Ex CADUCEUS MAJOR – Visit Report Observations from a visit to a joint full-scale exercise conducted by PHAC and PSC in Toronto (November 2007)
Background
The Public Health Agency of Canada (PHAC) established the National Office of Health Emergency Response Teams (NOHERT) within its Centre for Emergency Preparedness and Response to improve its ability to respond in a coordinated and efficient manner to support provincial, territorial and local government management of health emergencies. The consequences of disaster often impose heavy demands on health systems to maintain existing health care services and to step up emergency treatment for disaster victims. In Canada, an afflicted jurisdiction can call on its neighbours and the federal government to draw upon additional all-hazards surge capacity such as NOHERT.
NOHERT is responsible to deploy all-hazards Health Emergency Response Teams (HERTs) that are capable of dealing with most emergency care priorities. The HERTs core capability contributes emergency medical response and mental health available for austere conditions. Teams can be enhanced with trauma, paediatrics, burn treatment, decontamination, infectious disease response and other capabilities to protect Canadians in need.
NOHERT leads Public Health Agency of Canada efforts to establish and train HERTs located in strategic locations across Canada. The Teams comprise practicing physicians, nurses, paramedics and other medical professionals who volunteer for up to two weeks of training and exercising annually. Medical Operations are supported by dedicated Mission Support Teams who manage all aspects of logistics and facilities administration onsite at a disaster location.
Exercise CADUCEUS MAJOR
NOHERT developed and designed this exercise to test the ability of HERTs to deploy and treat simulated patients with a range of serious injuries and ailments over a 24 hour period. PHAC’s National Emergency Stockpile System (NESS) provided portable hospital equipment and medical supplies and the logistics and transport needed to support the response.
For this exercise, NOHERT joined with Ontario’s Emergency Medical Assistance Team (EMAT) in order that interoperability could be assessed and best practices for medical operations developed. Exercise CADUCEUS MAJOR was conducted in joint partnership with Public Safety Canada’s Heavy Urban Search and Rescue (HUSAR) Program. HUSAR Teams (Vancouver, Calgary, the province of Manitoba, Toronto and Halifax) were to demonstrate a continued ability to deploy and sustain operations using a unified command system.
The exercise scenario was set in the fictitious community of Constellation, Ontario – described as the financial centre of Canada. An explosion occurred in a busy office complex linked by a pedestrian walkway – it was not known if the explosion was a terrorist attack or accident. Massive and urgent efforts were required to evaluate risks of further explosions or possible terrorist use of weapons of mass destruction. It would become quickly apparent that outside assistance would be needed to support intense efforts to stabilize damaged buildings, rescue trapped victims and provide immediate medical aid.
Organizers estimated that Exercises CADUCEUS MAJOR would represent one of the largest simulations of its type in Canada. Close to 1,000 personnel would be onsite, working 24 hours a day over the weekend as responders, simulated victims and evaluators. To prepare for the exercise, NOHERT trained 165 medical responders and mission support teams (who would maintain facilities and support medical operations). PHAC allocated $2.3M to equip and prepare HERTs to respond.
The key NOHERT goal was to gain the experience and hard evidence to validate a core or generic configuration and contribute to future HERT “blueprints”.
It was stated in writing that “NOHERT and its partners are committed to the development of a comprehensive approach to managing public health emergencies through a Pan-Canadian system with a robust, integrated and seamless emergency preparedness and response capacity. For Canadians, the benefit will be improved capability to face any disaster that would require prompt, organized medical assistance.”
Observations
The observations I make by way of this Visit Report brush on my personal level of understanding, the scenario, the set-up, and interoperability and integration aspects of the HERT. Although I might make observations on other aspects of the exercise, e.g. HUSAR, these are out of scope.
Personal level of understanding
I fully understand that an event such as an explosion in a downtown busy office complex in a “financial centre of Canada,” with the possibility of thousands of casualties, would create a considerable (overwhelming) surge on the affected community’s health services. However, I would expect, following recent events beginning with the 1995 Oklahoma City bombing, the 9/11 series of attacks, and the London City bombings, that most urban hospitals today should have common, all-hazards, Incident Command/Management Systems in place and that these hospitals should also have areas internal to hospital (and perhaps immediately adjacent to the hospital) pre-designated for de-con, triage, minor treatment, etc., to alleviate the pressure caused by a surge event.
Expectedly, there may be medical staffing, materiel, and accommodation resource shortages at (hospital) site and regional levels. It follows that, at provincial/territorial/federal levels, support/response initiatives should and would be focused on easing these expected resource shortages in short delay. Unfortunately, what I learned and observed on November 23, 2007, did little to reassure me of any such thing.
