General Disaster Response Information 

The military is often called on assist in civilian authorities in disaster relief operations both within the United States and in foreign countries. While the players in international and national disaster relief operations differ, medical considerations remain relatively constant. Rapid assessment of the medical needs created by the disaster is critical. Often, this task will have already been accomplished by local, state, or national agencies. Generally, military medicine can best support disaster relief efforts with preventive medicine detachments and environmental sanitation and vector control assistance. Treatment and surgical teams may be required primarily to support other non-medical JTF units, although care of the civilian population may be directed. If the operation is conducted in a foreign country, interpreters attached to medical units are valuable. 

Myths and Erroneous Assumptions About Disasters. There are a considerable number of assumptions we often make about disasters that are far off the mark. For example: 

• Local authorities and agencies are clueless; they drastically need military assistance in planning, coordinating, and supervising the disaster response effort. Not true. In the United States and other developed countries, local emergency management authorities know what they are doing, have plans, are more familiar with disaster response, and are more aware of what is required than any newly deployed military unit.
• The local population will be shocked into a helpless stupor or in a state of panic. Not true. Local agencies and the local population will most likely have recovery operations well underway by the time the first military assistance unit ever arrives.
• Lawlessness and looting will be prevalent. Not necessarily true. Don’t confuse a disaster with a riot. Often times, physical destruction is such that there is no property left worth looting. More importantly, populations behave similarly before and after a disaster. If a population is law abiding before a disaster, it will be law abiding after a disaster. If a population is violent and lawless before a disaster, there is no reason to suspect that a disaster will reform the citizenry.
• The magnitude of the disaster is directly related to the magnitude of the incident. Not true. The 1989 Loma Prieta earthquake in San Francisco killed 62, injured 3,800, and left about 12,000 homeless. A much less violent earthquake in Armenia the year before killed over 25,000, injured over 31,000, and left 514,000 homeless.
• Unusual disaster conditions, like floods, will create unusual medical problems, like snake bites. Not true. Epidemiological studies show no evidence of snake bite increases during floods (except in one region of India).
• All assistance-- especially medical personnel, military hospitals, and medical supplies--is valuable. Not true. Assistance is only valuable if it is needed, timely, and competent.
• Dead bodies constitute an immediate threat to public health and require mass burials or cremation. Not true. Corpses resulting from a natural or terrorist disaster pose no great immediate public health risk.
• Death from exposure is a grave threat to victims trapped in rubble. Not true. Trapped victims may die from other injuries or suffocation, but exposure is not usually life threatening unless accompanied by wet and cold weather.
• Mass immunization campaigns are needed as epidemics, especially typhoid and cholera, will pose a serious threat to public health. Not true. Mass immunization campaigns are not needed and only divert medical resources from more immediate environmental and sanitation efforts.
• Military medical treatment facilities are urgently needed to treat casualties from the disaster. Possibly true, but emergency medical treatment units are needed most within four hours of the disaster and augmentation hospitals are needed most within seventy-two hours. It is unlikely many military medical units can be deployed in those time frames. Military medical treatment units are most valuable in caring for non-medical members of a JTF involved in disaster recovery efforts.

Floods. By far, the major cause of death in floods is drowning. Other causes include combinations of drowning, trauma, and hypothermia. Less than 2% of survivors require medical care. Injuries are generally minor lacerations, rashes, and ulcers. Wounds are frequently contaminated, and there are a surprising number of burn injuries resulting form fires started when rushing water disrupts gas lines or fuel tanks. 

Cyclones, typhoons, and hurricanes. 90% of all cyclonic fatalities are storm surge drownings. Other causes of death are housing collapse, mud slides, electrocution, penetrating trauma, and blunt trauma. Most fatalities occur among those less than 4 or over 70 years old. Most survivors are relatively unharmed. Injuries are generally minor and include lacerations, closed fractures, penetration wounds, and cyclone syndrome. Wounds are potentially highly contaminated. Most severe injuries are suffered by trailer park residents or occur during clean-up operations. 

Tornadoes. Only 3% of tornadoes cause casualties, and only 4% of all tornado injuries are fatal. Fatalities are, however, 40 times higher among occupants of mobile homes. Causes of death are most frequently craniocerebral trauma and crushing wounds, but fewer than .2% of casualties suffer severe injuries. Most common injuries are lacerations and penetrating wounds. Wounds are usually highly contaminated, and sepsis is common even after surgical debridement. 

Volcanoes. Almost 90% of fatalities are from the pyroclastic flow: suffocation from ash, steam scalding, and lethal gasses. 10% are from suffocation, drowning, and/or scalding in lahars or mud flows. Common injuries include eye and mucus membrane damage, respiratory system damage or disease exacerbation, trauma from collapsed buildings, severe burns, and dehydration. Major wound complications like gangrene, sepsis, and osteomyelitis are common. 

Earthquakes. The primary causes of earthquake deaths are crushing injuries, exsanguination, and asphyxia from building collapses as well as drownings from tsunamis. 93% of all victims extricated from rubble within 24 hours survive. 95% of all deaths occur before extraction. Approximately 5% of casualties suffer critical injuries to include multiple fractures, head or internal injuries, hypothermia, organ failure, myocardial infarction. Most injuries, however, are minor: closed fractures and superficial trauma. Exacerbation of preexisting diseases (diabetes, hypertension, respiratory conditions) and mental health problems is common. 

