Mass-Casualty Exercise Design for EMS Agencies

Communities of all sizes require disaster planning, and exercises are a fundamental part of ensuring preparedness for emergencies. Over the past six years or so, the largest cities in the United States have received substantial amounts of anti-terrorism and disaster-preparedness funding through a variety of federal programs. These initiatives have, among other things, afforded certain jurisdictions the opportunity to receive exercise support from federal contractors, including expert assistance in developing and executing tailor-made exercises. These opportunities have allowed EMS agencies in these cities to assess personnel, procedural, equipment, supply and training needs, as well as to practice dealing with interagency operations and unfamiliar scenarios. For the many smaller jurisdictions that have not yet received federal support, valuable exercises can be designed and implemented using many of the same principles followed by the experts in this area. This article provides conceptual guidance for local EMS agencies regarding the design of effective mass-casualty exercises.

It is important to note that many federally supported exercises are required to involve weapons of mass destruction (WMD). However, even in a post-9/11 world, not every mass-casualty exercise needs to involve WMD. Any opportunity to stage an exercise dealing with large numbers of patients and/or hazardous materials increases an EMS agency's preparedness for hazards of all types, including those posed by potential terrorism. By the same token, a WMD exercise yields benefits in terms of preparation for garden-variety mass-casualty and hazmat incidents.

A realistic and challenging, but not overwhelming, scenario often proves the best course of action. Planners should avoid the standard bus accident drill and consider the unique possibilities within a community for disaster, including transportation hubs, industrial facilities, hospitals, nursing homes and schools.

Types of Exercises

A comprehensive exercise cycle usually involves four types of exercises: drills, tabletop exercises, functional exercises and full-scale exercises, each successively increasing in complexity and scope of activities.

1. A drill is conducted on the individual agency level, and allows for practice in one particular aspect of disaster response, such as triage, the use of a new piece of equipment or the setup of a treatment area.

2. A tabletop exercise allows responders to think through a paper scenario without actually practicing the response itself. The scenario may gradually unfold over a period of time, requiring participants to adapt their responses to a dynamic situation. While tabletop exercises can prove useful for an individual EMS agency, they are even more valuable when conducted community-wide. This allows members of various agencies to practice working together and coordinating their respective emergency operations plans.

3. A functional exercise involves a live response to a simulated emergency in real time, testing one specific function. These exercises are often used to test the operations of state and local emergency operations centers (EOCs) in coordinating emergency responses.

4. A full-scale exercise usually involves multiple agencies, real time, real equipment, real personnel, mock victims and other steps to create as much realism as possible. They aim to provide the closest possible simulation of an actual disaster and provide an excellent opportunity to assess many aspects of an EMS agency's and an overall community's respective preparedness. Full-scale exercises involve a great deal of planning and coordination, and some expense.

It is vitally important that appropriate training precede any type of exercise. The exercises should assess the efficacy of training programs and reveal unanticipated operational weaknesses.

Agencies should avoid overwhelming responders with prematurely complicated exercises. For example, an agency can begin by conducting separate drills on triage, the incident command system and equipment utilized in mass-casualty incidents. Next, it could conduct a tabletop exercise with other agencies to assess respective roles, responsibilities and needs in such an incident. Finally, the jurisdiction could hold a full-scale exercise to test the efficacy of the implemented solutions to issues identified in the drills and tabletop. Utilizing such a strategy helps agencies highlight and correct both major and minor issues early, allowing the more complex exercises to be better opportunities for evaluation, practice and fine-tuning.

The Exercise Planning Process

Whether an exercise involves a single agency or those of an entire community, its educational value and success hinges on appropriate participation and commitment of resources.

Planning an exercise necessarily requires input from representatives of all areas. If an EMS agency tabletop exercise involving a building collapse would include operations, special operations, communications and rescue divisions, then representatives from all these areas should drive the planning. For a community-wide exercise, especially a full-scale training event, representatives could include law enforcement, the fire service, EMS, hazmat, public health, hospitals, local and/or state emergency management, public works, National Guard and representatives of the exercise site.

