How three New England states formed a Metropolitan Medical Response System, bringing joint disaster response planning to a predominantly rural region.

By Robert Gougelet, M.D., Director
Northern New England Metropolitan Medical Response System

When the national Metropolitan Medical Response System program emerged in 1996, the intention was to mitigate casualties from terrorist events using weapons of mass destruction by improving and coordinating planning efforts within metropolitan areas.

But if major metro areas can benefit from such efforts, predominantly rural states, which have an inherently limited capacity to respond to mass-casualty events, should benefit even more.

During a disaster medical conference at Dartmouth College in June 2001,  a scenario was played out in which a clandestine bio-attack with tularemia at Dartmouth's sports arena resulted in 5,000 casualties. Widely accepted models for community-based surge capacity clearly demonstrated that a large gap existed between locally available resources and the expected influx of federal resources. The results of this gap included additional illness and death, because of the lack of skilled response teams and less-than-adequate availability of critical medical supplies and pharmaceuticals.

Following the conference, with the specific goal of mitigating these gaps, and regionalizing mass-casualty planning, a multidisciplinary group of leaders from Maine, New Hampshire and Vermont established the Northern New England MMRS.

Using what's already there
The NNE MMRS serves as a coordinating resource for the three states in preparing for and responding to the health and medical consequences of a mass-casualty event affecting the tri-state region. Recent events, such as Hurricane Katrina, fears of an avian flu pandemic, the arrest of 17 terrorism suspects in the Toronto area in June, and New England flooding in May and June, have underscored the need to improve the region's all-hazards planning and response efforts.

The population of the three northern New England states exceeds 3 million, with 52.6% of the population residing in rural areas. Seasonal tourist attractions, active commercial ports and major population centers each represent significant vulnerabilities for terrorist attack. Close cooperation with Canadian partners is a necessity, as all three states border Quebec and Maine adjoins New Brunswick.

In addition to direct threats to northern New England, there is concern about the consequences of an incident, or an alert from the federal BioWatch monitoring program, in a nearby urban center. While injured or ill patients may be medically transported to hospitals within northern New England, it's also likely that tens of thousands of individuals minimally affected by the event might flee the urban areas, overwhelming resources in the northern states and potentially spreading disease.

The combination of rural and urban environments, international borders, coastal areas, and proximity to the dense urban areas of southern New England underscores the importance of developing the nne MMRS. This multi-state approach and largely rural demographic presents a significantly different planning landscape than is found in the other 124 MMRS jurisdictions across the United States.

The NNE MMRS approaches its mission of enhancing preparedness by building on existing systems and relationships and promoting regionalization. No new entities or planning groups are created; instead, collaboration and cooperation across state lines are emphasized. Consequently, the NNE MMRS has constructed a series of memorandums of understanding that detail the relationships and expectations of key emergency preparedness players in the respective departments of health or safety from each state.

It's worth noting that the region's three academic medical centers have been close participants in developing the nne MMRS, specifically: Maine Medical Center in Portland; Dartmouth-Hitchcock Medical Center in Lebanon, N.H.; and Fletcher Allen Health Care in Burlington, Vt.

Relationships among practitioners, responders and planners form the basis of any preparedness work. To foster a regional approach, the NNE MMRS enhances the existing relationships and builds new ones through a series of collaborative activities. Cooperative planning, learning, training and exercising not only develop skills, but also provide a forum in which community members build trust and learn about one another's capacities.

And by participating in the International Emergency Management Group www.iemg-gigu.org, the NNE MMRS is expanding on the concept of regionalization by assessing available resources in concert with authorities from Canada's eastern provinces.

The NNE MMRS has five essential elements:

• coordinated planning,
• coordinated training and education,
• cross-border coordination,
• medical strike teams, and
• a regional pharmaceutical cache.

Coordinated planning
The NNE MMRS is a mechanism for Maine, New Hampshire and Vermont to coordinate needs assessments and planning. These coordination efforts are facilitated by a regional information-sharing structure rooted in the nne MMRS Steering Committee.

This committee consists of about 26 key state preparedness stakeholders, including high-level representatives (or their designees) from emergency management, public health, EMS, public safety and state hospital associations, as well as a representative from Quebec.

Each of these individuals brings policies, plans, statutes and organizational descriptions to the table for analysis by the steering committee. Key considerations are gaps in capabilities, compatibility and sustainability. Members of the steering committee can then provide guidance back to their organizations to ensure harmonization with comparable agencies across borders.

