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Welcome to the Maine Train-the-Trainer program.
This presentation has been prepared by the Harvard School of Public Health Center for Public Health Preparedness to provide an overview of emergency preparedness. This presentation is intended for use by individuals for personal education, or by educators and trainers to present to a class of students.
The content has been developed for public health professionals, but should prove beneficial to hospital personnel, first line-responders, and the general public interested in learning more about emergency preparedness.
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•Upon completion of this presentation, we hope to accomplish the seven following learning objectives
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•Emergency preparedness is important because it places communities in a position of ability to mitigate public health threats, prepare to respond and recover from public health emergencies or crisis.
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•Emergency preparedness is important in Maine because it is vulnerable to various types of public health emergencies considering its unique vulnerabilities shown on the upcoming slides
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Now that you know what a public health emergency is and potential or unique threats to public health, you will be expected to know how to prepare for public health emergencies.
 
•Emergency preparedness can be broken down into 5 fundamental components, the 5 progressive steps you must take in order to be prepared. These 5 steps are the framework for this presentation:
•Understand Roles and Responsibilities – Know what you and your organization will be expected to do, know who the other players are and what you can expect them to do in the event of an emergency.
•Develop a Plan for Preparedness – Emergency response doesn’t just happen, you need to establish detailed plans and protocols to follow in the event of an emergency.
•Assess Resources – Staff, Supplies, Space – Once you develop your plan, you must identify and acquire the people, equipment, and other resources that will allow you to put this plan into action.
•Communicate & Train – You have your plan, you have your resources. Now, everyone involved needs to know that they’re involved, and know exactly the way in which they will be expected to participate.
•Practice – Once everyone knows their roles and responsibilities specific to your emergency response plan, the final step of preparedness is to take every opportunity possible to practice and drill.
•Before we get into these, we will start with a review of the history of emergency preparedness.
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•In a major emergency, public health often provides primary response, therefore must be prepared
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•Importance of close working relationship between public health organizations and hospitals
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•In summary, public health focuses on the health of populations, while medicine focuses on the care of individuals
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Of course I wish I didn’t have to mention September 11th, the attacks on the World Trade Center and the Pentagon.  Public health played a huge role here.  Yes, hospitals were prepared for victims, but really no victims came after the first few hours.  It wasn’t a matter of preparedness for mass medical care, so much as a matter of preparedness for mass psychological care, mass protection from environmental hazards – you can see here the dust cloud that covered most of Manhattan and Brooklyn.  It was a matter of preparing to provide longer-term care for the rescuers.  It was a matter of surveillance, which is a public health function, in order to try to figure out what was actually going on: were there rescuers at risk, were there hazards in the environment, was there a concurrent bioterrorist attack, for example.
*Instructors’ Note: For those teaching this course to a hospital-based audience, this is a good place to talk more about preparedness for hospital coordination, point out the need for hospitals to be closely tied in with public health departments for surveillance.  Also, point out the need for hospitals to have their own disaster plans to deal with issues related to the challenges of providing mass medical care.
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•Importance of close working relationship between public health organizations and hospitals
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•The key point is that all emergency response is local, therefore all preparedness must be local
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Some events require close cooperation between public health departments and hospitals.  For example, following the 9/11 attack on the World Trade Center, public health officials were prepared to ensure that there were medical personnel available to provide on-site assessment of the health risk, to treat people who were injured on-site: people caught in rubble, hand and foot injuries, eye injuries, respiratory ailments.  These are areas where the public health department may not have the personnel of expertise to provide the actual hands-on medical treatment.  Therefore, the public health departments need to have a preparedness plan to enable them to communicate with hospitals in the area should the need arise, to request assistance of this nature.  The federal government can handle this to an extent, but this doesn’t happen right away, so the preparedness plans at the local level must address these issues. 
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•Reiterate that all response is local
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•The investigation and control of epidemics is the responsibility of local public health officials
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•Approach to large scale emergencies such as bioterrorism is the same as the more routine response employed during any epidemic
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The investigation and control of ongoing epidemics and the prevention of future epidemics is up to public health officials.
Some examples of local emergencies include the Milwaukee cryptosporidium epidemic in 1993, where 40,000 people became ill following exposure to contaminated water.
The local public health response was key during the arsenic poisoning that occurred in Maine in April 2003.
These are all examples of emergency actions, though we may not think of them as such.  Yes, they disrupt routine, but the average public health officer does not think of response to cryptosporidium epidemic as an emergency in the same sense as a bioterrorist event.  Though epidemics such as this are more routine than a potential larger scale disaster such as a bioterrorist event, the overall public health approach to emergency response is the same.   
