Ambulance Strike Teams

The systems we create before a disaster occurs will have a significant impact on our ability to respond to the disaster. Even small things left unprepared can develop into complex problems, which can unnecessarily consume a large amount of time during disasters. Careful planning and system construction will help prevent the emergence of these complex problems.

History
California's Emergency Medical Services Authority (EMSA) began efforts to create the framework for a structured ambulance response to disasters soon after its formation more than 20 years ago. Through the years, this need was reinforced on a number of occasions where management and support proved difficult due to the lack of an organized response within the framework of a unified system. When California suffered major flooding during the winter of 1997, the response by private ambulances was poorly organized and left some counties without enough resources to meet their day-to-day needs.1

After September 11, 2001, officials from Los Angeles County and American Medical Response (AMR) met to formulate a plan for an effective joint disaster response within Los Angeles County. They developed a strike team model similar to the one adopted by the state.2 AMR was able to test this model during the firestorms of 2003 in San Bernardino, Los Angeles and San Diego counties with a great deal of success. This success demonstrated that a coordinated response by private nonfire-based providers, within the framework of the Incident Command System (ICS), was possible. The strike teams were successful in evacuating hospitals and other medical facilities, backfilling cities where fire resources were all committed to the fires, and handling the surge of emergency calls surrounding the communities directly affected by the fires.

In 2002, EMSA confirmed that development of ambulance strike teams (ASTs) and medical task forces (MTFs) were a critical component of the state's ability to respond to disasters and homeland defense efforts. EMSA, the governor's Office of Emergency Services (OES), the California Fire Chiefs Association, the California Ambulance Association (CAA) and others worked together to develop guidelines for the use of ASTs and MTFs during disasters.

A committee of multidisciplinary industry professionals was formed under the guidance of EMSA. This Ambulance Strike Team/Medical Task Force Committee met frequently in Sacramento to produce a foundation of documents and create a framework of cooperation necessary to bring together the public and private sector emergency management teams in an unprecedented cohesive effort.

Concept of Operations
An AST is made up of self-supporting units of the same type and kind of resource, with common communication and a leader. These units are able to receive, triage and transport victims from the scene of a disaster. There are two possible complements of ambulance strike teams according to the EMSA plan. Type I-ALS strike teams consist of five ALS ambulances and one team leader with a vehicle. Type II-BLS strike teams consist of five BLS ambulances and one team leader with a vehicle.

A medical task force (MTF) is defined as a group of resources with common communications and a leader. An MTF may be sent to an incident or formed at an incident and can consist of a combination of resources. MTFs consisting of combined Type I-ALS and Type II-BLS strike teams and individual resources were utilized for hospital evacuations during the 2003 firestorms.

The use of strike teams makes resource management more effective by maximizing use of the resources, limiting the supervisors' span of control and simplifying communications. AST/MTF are utilized within the framework of the Standardized Emergency Management System (SEMS), using the Incident Command System (ICS) to provide the best response during a disaster.

A paramedic who responds to another EMS jurisdiction within the state of California receives reciprocity of accreditation. That is, he may operate under the scope of practice for the area in which he is accredited according to the policies of his accrediting local EMS agency. An EMT-B operating outside his local jurisdiction may operate under the state EMT-B scope of practice, as well as any expanded scope of practice skills his agency has authorized him to use.

Training
After the AST/MTF Committee completed its task of outlining the critical leadership position in spring 2004, a team of educators was recruited from the Allan Hancock College (AHC) EMS Training Program in Santa Maria, CA, to develop and launch three pilot courses for training AST/MTF leaders. This team consisted of AHC EMS instructors, AMR paramedic Michael McDonough, AHC EMS Program Coordinator Michael Messina and Fire Chief Carmon Johnson. Its members had backgrounds in both private and public sector EMS and years' worth of experience working in the areas of ICS, ambulance and fire service operations, as well as disaster management.

In an effort to immediately ground students in strike-team logic and style, the entire course was run as an ICS-based emergency incident utilizing a strike team, thus incorporating the strategies and job titles of ICS, complete with wearing orange strike-team leader vests. Upon arrival on the first day of class, each student was immediately assigned to a five-member "strike team," complete with a designated strike leader. All group exercises, including the hands-on final, were conducted within the scope of these assigned strike teams. Instructional staff members even factored into this concept, wearing vests and acting as ICS command staff and group leaders. This ICS classroom atmosphere fostered the concepts of both leadership and teamwork as students worked their way through scenario-based tasks, including a tabletop exercise.

After months of development, the first pilot AST/MTF Leader course was presented at the AHC South Campus in November 2004. Subsequent pilot courses in Sacramento and Riverside resulted in nearly 150 people completing the 16-hour trainee-level course. During the two-day course, the students were provided with a trainee manual, handouts, CD-ROM materials and the latest edition of the FIRESCOPE FOG manual. Included in their trainee manual was the AST/MTF Trainee Task Book, similar to those used to train fire department strike team leaders. Completion of this book while participating at various large-scale events, both real and simulated, results in certification as an AST/MTF leader in the state emergency response system.

Lessons learned from Katrina & Rita
California sent multiple ASTs and MTFs to the Gulf Coast in response to the hurricane crisis in 2005. Unfortunately, many of the team leaders reported that once they arrived in areas of operations, few people within the command structure overseeing the incident had even heard of the AST/MTF concept and were not clear on how to utilize them. There was plenty of work, but the lack of experience with the concept made it more difficult to integrate the teams operationally.

Strike teams were assigned non-traditional tasks such as body recovery and going door-to-door in some towns to check on residents and provide tetanus shots and food. The duty was hazardous and there was no communication between units.

This deployment demonstrated that while the AST/MTF concept is useful, it requires greater national awareness before being able to be successfully deployed. This also reinforces the need for communications and operational plans to be in place before the strike teams are even deployed.

Conclusion
September 11, 2001, changed the way this country responds to catastrophic emergencies--both man-made and natural. The truth of the matter is, the majority of ambulances in California, like many states, are found within the private sector--a part of EMS response not traditionally included within the ICS/strike team framework. Why not have these valuable resources respond within the control and mission of the Incident Command System?

Like any new program, the ambulance strike team concept has not been without its critics. Despite debate and discussion, it is the belief of the California EMSA, the California Ambulance Authority, AHC and others that not only is the ambulance strike team concept the right idea, it is a concept that is no longer just an option for effective EMS response to large-scale and catastrophic incidents in today's world. As a fire department participant in one of the first classes said, "What would you rather manage at your MCI: 50 ambulances or 10 strike teams?"

Michael McDonough, EMT-P, is employed by American Medical response, Santa Barbara County Operations, CA.

Michael V. Messina, EMT-P, is EMS program coordinator for Allan Hancock College, Santa Maria, CA.