unnecessary loss of lives and untold chaos. This paper’s intent is to define California’s present emergency management system (EMS) infrastructure from local to state level and educate healthcare professionals for disaster activation.

of health professionals, citizens, and families in

Disaster and Surge Capacity

a timely manner without duplication. PURPOSE.

This paper’s intent is to define

California’s present emergency management system (EMS) infrastructure from local to state level and educate healthcare professionals for disaster activation. CONCLUSIONS.

It is imperative that all voluntary

healthcare professionals learn the chain of command within the disaster response system. Each disaster response begins with the individual’s preparedness at the local level and all

local disaster drills. Search terms: American Red Cross, disaster response, health care crisis, mass causality, medical response, public health 4

Initially, it is important to define terms that all readers will be of common understanding. There are several definitions of disaster, emergency, and surge capacity. The dictionary describes a disaster as a sudden extraordinary calamity, often long-term in nature (Webster’s Unabridged Dictionary, 1913). An emergency is different, Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

Figure 1. Medical Emergency Management. Modified from Putnam, J. L. Tapped Out: Improving Our Country’s Medical Surge Capacity, June 2004

in that it calls for immediate action and is one part of a disaster. A lesser part of an emergency is a medical emergency. Medical emergencies are best managed by preplanning, prevention, and preparedness to lessen morbidity and mortality. However, in the event of a medical emergency, the ability to access acute care is critical and reflects an emergency medical systems surge capacity (see Figure 1). The definition of surge capacity is a measure of an ability to expand acute medical care capabilities for an increased volume of patients. This encompasses patient beds, medical supplies, professional staff, and an area to conduct medical treatment. In order to assess a local county’s surge capacity, it is necessary to first evaluate the emergency medical response system. The present day system includes first responders, emergency rooms, and hospital’s availability of acute care beds. Health Resources and Services Administration The Health Resources and Services Administration (HRSA), a branch of the U.S. Department of Health and Human Services (DHHS), has granted funding within a National Bioterrorism Hospital Preparedness Program (NBHPP). HRSA has the task to improve our country’s surge capacity by dividing grant monies between the Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

states. The NBHPP’s mission statement is “To ready hospitals and supporting health care systems to deliver coordinated and effective care to victims of terrorism and other public health emergencies” (Health Resources, n.d.). HRSA awarded $135 million in 2002, and $514 million in 2003, to states in order to improve their emergency response (Health Resources, n.d.). Many hospitals received $20,000 to $50,000 to enhance hospital infrastructure. The HRSA grants focus on the three main elements of emergency medical response (Austin, 2004).

The definition of surge capacity is a measure of an ability to expand acute medical care capabilities for an increased volume of patients.

Pre-hospital care presently involves first responders activated in the 911 system. First responders are fire paramedics, ambulance paramedics, or emergency 5

Understanding the Chain of Communication During a Disaster

medical technicians (EMT). These emergency personnel stabilize and transport emergency cases from the scene to a nearby receiving hospital. HRSA is providing protective equipment and training for these responders. Hospitals are the receivers of emergency medical transport. HRSA is providing grant money to expand acute care capacity. HRSA grants’ focus is to enhance the current capacity by 500 acute beds per 1 million population; increase by an additional 500 decontamination beds per 1 million population; and increase negative pressure beds to at least one room that holds a minimum of 10 beds per hospital. Adequate staff is essential to surge capacity. The HRSA’s funding aims to increase hospital personnel as well. The goal is to increase healthcare personnel by 250 persons per 1 million in urban areas and to increase personnel by 125 person/million in rural areas. Surge capability is the ability to manage patients during an unusual or complex medical event. These capabilities are not usually available at local levels. A medical response will require the coordination of public health, emergency management systems, and other critical assets (CNA, 2004). The Strategic National Stockpile (SNS) is reserved for such a complex event such as a bioterrorist attack or those involving weapons of mass destruction. The federal Disaster Medical Response Teams (DMAT) also is available. The requests for SNS and DMAT teams are based upon preplanned scenarios and require FEMA activation (Esbitt, 2003). History of California Disasters and Emergency Infrastructure California is one of the first 50 states to invest early into emergency planning and from this effort we can learn about the development of the Office of Emergency Services (OES) and the role it plays in disaster response. The original impetus began during World War I to prepare for wartime emergency response. California developed an emergency organization, in 1917, called The State Council of Defense. This council developed a plan for wartime casualties. In 1929, the 6