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•The first component of emergency preparedness is understanding roles and responsibilities
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• Know what you and your organization will be expected to do in the event of an emergency
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• Know who the other players are in your locale and what you can expect them to do in the event of an emergency
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•All response is local
•In the event of a large-scale emergency, the state may provide resources to the locale
•Eventually, the state may request assistance from the federal government
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•Federal assistance is available in specific areas and limited in other areas, so locales must be prepared
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Now it is important for anyone involved in emergency planning and response to know who does what.  The hierarchy shown here is the federal model and the model used by most of the states.  Any emergency starts off being under the local jurisdiction, such that it is up to officials in the city or town to run the show at least until things really get out of hand.  For example, take an epidemic in Portland, Maine, perhaps a foodborne outbreak originating at a restaurant.  This would be handled by the city’s department of public health, not at the state level, the same way a fire is responded to by the local fire department.
In the event of a large-scale emergency, the state may provide resources to the locality: money, staff, equipment, drugs.  Eventually, the federal government may come in, typically after several days, if invited by the state.
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•In this next section, the objective is to identify the agencies available in your locale that would be involved in response in the event of an emergency
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•Do you know the people in your neighborhood? Can you name representatives from these organizations?
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One of the best ways to handle this section for many groups is to ask people if they know who they would talk to in the event of a particular problem.  For example, ask hospital personnel if they know who to call if they see patients who appear to have smallpox.  Ask the public health officials if they know who is running their local hospitals.  Ask police and fire officials similar questions.
The point here is to go through the list, mention the various local agencies, tell people that they need to be working together on a regular basis, not just in the event of a large-scale emergency.  Forming relationships during non-emergency times will make communication and coordination much smoother in the event of an emergency. 
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There is a concept of mutual aid between fire departments, police departments, and EMS in neighboring communities.  That concept actually hasn’t been very well developed for hospitals.  For example, in Boston, MA there are four hospitals in the Longwood Medical Area: the Brigham and Women’s Hospital and the Beth Israel Deaconess Hospital which are both acute care general adult hospitals, Children’s Hospital, a pediatric acute care hospital, and Dana Farber Cancer Center.  All four now agree to help one another with supplies, personnel, and patient transfer in the event of a major disaster, but this wasn’t the case five years ago.  Prior to establishing this plan of mutual aid, one of those hospitals may have been overwhelmed, and the others may not even have been aware of the problem.  Hospital-to-hospital mutual aid must be arranged in advance – you cannot simply call someone up when disaster strikes and hope to get organized help.
Public health department mutual aid should be organized in a similar manner.  Unfortunately due to funding constraints in most jurisdictions, most public health departments are understaffed.  Smaller communities may just have one part-time person.  What if that person needs help?  Traditionally, the protocol has been for the local public health department to call the state health department, going up the chain, but there is no reason why one couldn’t start off calling neighboring jurisdictions and getting assistance from them, as this may be faster than calling a higher level of government.
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•Sometimes there are complicated and overlapping jurisdictions
•Roles of Washington D.C. Department of Public Health vs. federal government
•What went wrong?
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Often you can have very complicated and overlapping jurisdictions, which can complicate an emergency response.  A classic example of this sort of complication is the anthrax attacks which were mailed to TV stations in New York, newspapers in Florida and New York, and to the Senate office building in Washington D.C.  In Washington D.C., this was considered a local problem, the attack happened within the borders of the District, so theoretically it was the D.C. health department who had the legal authority to handle this.  However, the attack occurred on federal property, so naturally the federal government should get involved and use its resources to respond to the emergency.  As it turned out, the federal government had a single doctor assigned as the congressional health officer – there is no question that this was far too big of an emergency for one person to handle.  Though an attack against the federal government, the D.C. health department ended up having to step in to the response on behalf of the postal workers who were infected on federal property, because most tended to live in D.C.  They had the D.C. health department offered prophylaxis at one end of the hallway, and the feds at the other end telling people not to worry and essentially contradicting the advice of the public health officials. 
The moral is that if you do not plan in advance for such scenarios and have a working understanding of roles and responsibilities, the response can be very confusing, to say the least – as illustrated during the anthrax attacks. 
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•Once everyone knows each other and is ready to work together, what is the practical next step?
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•Establishing a comprehensive emergency response plan
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Now we’ve come to the slide titled, “Develop a Plan for Preparedness”  This is where you as the instructor really need to motivate the audience. They have just heard an introduction, and most likely now they are sitting there thinking, “oh no, it’s bad, I haven’t done any planning, it’s all so complicated, I can’t handle this.”  This slide is where you’re going to motivate the audience to go out after this talk and set up their local response plan, so your lecture needs to be shaded towards whatever group predominates in your audience.