Manmade Disasters. Manmade disasters may also cause significant casualties, though not in the same magnitude as natural disasters. The most potentially serious manmade disasters include hazardous materials spills or leaks, radiation accidents, terrorist bombings, and terrorist biological or chemical attacks. 

Military Civic Actions 

Today, more than ever before, U.S. forces may participate in military civic actions (MCA) to include international security assistance (SA), international humanitarian assistance (HA), foreign internal defense (FID), international internal development, international peacekeeping operations, or national military support to civil authorities (MSCA). While some of these operations (like FID and SA) have been performed by SOFs for years, others are relatively recent additions to the military’s mission list. 

The State Department is responsible for all international assistance. This includes the Military Assistance Program (MAP), which is administered by the Department of Defense, and internal development, which is the responsibility of the U.S. Agency for International Development (USAID). Any unified command may be tasked to support international MCA, and JTFs may be activated to accomplish these missions. 

The Federal Emergency Management Agency (FEMA) is the executive agency responsible for coordinating responses to previously described national disasters and emergencies. If military assistance is needed, FEMA requests military help through the Department of Defense in accordance with the Federal Response Plan (FRP). The Army is the Defense Department’s executive agent for MSCA. USACOM is the unified command responsible for executing national MSCA operations. The Army passes MSCA operational guidance and direction to USACOM through the Chairman of the Joint Chiefs of Staff. USACOM will likely activate a JTF to accomplish any assigned MSCA missions. The U.S. Public Health Service is responsible to FEMA for coordinating the federal medical response to CONUS disasters which is does though its Office of Emergency Preparedness (OEP) and National Disaster Medical System (NDMS) in accordance with Emergency Support Function (ESF) #8 of the FRP. An on-scene FEMA Federal Coordinating Office (FCO) directs all federal assistance at the disaster site.I 

All MCA, to include medical actions, require extensive coordination. Ideally, a CJTF coordinates any anticipated defense or development actions through the unified command. Ideally, but not necessarily, the unified CINC grants the CJTF direct liaison authority to accomplish his mission. From a medical perspective, for an international MCA operation to be effective, coordination must be conducted with the ambassador and country team (they have the lead), host nation cabinet officers, host nation medical agencies, USAID, SA forces, civil affairs offices, SOFs, and non-governmental organizations (NGO) in the region. Similarly, for national MSCA operations, coordination must be conducted with FEMA, state agencies, local municipalities, and volunteer organizations. 

There are a number of potential MCA missions and operations in addition to disaster response. Some of them are: 

Peacekeeping operations. Coordinating medical support of peacekeeping operations is difficult for several reasons. Peacekeeping forces are often an amalgam of units from multiple nations. Additionally, few of these deployed units may have any on-site medical support. Units assigned to peacekeeping operations are frequently rotated, and peacekeeping forces are often located in remote locations with minimal lines of communication. As a result, evacuation, hospitalization, and medical resupply are difficult at best. HSS to peacekeeping operations should focus on providing care to the peacekeeping force and not the local populace. 

Refugee and migrant management. In the early and mid-1990s, decisions by the federal courts and the Immigration and Naturalization Service (INS) caused Haitian migrants and refugees to be detained at military bases in the Caribbean and Latin America for over two years. Additionally, it is possible that, if a massive influx of refugees or migrants into the United States occurs, the military may be ordered to establish camps within CONUS. In these situations, camp health care is of immediate concern. Internees must be examined, immunized, and treated. Some will require quarantine. Hygiene and sanitation programs must be implemented. A medical supply system must be established, and coordination must be effected to permit patient transfer to medical facilities if the need arises. A JTF Surgeon cannot depend on promises from NGOs; many offer assistance and, while some offers are legitimate, others are looking for free publicity or an opportunity to advance a political agenda. JTF Surgeons must also be prepared to answer charges from immigrant rights groups that inadequate medical care is being provided. These are often made in attempts to force the INS to admit or parole internees into the United States. A JTF Surgeon who finds her or himself involved in migrant and refugee care should expect to keep the mission for a long time as court procedures between immigrant rights groups and the Justice Department may result in a long-term judicial stalemate. 

Internal defense and development. Historically, most other medical FID, SA, and internal development missions have been nebulous. JTF Surgeons and medical commanders have often been given considerable latitude in developing and executing their own missions. The temptation to set up sidewalk clinics and dispense pills should be avoided. Such an operation is a good photo opportunity, but does little to help the populace. These type of actions unrealistically increase expectations of local citizens and result in long-term resentment and hostility. It is far better to conduct an environmental sanitation or health education program that may be less visible but has long-term value. A good assessment of the health care status of the country or locality is the key to success. FM 8-42, Combat Health Support in Stability Operations and Support Operations , has an excellent checklist. Assessments should include an examination of the general health of the population, especially nutrition, sanitation, endemic diseases, local primary care capabilities, infant mortality, the health care system, health care facilities, and medical staff competency. Operations should be tailored to the results of the assessment, and the host nation should be deeply involved as U.S. forces will probably not be around to follow up. If possible, medical actions should be integrated into broader programs. For example, training of medical practitioners can be combined with the renovation of a local clinic, or sanitation problems can be corrected in conjunction with road building projects. These types of medical MCA, while not highly visible, provide long-term benefits to both the local population and the local health care provider.