I found the statement in the backgrounder provided at the exercise briefing that “…HERT core capability [is designed] for austere conditions” a little puzzling. Urban hospitals responding to disasters may indeed experience a lack of necessary resources, but are, in my opinion, far from suffering from “austere conditions.” Perhaps the word “austere” requires more explicit definition. In the mean time, it appeared to me that NOHERT capability, as demonstrated, is better suited to meet (intended for) more rural (austere) applications.
Scenario
The deployment of NOHERT resources was centered on an explosion in a “busy office complex linked by a pedestrian walkway…” with the possibility of “further explosions or possible terrorist use of weapons of mass destruction.”
It was not stated explicitly in the backgrounder that the event was CBRNe associated, but mention of CBRNe was made at the briefing and was often overheard on site. What was mentioned at the briefing, however, was that “…our cousins from CSIS have given us advanced notice of a possible event,” thereby allowing the pre-positioning of resources nearby. I question the realism of this statement and assumption… How long would it take to assemble, deploy, and set-up NOHERT/NESS on zero notice?
In this scenario NOHERT is supported by NESS and Ontario EMAT resources.
Set-Up
Staging Area. The staging area was adjacent to the Regal Constellation demolition site which was “moulaged” to add realism to the scene. I overheard many oohs and ahhs, and would agree that “tent city” was quite impressive. Nevertheless, I have many questions surrounding this type of deployment in support of an urban scenario.
Tent City
The scenes of the Alfred P. Murrah building in Oklahoma City, Ground Zero at NYC, and the City of London in the immediate after-math and beyond show no pictures of tent cities, lumber mills, or on-scene treatment areas. The evidence to date would suggest that first responders (with augmentation from other agencies and organizations from other jurisdictions and surrounding areas) work hard to rescue, triage, stabilize, and transport as quickly as practicable to existing health services institutions, i.e., hospitals.
In response to a sudden impact mass casualty event, hospitals and health service providers activate their mass casualty incident plans, innovate, and improvise to the best of their ability and resources and begin receiving casualties from EMS, self-presenting, or otherwise. In the urban setting, I can’t think of a better way to deal with casualties but to rapidly transport them to established trauma centres.
With respect to the proximity of “tent-city” to the disaster site, I understand and the organizers explained that it would not necessarily be as close to the wreckage (and potential danger) as it was. But it does beg the questions: “If the event were to happen on the corner of Bloor and Yonge, where would you find the real estate to set all of this tentage, and generators, and semi-trailers, and lumber-mill?” “Would you really have to?” and “What if it was a CBRNe event?” I did not notice (was not shown) any decontamination areas or HOT and COLD Zones. There was only one “Triage” entrance and was in no way ready to receive dirty patients.
Lumber-mills. In any case, and back to the set-up, I was awed that in the 21st century we should be relying on lumber as much as it appeared we were. Lumber may be available in large quantities in this country, but how long would it take in a sudden-impact mass casualty event to have all of this lumber found and delivered to the site? Where did it all come from? Is it part of the HUSAR inventory?
MB USAR Lumber Mill
Although outside the scope of this observation report, I was amazed that Canadian Heavy Search and Rescue Task Forces resource inventory would not include re-usable hydraulic stabilization, jack systems, and other wreckage support/shoring systems other than lumber milling equipment. Are the table-saws and other carpentry equipment part of the HUSAR inventory? I noticed a large component of the MB HUSAR Task Force was committed to carpentry. Is this the best use of EMS/FireFighter and Rescuer resources?
Another surprise to me, and others in our tour group, was that these hundreds of pieces of lumber would be manually hammered together. In response to a question from our group, the Tour Guide explained that powered hammers are too imprecise for use under these conditions and circumstances. I did not understand.
Portable Power. I was also surprised to see tons of NESS crates (more lumber) lying around the site unopened including many crated 10KW generators. My observations revealed many rental generators on site prompting my question to the Tour Guide: “Why aren’t we using and testing the NESS generators?” To which he replied: “Don’t know.” Is it because uncrating the NESS equipment means that the equipment has to be re-crated later? On this topic, why hasn’t NESS considered disbanding its carpentry shop in favour of ruggedized, re-usuable, colour-coded, plastic crating?
Equipment. It was not obvious to me what the rational was for using EMAT vs. NESS equipment, but I’m almost certain that EMAT equipment predominated the scene – the equipment in use in the medical tents appeared modern (packaged in ruggedized, re-usable, colour-coded, plastic crating) and included patient monitoring equipment, which I don’t believe is included in NESS stocks. It was also not obvious that NOHERT/NESS connected well with the provincial EMAT. Generally, I found the site quite untidy with NESS crates and NESS stocks strewn all over the place.