If your audience is comprised of mostly public health personnel, their emergency preparedness effort will entail setting up protocols, actual detailed plans and procedures for emergency response in their city or town.  How will they issue a quarantine order?  Who will give advice to the police, fire, EMS, the mayor, the governor?  How will they communicate with the general public?  What information will they provide? What is their plan for conducting mass vaccination or mass administration of prophylaxis?  These are all public health questions, and it is the responsibility of local public health officials to have answers to these questions in advance, in the form of detailed protocols.
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•Importance of contact number staffed round-the-clock
•Get on local/state federal alert networks
•Be ready to answer questions – anticipate them in advance and have information prepared
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All communities need to have a round the clock contact number.  Police, fire, and EMS need to be functioning 24 hours a day.  If a call comes into the Public Safety Answering Point (PSAP), operators there need to be able to reach public health officials at any time.  If a white powder is reported at 3:30 in the morning on a Saturday, PSAP needs to be able to reach a public health representative immediately.  If a major train crash has just happened in town, PSAP needs to know who to notify at the local hospital so that the hospital can prepare for the mass influx of patients. 
First, know at all times who has the beeper, who is on call, make sure everyone who needs this information has it.
Second, you need to know what is going on. Be a part of whatever local, state, and federal alert networks exist.  Often times, police and fire departments are connected by radio.  Perhaps public health departments and hospitals should also have radios and know how to use them.  Telephones may fail, and radios may be required.  Additionally, local public health departments should be connected to the statewide electronic alert network.
Third, be prepared to provide information and answer the kind of questions that will inevitably arise.  People in your community are going to call, and they will want to know about chemical problems such as paint thinner in school, spills in laboratories, evacuation strategies.  What do we do about white powder in our jurisdiction?  What about mental health issues such as PTSD – do you have information for people, counselors to whom you can refer them?  You must anticipate these questions and have answers ready.
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•Here are some Maine-specific emergency contact telephone numbers, because knowing who to call and how to reach them is key to communication during an emergency.
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•This third step is more concrete – put together a plan for a mass point of dispensing.
•In the event of a bioterrorist attack, the biggest role public health will play is setting up vaccination or prophylaxis clinics for an entire city or town – you must have a plan for this.
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•Preparation for establishing Point of Dispensing
•Here’s a quiz for everyone in the audience: what is wrong with this picture?
•Answer: the person administering the vaccine is not wearing gloves!!!! Violation of the benchmark rule of public health!
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Certainly if you even get to the point where smallpox vaccination is required, an organized plan for a point of dispensing is required in advance.  The legal authority during a mass vaccination response generally rests at the local level, and is not under federal jurisdiction.  Communities need to decide where to administer vaccinations, who will staff these facilities, and establish a plan for carrying this out.
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•A part of planning for isolation and quarantine is evaluating whether personnel are prepared to work in situations where they have to wear personal protective equipment.
•Only people who know how to use such equipment should use it.
•Specific situations to consider include:
•operating a respirator
•the appropriate equipment required for treating patients or delivering food/supplies to people in isolation or quarantine
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•All response is local, but what if you need additional support?
•There are a number of federal agencies that can offer support in the event of an emergency
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•Support comes through the Federal Emergency Management Agency (FEMA)
•FEMA coordinates this support through the Federal Response Plan which involves 27 Federal agencies and the American Red Cross
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This slide depicts how needs identified by local governments are first supported by the State, and then by the Federal government.
Note that in the event of an emergency where federal support is required, the local public health department must contact the state governor to request that he or she contact the federal government to initiate the Federal Response Plan.
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•Federal health and medical resources are vast
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Typically, the feds will provide knowledge and identify experts.  They will be able to provide small numbers of medical personnel and field hospitals in the form of DMATs, or Disaster Medical Assistance Teams, under the National Disaster Medical System.  Urban search and rescue teams can be dispatched.  Sometimes the military gets involved, but this is not very common, as most of the military medical capabilities are already overstretched or overseas.  The point is, you will not get a large number of medical providers by asking for federal help, this remains on the shoulders of the local community.  As a result, local public health officials are faced with the challenge of determining where the personnel are going to come from to provide medical assistance in the event of an emergency.