first State Emergency Council was developed. This council was chaired with department heads from military, public works, public health, finance, and a representative from the American Legion and American Red Cross. This council focused on designing a single plan that would respond to all types of emergencies and mandated that all local governments cooperate with the state. The council members received no pay except for out-of-pocket reimbursement. In 1943, the first statewide mutual aid program was designed. In 1945, the California State Disaster Council came to pass and to develop a State Disaster Preparedness Plan for both natural disaster and wartime events. The State Disaster Council expanded during the Korean War and developed both the disaster relief plan and mutual aid regional divisions. In 1968, then Governor Ronald Reagan developed the Emergency Resources Management Plan that included the private sector to volunteer during an emergency. In 1970, the California Emergency Services Act replaced the California Disaster Act and renamed the State Disaster Council to the California Emergency Council. Around the same time, the Office of Emergency Services (OES) replaced the California Disaster Office. One of the most encompassing agreements, created by the OES, is the Master Mutual Aid Agreement. The Mutual Aid Agreement, signed by all counties and most cities, gave local authorities a span of control over local personnel and supplies, while the state could provide support from a larger pool of resources, if necessary. California is divided into six mutual aid regions. If requests for aid overwhelm a region, then the State OES coordinates with other regions. The state will only forward the request for federal support if the state is unable to supply the provisions needed. Standard Emergency Management System The Standard Emergency Management System (SEMS) (Governor’s Office, 1994) is an incident command system (ICS) and was initiated into California law in 1991. The basics of SEMS is to enhance coordination Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

Figure 2. The Incident Command Structure SEMS. Adapted from SEMS Guidelines (Governor’s Office, 1994)

and communication of information and mutual aid resources between local and state authorities during an emergency. The SEMS structure was formatted from the military’s ICS and can function within many organizational levels, including the field response, local government, operational area, regional, and state (San Bernardino and Riverside County, n.d.). The benefits of an ICS emergency response format as described by the Medical Surge Capacity and Capability report (CNA, 2004) are as follows: • Common Terminology: All resource description and incident command organization must function across all disciplines. • Integrated Communications: Each organization must have internal and external communications to send and receive information to other disciplines. • Modular Organization: Response resources are organized according to responsibilities. Each functional unit may be flexible depending on requirements for the incident. • Unified Command Structure: A unified command structure is created when all organizations follow the same format. The SEMS format prevents conflict of information and duplication of efforts, while providing Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

a chain of command with flexibility to accomplish chaos management during a complex event. • Consolidated Action Plans: Formal documentation of each organization’s incident function, goals, and objectives with prearranged Memorandum of Understanding (MOU) to unify strategies in order to accomplish objectives. • Resource Management: A comprehensive system must be in place to maintain, describe, identify, request, and track resources. • Incident Management Facilities: Advance assignment of location for critical incident-related functions (Exhibit I-3, p. I-14). The incident command system is based on a linear hierarchy of chain of command, and provides flexibility to expand or contract, depending on the size of the incident (Governor’s Office, 1994, Part I, Section B, p. 3). There is a 1:7 supervisor-to-staff ratio used at all times to assure communications and outcome (S. Long, personal communication, 2004) (see Figure 2). The four primary divisions managed under the Incident Commander are Operations, Logistics, Planning, and Finance. Command includes the incident commander 7