NBC Defensive Operations 

In planning to conduct NBC defensive operations, the JTF Surgeon should make good use of the numerous publications each service produces and consider potential defensive measures. These defensive measures should include targeting key areas for surveillance, employing personal protective measures to help prevent exposure, and instituting detection strategies. 

Casualty management. NBC operations can create large numbers of casualties who have been exposed to agents, toxins, radiation, or infections. That the exposure was deliberate does not alter the basic principles of treatment. Medical facilities should, however, be prepared to respond rapidly as casualty workload will likely peak quickly with little advance warning. As biological agents are transmissible between humans, they may cause problems for some time after any initial attack. 

Preventive medicine. Preventive medicine specialists play an important role in assessing the medical threat posed by an NBC attack. They can identify potential health hazards and determine when to use immunizations, prophylaxis, and other prevention measures. Following any NBC attack, special emphasis should be placed upon food and water sanitation, hygiene, and common prevention measures that reduce the spread of disease. All food, except canned goods, must be thoroughly inspected before consumption. Insect and rodent control becomes more important following an NBC attack because vectors can serve as continuing sources of infection. Rigid enforcement of water sanitation and personal hygiene measures may reduce the attack’s effects. 

Patient evacuation. One of the first considerations following an NBC attack is to determine to what extent evacuation assets will be committed to contaminated areas. If uncontaminated personnel are to be sent into contaminated areas to evacuate casualties, some type of exposure guide must be established and followed. Every effort should be made to limit the number of assets and people that become contaminated. The decontamination of patients before evacuation will help limit the spread of contaminants. 

Patient decontamination and triage. Decontamination of patients serves two purposes. It reduces the amount of contaminant that is absorbed by the patient, and it protects the medical staff. Decontamination and triage of NBC casualties will obviously vary with the situation and the contaminant. Therefore, medical units should have a basic NBC mass casualty plan that can be modified to meet varying situations. Decontamination should be decentralized to avoid a backup of casualties awaiting cleanup at a central location. Each medical facility must be able to establish its own decontamination area. As in any mass casualty situation, arriving casualties should be examined at a triage point and directed to the proper area. An additional triage decision in NBC mass casualty situations is whether patients have medical conditions that take priority over decontamination. Ninety percent of all decontamination can be performed without interfering with medical treatment, simply by removing a casualty’s outer clothing and shoes. 

Impact on HSS. Even if an NBC attack produces few fatalities, it may likely result in numerous casualties who require extensive treatment. Medical staffs will be taxed. Additionally, medical personnel may need to work in military operational protective posture (MOPP) gear which will reduce their effectiveness. Decontamination efforts may reduce staff available to perform medical functions. As a result, the unit will be considerably less effective. 

Combat Search and Rescue (CSAR) 

Although CSAR is not a medical mission, JTF Surgeons have an advisory role in ensuring adequate emergency medical services are provided during CSAR operations. A CSAR operations cell will be established, usually as part of the operations office (J3). It is important to remember that the primary role of Army air ambulances is to evacuate casualties or transport patients, not to conduct CSAR. CSAR is only a secondary mission for these valuable medical assets, and even then they must only conduct rescue missions after downed personnel have been accurately identified, located, and a medical need is established. 

Special Operations

Direct Action (DA). DA missions are usually conducted considerable distances from friendly treatment facilities. SOF medics provide on-site emergency treatment. Dedicated medical evacuation aircraft are often not available to support these operations, so operational and logistical assets must be used to transport casualties. 

Special Reconnaissance (SR). Medical support for SR missions may be even more austere. As aerial evacuation of casualties could compromise a mission, treatment is limited to self-aid, buddy-aid, or SOF medic support until the mission is completed and the team extracted. A thorough medical threat assessment should be conducted prior to inserting SOF on a SR mission. 

Unconventional warfare. Unconventional warfare usually results in fewer battle casualties and a greater incidence of disease and malnutrition than does conventional fighting. Medical elements supporting resistance forces must be mobile and effective in both preventing disease and restoring casualties to duty. During combat operations, medical personnel may need to establish casualty collection points. Casualties may later be evacuated to a guerrilla base for further treatment. If the situation does not permit aeromedical evacuation, a clandestine evacuation system may need to be established to transport casualties to conventional medical facilities. 

Foreign internal defense. FID operations focus on developing friendly relationships between indigenous populations, their government, and the United States. Providing medical services has historically proven to be one of the best methods to generate local support of a host nation government. Medical operations might include providing education in sanitary procedures, hygiene, preventive medicine, waste disposal, or improving the potable water supply. All medical operations should emphasize improving basic standards of living and health, involving the local population, and enhancing the abilities of local authorities.