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•A field hospital, set up by DMAT MA-1 at the World Trade Center
•Even fully deployed federal medical response cannot be counted upon to provide patient care for an entire city – it is a stopgap
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As an example of federal support, this slide shows a field hospital, set up by DMAT MA-1 at the World Trade Center. This is the DMAT team that would serve Maine in the event of emergency. This particular tent had 6 beds in it, and is equipped to handle many procedures including an appendectomy and cardiac resuscitation.  It was not used for these purposes on and after 9/11, but rather to treat ailments such as corneal abrasions, asthma, and hand and foot injuries.  While helpful, a field hospital of this size cannot handle a very large proportion of casualties in the event of a disaster.  Furthermore, there are only 26 DMAT field hospitals like this in the country – evidence that even fully deployed federal medical response cannot be counted upon to provide patient care for an entire city.  However, it’s a stopgap, and the federal government can bring in people with specific skills.  For example, on 9/11 burn nurses were in short supply, so the NDMS recruited burn nurses from across the country.
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•Under the International Emergency Management Assistance Memorandum of Understanding, Canada and the United States have a legal agreement of mutual aid.
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•Relevant in Maine due to the proximity to Canada
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It’s not just the U.S. federal government that can provide assistance.  Depending on where you live, and certainly in Maine this is relevant, Canada will provide disaster relief to communities in the U.S.  Under the International Emergency Management Assistance Memorandum of Understanding, Canada and the United States have a legal agreement of mutual aid.
There may be other nations that can assist in the event of an emergency, depending upon how grave it is.
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•We’ve covered the key elements of preparedness plans for public health, now let’s look at the elements of a hospital preparedness plan.
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If your audience is comprised of mostly hospital personnel, they need to know how to plan within their facility.  What is the plan for mass quarantine and isolation of patients?  How will they conduct evidence collection?  How will they communicate with the local political response structure?  How will they identify an outbreak, and how do they communicate the existence of an outbreak to the proper officials?  When the 15th patient of the night comes in with a bizarre rash and fever, does the hospital know who they’re supposed to notify of this?  Additionally, hospitals must be prepared to serve as the first line treatment during major events such as bombs or chemical weapon attacks.  How will they prepare for mass casualties?  Finally, from the hospital point of view, the main issue during events that involve mass prophylaxis and vaccination is taking care of their staff.  Staff are not going to come to work unless you offer them antibiotics for themselves and for their families, so a hospital needs to have a plan in place to do this.
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•Hospital security is a major issue
•Hospital can be targets, so entrances and ventilation systems must be secure
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•Now you Understand Roles and Responsibilities
•You are also prepared to Develop a Plan for Preparedness
•Next you need to Assess Resources – Staff, Supplies, Space – Once you develop your plan, you must identify and acquire the people, equipment, and other resources that will allow you to put this plan into action
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•Whether you’re with public health or hospitals, you are going to find that the biggest challenge in the event of an emergency will be finding staff. 
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•Redistribute staff among and between locales
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•Promote medical students to serve as medical personnel
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•Adapt the roles of dentists or veterinarians to utilize their medical expertise in a different setting than usual
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•Rejuvenate retired medical personnel 
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So what can you do?  One example is to have plans to redistribute staff from town to town. 
Another example is promotion – you could use medical students to serve as medical personnel, however you may run into regulatory issues so set up this plan ahead of time. 
Perhaps the best solution is adaptation - utilizing the vast pool of medical personnel who have applicable skills who may not normally be part of an emergency response.  For example, dentists and veterinarians have medical expertise, they can perform minor surgical procedures, administer drugs and anesthesia, prescribe medication – all legally.  Additionally, pharmacists may be trained to give vaccinations, paramedics could be used in hospital settings.
A final example is rejuvenation, using retired medical personnel who have left the workforce, so long as lapsed licenses do not cause regulatory problems.
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•Don’t forget that you have to take care of your workers
•Have plans for feeding your volunteers, beds, sanitation facilities, telephones so workers can keep in touch with their families
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At the WTC, for example, Verizon set up free telephone booths for all of the site workers to call their families.  Restaurants delivered food continuously.
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•Importance of planning for staff in the event of an emergency
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On 9/11, thousands of medical professionals showed up to offer support, and there was no quick way to verify people’s credentials.  Perhaps you could derive a system of pre-event credentialing, that would be marked by giving qualified people a sticker to put on their driver’s license.
A lot of work of this nature is occurring at the state level.  It’s valuable to talk to someone in your state to see what they’re doing for credentialing, liability, and workers’ compensation as they relate to emergency response.  People who are assisting will want to know about these issues, and it’s good to know what the practices are in your state. 
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•In the event of a large scale emergency, the converse situation of too many people wanting to be involved can also become problematic.
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Emergencies often stem convergent volunteerism, many people coming forward to help, most who do not have any training in the field of emergency response.  You must anticipate this and have plans to cope with convergent volunteerism, the plan could be as simple as not letting any volunteers assist, but then you forgo the possibility that there may be useful people in the group.