Understanding the Chain of Communication During a Disaster

and his or her advisory panel who are responsible for the emergency response action plan. This office is the liaison to other agencies. The Operations division is responsible for the direct response to the incident and responsible for providing personnel, services, equipment, and supplies in support of the tactical response. Planning and Intelligence is responsible for observation, assessment, and documentation of all information regarding the incident. It is also responsible for providing the plan that operations follows and the collection and evaluation of emergency response information. Logistics provides the response with services, personnel, equipment, and supplies in support of the tactical response. Finance is responsible for administrative financial and cost analysis documentation and is in charge of documenting all costs and completing a cost analysis on the incident (Governor’s Office, 1994, Part I, Section B, pp. 3–4). The Emergency Operations Center Incident command activation first occurs when the actual emergency event response begins. The command post is set up, oftentimes near the main event, where the command activities occur (Governor’s Office, 2003). The field Incident Commander communicates with the Emergency Operations Center (EOC), of either the response agency or local government, if activated. The EOC is strictly a location where representatives of emergency management meet to provide support for the command post, at least, and mutual assistance to responders, at best. Dependent upon the need for activation, each agency (i.e., Fire, Police, Sherriff, Emergency Transportation Companies, hospitals, Public Health, and Red Cross) and/or level of government (i.e., local, state, or federal) will activate their own Incident Command System management structure with a unique EOC. If an EOC is activated, it is required that each EOC must continually update other involved EOCs in a timely manner. An EOC’s main function is the coordination of perpetual planning amongst command posts, other agencies, and governmental jurisdictions. 8

The EOC’s job is to locate, allocate, and provide whatever resources are needed by the command post (Governor’s Office, 2001). There are four stages of emergency management (Governor’s Office, 2003): 1. Mitigation: The identification of any possible vulnerabilities and hazards and do whatever is necessary to prevent and minimize a poor outcome. 2. Preparedness: Pre-disaster work which involves creating relationships that will both recognize and respond to communications during an emergency event. Each agency must educate, train, and organize personnel to develop modular response systems, before an actual disaster. 3. Response: The direct activities focus solely on the tactical response to an emergency event. The EOC will follow an emergency operations plan (EOP). 4. Recovery: All activities directed to return an affected community to normal. A good EOP will begin recovery early in the response stage. Recovery is a process that eventually will be handed over from the emergency management system to the daily emergency medical system (EMS). Each EOC has preplanned levels of activation during a disaster or emergency (Office of Public Affairs, 2006): 1. Level One—This management mode is similar to day-to-day operations. 2. Level Two—This operation mode is activated when the emergency response requires several units or agencies to interact. Incident managers and on-site emergency services continue to report through established twenty-four hour dispatch facilities. 3. Level Three—This operation mode is activated during a major disaster that would render it impossible for the organization to function effectively in either of the other modes. At this level of activation, all coordination and direction of activities are accomplished from the EOC (“Emergency Levels of Activation” section). Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

Figure 3. Example of Operational Areas.

The Operational Area The state of California has designed intermediate areas called operational areas (OA) that are in each county and all the local subdivisions within (Governor’s Office, 1994). The OA is the link between each local Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

agency’s EOC, the regional EOCs (REOCs), and state OES. Any government may be selected to be the lead agency within the OA. Each county OA has its own EOC with a similar SEMS incident command structure. A county OA should allow each local government representation. The OA will provide whatever resources 9