Areas of emphasis include mass-casualty response, disease surveillance and information-sharing, planning and development of specialized stockpiles, incorporation of

Strategic National Stockpile resources, surge capacity, patient transport, communications procedures and equipment, and hospital cooperation.

To assist in creating and analyzing plans on these diverse topics, steering committee members are encouraged to create state-level ad hoc advisory committees of subject-matter experts.

In addition, the NNE MMRS maintains a regional office at the New England Center for Emergency Preparedness at Dartmouth-Hitchcock Medical Center, roughly in the center of the region. Staffing consists of a regional director, a regional coordinator and an administrative assistant.

The regional office provides guidance to appropriate state agencies on the content and coordination of plans and procedures in the MMRS's contract with DHS. The regional office may also provide guidance in other areas, as approved by the steering committee.

Coordinated training and education
For many aspects of preparedness, work is under way to find solutions, but finding the solution is not enough on its own. Full implementation requires that the solution be shared and that key personnel be trained in its use, whether it is a piece of equipment, a procedure or a completely new approach. Once education and training are under way, it's necessary for the region to exercise the solution and incorporate the lessons learned back into the planning, education and training process.

The NNE MMRS encourages and provides assistance with regional education, training and exercising among agencies and hospitals through design guidance, operational participation where possible, and observation and evaluation. MMRS staff also assist exercise designers in making sure that lessons learned are captured and presented in a form that can be used by exercise participants and planners.

Special areas of education, training and exercise emphasis include the Hospital Incident Command System, surveillance and notification protocols, coordination for mass-casualty events, wmd event response, and alternative care facilities. To minimize training costs, the MMRS is also working to increase the availability of applicable train-the-trainer programs in the region.

In December 2004, the NNE MMRS provided planning, logistical and staffing support for a mass-vaccination exercise at Dartmouth College, during which flu vaccine was administered to eligible recipients. Of particular interest to the evaluators were the clinic's overall throughput and pinpointing choke points in the process.

In addition, the MMRS has helped to bring to the region such programs as the Advanced Disaster Medical Response Provider Course, which gives medical professionals a baseline understanding of the expectations placed on them during a disaster, and the Advanced Hazmat Life Support: Toxic Industrial Chemicals and Toxic Industrial Materials course, an overview of common dangerous chemicals and materials that could be used by terrorists or released during an accident.

In conjunction with the Society of Critical Care Medicine, the NNE MMRS will hold a two-day course Sept. 11–12 that's designed to increase the awareness and refresh the critical-care skills of healthcare professionals, specifically physicians and nurses, who don't traditionally practice within this discipline.

Cross-border coordination
The NNE MMRS is available as a support mechanism for the coordination of state-to-state activities during cross-border response in regional emergency operations. Each state designates a cross-border coordination role and the individuals likely to serve this role, within their Support Function 5, Information and Planning, or equivalent. During a response, these individuals participate in cross-border information-sharing and coordinate planning activities.

During a response, the nne MMRS regional office would be available to facilitate communication and coordination among these individuals within each state's EOC, providing communications technology, administrative support and expert guidance as requested.

Medical strike teams
Each state within the NNE MMRS is developing a Medical Strike Team made up of specially equipped and trained volunteers for use during disasters. Each strike team will remain an asset of its state host agency, and activation will occur through traditional emergency management channels. Teams may also be made available to neighboring states through the Emergency Management Assistance Compact.

Because the MMRS believes that individuals have a responsibility first to their local community, facility or agency, once accepted onto a strike team, members are requested to have their employer sign a memorandum indicating that they understand their employee may be asked to respond during a disaster. We envision the typical deployment to last roughly three days.

The application process for the strike teams includes prioritizing professional  commitments  during the time of an emergency. Individual responsibility, mandatory coordination with their employer and close working relationships with Medical Reserve Corps units, DMATS, National Guard units and other community-based response groups are all efforts to avoid the "two-hat syndrome," where a person might have commitments to a strike team and also to another disaster response unit.

Initially, the NNE MMRS regional office provides each strike team with basic medical supplies, equipment and training through federal contract funding. Each state may supplement the supplies, equipment and training as they see fit.