NESS Stretchers
Medical Tent Equipment
Medical Tent Crowding
Ontario EMAT Equipment
Personnel Accommodations. Our Tour Guide and most of the others in expensive paramilitary wear were eager to tell us how little sleep they were operating on. I found this condition of sleep-depravation an unsafe practice (given the work environment, consequence of error, life-safety, etc.) and disconcerting. Moreover, I was shocked at the pride NOHERT/NESS expressed over the self-contained capability of the teams/taskforces. I would have thought that the life-safety implications of the work would dictate that rescuers get better treatment than to sleep on cots under canvas in adverse weather. I should think that, in the urban setting, hotels would be relatively vacant and that room availability would be high. Failing that, I should think that, in the urban setting, other hard shelter arrangements would be relatively easy to make.
I don’t get the attraction to battle-like accommodations, in the urban setting, when other options are rife. I obviously didn’t see the same glamour in the “austere” conditions of NOHERT/EMAT/HUSAR as others may have seen.
I haven’t had time to survey the aspects of HUSAR in other countries, i.e., US, Australia, New Zealand, France, UK, Germany, Israel, etc., but would be curious to compare and contrast capabilities and mind-set.
MASH. Why would you want to set a MASH (Triage and Treatment for Red, Amber, and Green Casualties) up in the urban setting teeming with trauma hospitals? On the medical set-up, I found access doors too narrow for speedy movement of casualties, was dismayed by the uneven floors and rail systems (stretcher and litter obstacles as well as human hazards) running across certain doorways, was shocked at the less than sterile conditions of the whole area, and was surprised at all the white-boards and markers for representation of the medical situation. When our Tour Guide was asked about automation support to the medical task, he answered: “we don’t want to be reliant on power for good management of the situation…”. I did not hasten to add that the whole set up is reliant on power.
MASH Crowding
Floor Obstacles
Situation Tracking
The scenario described in the initial briefing called for thousands of casualties. I found the medical set-up overcrowded by staff and believe that the expectations that this type of set-up would be able to handle this type of load optimistic at best – unrealistic at worst.
There were allusions to a CBRNe event, which should have called for a chemical/biological/radiological decontamination capability and a trauma unit for blast lung, severe burn, eye, ear, and head injury. I didn’t observe (was not shown) any such capability.
Interoperability and Integration
Coming from a Regional Health Authority background, I was expecting to see some kind of link between NOHERT/EMAT and the standing health provider system. I saw nothing. I heard nothing. What I observed was a quasi-independent Triage and Treatment facility seeming to be working in isolation from existing health provision structures.
Some of the questions that came to mind were: Are all EMS systems continuing to function as normal? Are the EMS resources entering the event site to collect and transport casualties to hospitals? Who gets what REDS, GREENS and AMBERS? Are NOHERT resources tracking all casualties or only the ones they are handling? Is the health system tracking all casualties or only the non-NOHERT ones? What about R and I? Where should families call for information regarding the status of loved ones? Where are the NOHERT interfaces to existing social structures? Where are the NOHERT interfaces with local and existing psychosocialspiritual resources? What are the palliative resources of NOHERT? What are the interfaces with provincial/local coroners?
I didn’t observe (was not shown or explained) the lines of authority between NOHERT and the local health authority and provincial health department. On what authority is NOHERT deployed? To whom does it report on arrival? On what authority is NOHERT released? The existence of interfaces and the capabilities of interoperability and integration are unknown to me.
Final Comments
Immediately following a disaster event, medical staffing, materiel, and accommodation resource shortages at (hospital) site and regional levels should be expected — counted on. It follows that, at provincial/territorial/federal levels, support/response initiatives must focus on easing these expected resource shortages in short delay. I believe in the NOHERT concept of deploying all-hazards health emergency response teams capable of dealing with most emergency care priorities. It is valid and implementation is necessary. To enlist teams of practicing physicians, nurses, paramedics, and other medical professionals supported by dedicated Logistics Teams for rapid deployment to a disaster scene anywhere in the country would certainly bolster medical readiness capability and grant a sense of hope to all of those local and regional health provision sites who shudder to think how they might respond on their own or even collectively to a mass casualty event, let alone one involving chemical or biological contamination.
It isn’t clear to me how the NOHERT demonstration of November 23, 2007 helps a hospital experiencing medical staff and materiel shortages fulfill its role of “first receiver” in a mass casualty incident.
Hospitals in general and EDs in particular need to be augmented and supported in responding to and recovering from disaster events. The provincial framework in which hospitals are found must be able to request support from the federal authority who, ideally, would be able to call upon its deployable resource (NOHERT) and task it to the province who may sub-task it to a regional health authority until no longer needed (as determined by the province or the regional health authority).
The NOHERT, in my opinion, does not have to come self-contained for 10 days or with all of the ancillary or equipment demonstrated. Rather, it should come ready to plug in and respond to the requirements of the requesting framework and to the requirements dictated by the event. Instead, the officials responsible for the conception and implementation of NOHERT should consider establishing event specific teams with event specific equipment.
Prepared by: Guy Corriveau, B.Sc., MPA, CEM®