Understanding the Chain of Communication During a Disaster

and assistance necessary by mobilizing resources from other cities within the county. If additional resources are needed, the request goes to the REOC. State support to the OAs is through their REOC and there are three state REOCs. The REOC may act as the state’s primary EOC, if the emergency is contained in that region, or, it can support all local cities and counties within the region and act as a chain of communication to state OES for resources and services (Governor’s Office, Part I, Section D). A Multi-hazard Functional Planning Guide (Figure 3) illustrates how, with an emergency event, the chain of communication works (Governor’s Office, 1994, Part I, Section D, p. 6). An incident always occurs at the local level (city). The first responders (i.e., fire, police, sheriff’s search and rescue) are the field EOC and act in direct response to the event. If the field cannot contain the event, then local city EOC is activated and may request that the operational area or county EOC be activated for support. Once the event disrupts more than two cities, and a local emergency is declared, the county EOC is activated. If the event involves more than one county, then the REOC is activated. If the REOC cannot sufficiently support the event with supplies and mutual aid, then the State Operations Center (SOC) is activated and there is a State of Emergency. The SOC sets up communication with the State Governor, Federal Emergency Management Agency (FEMA), state Mutual Aid Coordinators, the REOCs as well as all volunteer and private emergency response agencies. When and if the president declares a National Emergency, then all federal agencies, each with their own corresponding ICS and EOC, begin to coordinate assistance down from the federal agencies through state agencies to the local level (Governor’s Office, 1994, Part I, Section A). There are various mutual aid response branches within the OES system. At every local, county, and state EOC there is a Medical Health Operation Area Coordinator (MHOAC) that participates at the local county OA/EOC to assess, communicate, and allocate medical supplies, equipment, and personnel as needed. At the local level, the Medical Health Operation Area Coordi10

nator position ensures a 24-hr point of contact for hospitals, emergency response personnel, and other healthcare entities to report issues during the event. The MHOAC is capable of communicating medical needs, collecting and providing consistent information, and relaying mutual aid requests to the regional level (EMSA, 2003). Generally, the MHOAC is often the local Public Health Officer (PHO), whereas the regional and state persons are full-time medical health specialists. The Regional Disaster Medical Health Coordinator and Specialist (RDMHC/S) will be activated based on the extent of the emergency event and provides direct communication to the state. If a State of Emergency is proclaimed by the Governor, then the Joint Emergency Operations Center (JEOC) is activated at the state level to oversee the medical emergency response. The JEOC coordinates medical and health priorities with other emergency response agencies to ensure the health and safety of all citizens. The JEOC is operated jointly by the Emergency Medical Services Authority (EMSA) and the Department of Health Services (DHS) in Sacramento. The State EOC works in tandem with the JEOC to combine the State OA’s response with the JEOCs to provide medical and health mutual aid, supplies, equipment, and personnel (EMSA, 2003). State Public Health System The California Department of Health and Human Services Agency (CHHSA) contains 13 departments, including Department of Health Services (DHS) and Emergency Management Services Authority (EMSA). The Office of Emergency Services (OES) and the State Office of Homeland Security (COHS) are separate branches that directly work from the Governor’s Office. Both the OES and the COHS, as well as DHS and EMSA, are involved with emergency management. Emergency Medical Services Authority The California Emergency Medical Services Authority (EMSA, n.d.) ensures quality patient pre-hospital care Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

by administering an effective statewide system of coordinated emergency medical care, injury prevention, and disaster medical response. It is involved with disaster preparation and training for EMT, paramedics, and hospitals. The EMSA works with DHS during an emergency to provide medical advice and aid when needed. There are local EMSA agencies called LEMSAs in each county or multiple counties. Department of Health Services Many departments are involved in emergency management. The License and Certification branch is responsible for ensuring that hospitals have disaster plans, evacuation plans, and have trained the employees adequately. As well, each hospital must participate annually in statewide drills to ensure JAHCO license renewal (California Department, n.d.). American Red Cross The Red Cross has a valuable contribution to every society in the world, which is to provide shelter and food in the time of an emergency. The International Red Cross maintains nonpartial status to all countries and provides medical services and training during wartime to prisoners of war, victims of war, and missing persons. The International Red Cross is a nongovernmental organization (NGO), and its headquarters are in Geneva, Switzerland (International Federation, n.d.). The American Red Cross (ARC) was founded by a nurse, Clara Barton, in 1881 and is one of 175 National Red Cross societies. The national headquarters for the American Red Cross is in Washington, D.C. The ARC trains communities in first aid and CPR, collects and provides half of the U.S. blood supply, and helps citizens with disaster preparedness. In 1900, the ARC received a congressional charter to be the country’s official relief response agency (ARC, n.d.). The ARC organization follows the same principles as the IRC; however, they do not provide medical care beyond Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