The teams' primary function will be force protection, providing prophylaxis or vaccination to responders and members of their households. After performing its critical functions, the team will support the incident commander as appropriate. Depending on the ultimate composition of the team, support areas might include establishing appropriate medical and mental health care for responders, hospital backfill, management of stockpiles, and coordinating with other state and federal health assets. The major issue in each state has been liability and workers' compensation for team members. While each team will be self-sufficient, the three teams will train together to ensure interoperability during deployment.

The Vermont strike team, led by Dr. Andrew Bushnell of Fletcher Allen Health Care Systems, became operational on July 1. The Maine team, led by Dr. Anthony Tomas­soni of the Maine Medical Center, and the New Hampshire team, led by Dr. Robert Gougelet of the Dartmouth-Hitchcock Medical Center, will also be operational  this summer.

Pharmaceutical cache
The NNE MMRS is purchasing a pharmaceutical cache capable of treating 1,000 victims of a chemical incident and 10,000 victims for the first 48 hours of a biological incident. The cache will be equally divided among the Maine, New Hampshire and Vermont strike teams. The goal for the MMRS cache is not to replace existing or planned state pharmaceutical caches, but to enhance availability during the early stages of an emergency.

Since protecting first responders and first receivers is paramount in ensuring a continued effective response during a mass-casualty CBRNE event, and since staffing is often the most difficult component to address in disaster planning, the cache's primary mission, like that of the strike teams, is force protection. We define this as the prophylaxis, vaccination or early treatment of individuals and their families predetermined to be critical for sustaining healthcare and emergency management services.

Additional projects 
The NNE MMRS is committed to the development of an academic knowledge base of best practices for disaster medicine through a series of partnerships with a multidisciplinary group of policy and response researchers, as well as participating in national policy and technical workgroups. Working closely with the MMRS are the New England Center for Emergency Preparedness, Interactive Media Lab of Dartmouth College, and Yale New Haven Center for Emergency Preparedness and Disaster Response.

The NNE MMRS also enjoys a working relationship with staff from the Edgewood Chemical and Biological Center, formerly known as the Soldier and Biological Chemical Command. sbccom was best known for the robust series of community planning documents created in response to the Nunn-Lugar-Domenici Domestic Preparedness Program.

In addition to promoting regionalization as a critical step in mitigating the gaps between local, state and federal response, the NNE MMRS is working with partner organizations on finishing development of a comprehensive all-hazards community planning guide. This guide will provide a common framework and templates necessary for states, sub-state regions or communities to respond to mass-casualty events. In addition, interactive and other electronic media–based training programs are in development through relationships with the Interactive Media Lab, the National Infrastructure Institute www.ni2.org and the Yale New Haven Center for Emergency Preparedness and Disaster Response ­http://yalenewhavenhealth.org/emergency/.

Hard to plan ahead
One concern nationally is the wavering funding for the MMRS program. With each federal budget cycle, MMRS funding has been cut only to be replaced late in the session. The MMRS program is currently operating at 50% of the funding level allocated over previous years. This uncertainty leads to sustainability and morale issues across the nation's 125 jurisdictions.

We at the NNE MMRS believe that for the MMRS program to be successful into the future, it will be essential to have dedicated long-term funding tied to performance-based measures. It's obvious that the major attributes of the MMRS program have stood the test of time. Community-based planning, multi-agency involvement and efficient use of resources are hallmarks of the solid foundation that the MMRS program has created for emergency planning and response across the nation.

One of the most inspiring aspects of the NNE MMRS has been the continued level of cooperation and professionalism among the project's many partners. This effort develops the working relationships across disciplines that are necessary to plan, exercise and respond together as a coordinated and efficient group.

While it's difficult to expect even the best of efforts to be perfect or fast enough, an enormous amount can be accomplished by working together and developing efficiencies of both resources and finances that become the foundations for sustainability.

About the author 
Robert Gougelet, M.D., is an assistant professor of emergency medicine at the Dartmouth Medical School and an attending physician in the Emergency Department at Dartmouth Hitchcock Medical Center. He was an early developer of one of the nation's first Disaster Medical Assistance Teams and through the dmat has responded to numerous national and international disasters, including Hurricanes Hugo, Andrew, Marilyn, Georges and Katrina; the Northridge Earthquake; the New York City postal anthrax response; and the Bam, Iran, earthquake. Gougelet provides medical direction for emergency response efforts in New Hampshire and Vermont and also directs the Northern New England Metropolitan Medical Response System.