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•It is important to know what supplies you will need in the event of an emergency, and to keep detailed inventory
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•Locales must have their own stockpile of supplies
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Cities and towns need to have some stock of the drugs and equipment that will be needed immediately in the event of an emergency, such as MARK 1 kits.  As we’ve previously discussed, you can get anything you need from the federal government, but it usually takes a few days.  Therefore, local jurisdictions must have their own stockpile of supplies to bridge the time between the event and when federal relief will arrive. 
Maine experienced this during the arsenic epidemic.  The BAL used in treating arsenic poisoning came from the state cache.
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•The Strategic National Stockpile Program can provide any drug, equipment, or supply within a few days
•Locale/state must manage the inventory
•Response is not immediate, so locales must have their own stockpiles of such drugs and supplies
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However, when it comes to money, drugs, and other supplies, nothing beats the federal government.  The Strategic National Stockpile Program can provide any drug, equipment, or supply within a few days.  This requires the local/state government to manage the inventory – the feds will deliver the requested supplies by plane or truck, but they’re not going to disperse supplies throughout the area – that is of local responsibility.
Supplies such as antidotes can be obtained from the federal government as part of the Strategic National Stockpile Program.  While you may think, we can’t wait several days for the antidote to a nerve agent that is lethal within minutes, such supplies would be issued to replenish the stockpile you already have, further illustration of the fact that you must have a local stockpile of such drugs and supplies in place.
 
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•Space is a simpler consideration than staff and supplies, but a thorough preparedness plan requires that places where your Point of Dispensing or quarantine units will be held must be organized in advance
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•Every jurisdiction needs to have a plan for setting up a POD
•You need to know in advance where you’re going to set up this operation - typically schools or other public buildings are used.
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•Now you Understand Roles and Responsibilities, you are prepared to Develop a Plan for Preparedness, and you have Assessed Resources.
•The next step is to Communicate & Train – You have your plan, you have your resources. Now, everyone involved needs to know that they’re involved, and know exactly the way in which they will be expected to participate.
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Back to our plan – so we’ve set up our point of dispensing, figured out a reserve staffing plan.  Now, what’s next?  At this point, public health should think of itself as a training resource.  Public health departments should develop plans for training the local police and fire, and also training citizens.  Develop brochures, publish plans in the local newspaper.  Another way to prepare is to use routine scenarios such as a flu clinic as a drill for mobilizing your POD – use the same location, staff, and logistics.
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•Under SARA Title 3, every community is required to establish a local emergency planning committee to manage hazardous materials
•This is an ideal forum for planning for other emergencies
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Under a federal law called SARA Title 3, every community is required to establish a local emergency planning committee to manage hazardous materials.  This is a committee that is established within a city or town to monitor activities involving hazardous materials, and has representation from police, fire, hazmat teams, EMS, hospitals, industry, and citizens.  This group is also responsible for planning how to respond to potential incidents involving these hazardous materials, for example a crashed chlorine tank, a large fire in a tire factory.  Public health needs to be a critical component of these groups. 
This is a great forum for planning for other emergencies, as by federal law this group has to meet or the city or town will not receive highway funds.  All of the key players are in one place, and this is an ideal opportunity to get to know one another and review your community’s emergency response plan.
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•Now that you Understand Roles and Responsibilities, you are prepared to Develop a Plan for Preparedness, you have Assessed Resources, and you are prepared to communicate and train
•The next step is to Practice – Once everyone knows their roles and responsibilities specific to your emergency response plan, the final step of preparedness is to take every opportunity possible to practice and drill.
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•Review the 5 fundamental components of emergency preparedness – everyone should understand these
Narrative
Emergency preparedness can be broken down into 5 fundamental components, the 5 progressive steps you must take in order to be prepared. These 5 steps are the backbone for this presentation:
Understand Roles and Responsibilities – Know what you and your organization will be expected to do, know who the other players are and what you can expect them to do in the event of an emergency.
Develop a Plan for Preparedness – Emergency response does not just happen, you need to establish detailed plans and protocols to follow in the event of an emergency.
Assess Resources – Staff, Supplies, Space – Once you develop your plan, you must identify and acquire the people, equipment, and other resources that will allow you to put this plan into action.
Communicate & Train – You have your plan, you have your resources. Now, everyone involved needs to know that they’re involved, and know exactly the way in which they will be expected to participate.
Practice – Once everyone knows their roles and responsibilities specific to your emergency response plan, the final step of preparedness is to take every opportunity possible to practice and drill.