simple first aid within their shelters. The ARC works closely with our U.S. Public Health System and states clearly that the health and safety during a disaster rests on the public health officials (Congressional Charter, 1999). The ARC keeps records of all first aid provided to victims and conveys this information to the Centers for Disease Control and Prevention for statistics and data collection using form 2100-C. Hospitals Most hospitals are privately owned and operate as separate business entities. Some hospitals are owned by stockholders, others by nonprofit corporations, and some by private owners. Generally, hospitals, in California, have adopted the Hospital Emergency Incident Command System (HEICS). Each hospital, mandated by DHS (licensing and certification), must have an emergency plan for internal emergencies. HEICS works very similar to SEMS, using the same organizational structure and terminology. The hospitals are not unified under a single command system during an external emergency, but they are mandated, by DHS, to have evacuation plans requiring MOUs with other hospital facilities to receive patients on request. Most hospitals maintain a 72-hr cache of food and medicines housed in a warehouse off the facility grounds (R. Hart, personal communication, 2004). Emergency rooms are critical during an emergency medical response. They are the hospital receiving stations for walk-in patients, ambulances, and paramedic transports. The paramedics work from protocols and treatment algorithms, and during transport will communicate with the receiving base hospital emergency room physician, via radio, for treatment orders. There are four levels of emergency department trauma capability: Level I trauma care which has all surgical specialty support within the hospital; Level II trauma care mainly because it misses one specialty for total support (e.g., cardiothoracic). Level III and IV trauma center generally are capable to provide stabilization of trauma patients for transfer to higher level of care 11

Understanding the Chain of Communication During a Disaster

(Designated California Trauma Centers, 2006). Most California hospital emergency rooms participate in disaster preparedness by using the Reddinet system on a daily basis. The microwave communication device relays daily bed status, trends in services rendered, and hospital diversion data to ICEMA and the county public health (S. Long, personal communication, 2004). Recommendations for our Future Emergency Response System Originally, the emergency medical system was designed to provide search, rescue, and stabilization to transport victims to an acute care facility. The system was intended for single or multiple events with people in an acute medical crisis. At the time when this plan was considered, our country was not involved with a healthcare cost crisis and our hospitals cared for the medically fragile and the general public was healthy. We cannot expect this same system to withstand a mass causality event. Our present emergency medical system, based on first responders transporting emergencies to hospitals, will quickly turn into ambulances circling emergency room and hospitals on diversion. The most recent California statewide disaster exercise practiced the entire emergency medical response system overwhelmed immediately with no 911, ambulance transport, hospitals, or emergency room capability. The public health system needs to assume responsibility for the medically fragile during a disaster. These people often have special needs, medications, and equipment that will be left at home or destroyed during a disaster. California’s EMSA wrote a report on the medically fragile during a severe flood in northern California in 1997 (EMSA, 1997). A toolkit was created to prepare counties for medically fragile shelters or infirmaries (Shelter Medical Group, 2001). An MOU is included that creates a preplanned arrangement with local Red Cross Chapters to provide shelters where medical treatment may take place (Shelter Medical Group, Appendix J). If the ARC cannot alter their charters to provide shelter to the medically fragile, 12

then another possibility is to use the HRSA funding to buy transportable hospitals (Peoples, Jezior, & Shriver, 2004). The benefit of a transportable hospital facility would be that it is more flexible than brick and mortar and can be deployed upon demand to a particular site. The facility would be useful during severe influenza seasons and could function as an emergency room or provide an increase in hospital beds. Either option will require medical personnel to staff the facilities. Since September 11, the Surgeon General has urged physicians and other licensed medical professionals to volunteer for a Medical Reserve Corp (MRC) within each county (San Bernardino County, n.d.). Presently, there are DMAT teams that are deployed by FEMA. However, DMAT teams must wait to respond when Federal assistance is activated. An MRC would be deployed by the local EOC to provide medical care, locally, in the field during a disaster. The MRC gives physicians and nurses an opportunity to work together separate from their affiliation with hospitals or medical groups. Each local MRC will provide medical disaster field response acting as first responders, enhance communications between public health and acute care facilities, and create a medical presence within the emergency response community (San Bernardino County, SBC MRC Brochure). Southern California Fire Storms, 2003 The Old Waterman Fire in San Bernadino, California (2003), demonstrates that the small to moderate health emergency response that transpired during a noninjury mass evacuation was strained beyond its limit. The Old Waterman Fire displaced 90,000 citizens, and required two hospitals and two nursing homes to evacuate within the first 72 hrs. The state predicts that 10% of the displaced population will be medically fragile, which means that 9,000 people were in need of some sort of medical attention during the evacuation (E. Frykman, personal communication, 2004). The medically fragile are a significant public health concern even in a non-injury disaster. The present healthcare Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

crisis restricts hospitals and emergency rooms from improving their surge capabilities and that, during a large surge, the emergency system will become overwhelmed. For instance, during the San Bernardino Old Waterman Fire, Loma Linda University Medical Center (Trauma Level I) volunteered to provide medical attention to the largest ARC shelter, with 2,000 citizens, to prevent a surge of the medically fragile arriving at their emergency department (R. Hart, personal communication, 2004). It is crucial that the local Public Health Departments, local EOCs, and local Red Cross chapters incorporate the newly developing MRCs to augment their emergency medical response system with deployable teams, infirmary shelters, or mobile clinics or hospitals. The flexibility of the mobile clinics, infirmaries, or hospitals will provide an increase in bed capacity while the MRC will enhance staffing demands to specific areas of need. This solution is feasible, cost-conscious, and alleviates financial burden and unrealistic expectations of our present emergency medical system to provide appropriate surge capacity in a mass casualty event.

governments stop funding failing systems, that medical communities pre-identify with their local MRC to establish the appropriate chain of command, and that individuals and families participate in our local disaster drills.

Appendix. Acronyms for Emergency Services ARC CHHSA DMAT DHS EMSA EOC EMS EMT FEMA HEICS HRSA

The Old Waterman Fire displaced 90,000 citizens within the first 72 hrs.

ICS IRC JEOC LEMSA MHOAC

Conclusion Finally, since September 11, every American has had to redefine their sense of security and safety. The present definition of a medical emergency has undergone radical change. On that horrific day, we watched first responders confront an emergency event that had never entered any realm of possibility, let alone preparation. There was no capability for an appropriate response and the only option was to sacrifice lives to save lives. It is this author’s hope that unrealistic expectations be confronted with real solutions, that Perspectives in Psychiatric Care Vol. 43, No. 1, February, 2007

MOU MRC NGO OES OA RDMHC/S REOC SEMS SNS SOC USDHHS

American Red Cross California Department of Health and Human Services Agency Disaster Medical Assistance Teams Department of Health Services Emergency Medical Services Authority Emergency Operations Center Emergency Management System Emergency Medical Technicians Federal Emergency Management Agency Hospital Emergency Incident Command System Health Resources and Services Administration Incident Command System International Red Cross Joint Emergency Operations Center Local Emergency Medical Services Authority Medical Health Operation Area Coordinator Memorandum of Understanding Medical Reserve Corp Nongovernmental Organization Office of Emergency Services Operational Area Regional Disaster Medical Health Coordinator and Specialist Regional Emergency Operations Center Standard Emergency Management System Strategic National Stockpile State Operations Center U.S. Department of Health and Human Services

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Understanding the Chain of Communication During a Disaster

Author contact: [email protected], with a copy to the Editor: [email protected] References American Red Cross. (n.d.). Museum—Explore our history. Retrieved November 3, 2006, from http://www.redcross.org/museum/ history/organizations.asp Austin, B. (2004). National bioterrorism hospital preparedness program. Lecture presented at Temecula, CA. California Department of Health Services. (n.d.). Retrieved November 2, 2006, from http://www.dhs.ca.gov/home/organization CNA Corporation. (2004, August). Medical surge capacity and capability: A management system for integrating medical and health resources during large scale emergencies. (Report prepared for the Asst. Secretary for Public Health Emergency Preparedness, U.S. Dept. of Health and Human Services, Contract Number 233-03-0028), Alexandria, VA: Author. Retrieved November 1, 2006, from http://www.hhs.gov/ophep/mscc_sept2004.pdf Congressional Charter of the American National Red Cross. (1999, November). Retrieved November 3, 2006, from http://www. redcross.org/images/pdfs/charter.pdf Designated California Trauma Centers. (2006, July). Retrieved November 3, 2006, from http://www.emsa.ca.gov/emsdivision/trma_ctr.pdf Emergency Medical Services Authority (EMSA). (n.d.). Retrieved November 2, 2006, from http://www.emsa.cahwnet.gov/dms2/ dmsrspns.asp Emergency Medical Services Authority (EMSA). (1997, August). After-action report on the Department response to the winter floods, January 1–29, 1997, EMSA #397-01. Retrieved November 3, 2006, from http://www.emsa.ca.gov/aboutemsa/ems39701.asp Emergency Medical Services Authority (EMSA). (2003, June). Disaster medical system guidelines. Retrieved November 2, 2006, from http://www.emsa.cahwnet.gov/aboutemsa/ems214.doc Esbitt, D. (2003, Jul–Sep). The Strategic National Stockpile: Roles and responsibilities of healthcare professionals for receiving the stockpile assets. Disaster Management and Response, 1(3) 68– 70. Governor’s Office of Emergency Services. (1994). Standardized emergency management system (SEMS) guidelines. Retrieved November 1,

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2006, from http://www.oes.ca.gov/Operational/OESHome.nsf/ 0/B49435352108954488256C2A0071E038?OpenDocument Governor’s Office of Emergency Services. (2001, November). EMMA: Emergency managers mutual aid guidance. Retrieved November 2, 2006, from http://www.oes.ca.gov/Operational/OESHome.nsf/ PDF/Emergency%20Managers%20Mutual%20Aid%20Guidance/ $file/EMMAGuidance.pdf Governor’s Office of Emergency Services. (2003, October). Emergency management in California. Retrieved November 2, 2006, from http:// www.oes.ca.gov/Operational/OESHome.nsf/PDF/EMGuide/ $file/EMGuide.pdf Hart, R. (Chancellor of LLUMC.) (2004). Personal communication. Health Resources and Services Administration (HRSA). (n.d.). National bioterrorism hospital preparedness program (NBHPP). Retrieved November 1, 2006, from http://www.hrsa.gov/bioterrorism/ International Federation of Red Cross and Red Crescent Societies. (n.d.) Retrieved November 2, 2006, from http://www.ifrc.org/ who/history.asp?navid=03_09 Long, S. (Regional Disaster Specialist, Region VI.) (2004). Personal communication. Office of Public Affairs, California State Polytechnic University, Pomona. (2006). Emergency procedures: Overview of EOC team operational procedures. Retrieved November 2, 2006, from http:// www.csupomona.edu/∼publicaffairs/emergency/eoc-team.shtml Peoples, G. E., Jezior, J. R., & Shriver, C. D. (2004). Caring for the wounded in Iraq—A photo essay. New England Journal of Medicine, 351(24), 2476–2480. Putnam, J. L. (2004, June). Tapped out: Improving our country’s medical surge capacity. San Bernardino and Riverside County Mountain Area Safety Taskforce. (n.d.). Retrieved November 2, 2006, from http://www. calmast.org/mast/public/index.html (General Information, About MAST, Overview, San Bernardino County MAST). San Bernardino County Medical Reserve Corps. (n.d.). Retrieved November 3, 2006, from http://www.sbcms.org/mrc/about.htm Shelter Medical Group. (2001, September). Shelter medical group toolkit: Local emergency preparedness planners guide for the care and sheltering of the medically fragile. Retrieved November 3, 2006, from http://www.emsa.ca.gov/dms2/toolkit.pdf Webster’s Revised Unabridged Dictionary. (1913). Retrieved November 1, 2006, from http://www.dictionary.net/disaster

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