Perhaps the most important step in exercise planning is the development of design objectives, which state what areas the exercise will attempt to assess. Determined by the planning team, these objectives propel the development of the scenario itself. While a full-scale exercise involving many agencies could have many objectives, it is best to limit the number to a few key objectives for any one exercise. Such objectives could involve triage, the tracking of patients, communications with hospitals, interagency coordination, staging, decontamination or any number of other possibilities. Analysis of past exercises or actual events often highlights areas worthy of further assessment. What an agency or community wishes to test will determine the scenario, including the location, context, number of victims and their injuries, agent used (if it's a hazmat or WMD scenario) and other challenges involved, such as simultaneous emergencies or road closures.

Details of the exercise, minus the particulars of the scenario itself, are set forth in an exercise plan. This plan contains information on the date, time and location of the exercise, participating agencies, logistical and safety issues, schedules, maps, radio frequencies and more. Information for the exercise staff, including the scenario elements, evaluation forms and activity log sheets, are often presented in another manual, which may be called a controller and evaluator handbook, control staff instructions or evaluation plan.

Control and Evaluation

Due to their intimate knowledge of the scenario, members of the planning group often form the core of the exercise staff. Aside from those responsible for logistical concerns, the exercise staff usually addresses two distinct but interdependent functions: control and evaluation.

In order for an exercise to fulfill its objectives, it must be delivered appropriately and proceed as planned. Managing the exercise scenario is the responsibility of controllers. While controllers should generally allow responders to address the scenario without interference, often input is needed to inject scenario elements, keep responder actions from undermining the value of the exercise and address safety hazards. Evaluators, on the other hand, attempt to be "invisible," capture observations about the response and maintain timelines of exercise activities. This documentation is invaluable for analysis in the after-action report.

It often works well to pair a member of a local agency with a subject-matter expert from another jurisdiction for the controller-evaluator team in each functional area. Such a pairing allows for both objective analysis and intimate knowledge of local standard operating procedures. Controllers in a tabletop exercise are often called facilitators, as they generally are responsible for leading discussion following scenario presentations by slide show or the equivalent. For any exercise, controllers and evaluators should participate in a briefing to orient them to their roles prior to the event itself.

The overall exercise is generally coordinated by an exercise director and/or senior controller, who takes responsibility for keeping time, interacting with the functional controllers and making global decisions about exercise conduct. It is important that a dedicated safety officer assist this person, just as he or she would assist an incident commander in any large-scale event.

Exercise Administration

The delivery of any type of exercise involves a number of special concerns related to administration and logistics. One concern is the response of vehicles to the site of an exercise involving actual responses. As running lights and sirens cannot be justified for a simulated emergency, vehicles must either respond from their home stations in nonemergency mode or respond from a staging or assembly area. The latter option often proves most effective, especially when units are held at that location from the time of dispatch for the duration of a pre-established "response time." Such an area also facilitates the pre-briefing of participants regarding exercise rules, artificialities and safety concerns.

Ambulance transport is another area of concern for a full-scale exercise. If an exercise will involve hospital play in addition to field play, either two sets of victims can be used or scene victims can be transported to the hospital. The former keeps more personnel at the exercise site to practice those activities, as victims pre-staged at the hospitals can be injected into play according to a timeline of "ambulance" arrivals.

Ambulances can also transport victims to a notional "hospital" elsewhere on the exercise site. This option better assesses the actual turnaround time of ambulances transporting patients.

One of the most complex logistical concerns, seen mostly in full-scale exercises, is the use of actors to play mock victims. The effective use of victims greatly enhances the realism of an exercise, especially if moulage is used and victims are well instructed on their roles. Victims can come from many sources, including schools, nursing and EMT programs, military bases, the American Red Cross, the Salvation Army, auxiliary groups and scouting organizations. It is best to present a variety of age groups reflective of the scenario, and incorporate special challenges such as elderly victims or victims with disabilities. To drive the responses of emergency personnel, victim injuries and vital signs can be conveyed using a combination of moulage and printed tags. However, it is important that responders understand that such tags may be consulted only following triage assessment of the patient. It often works well for the victim to hide a single-sided information tag and reveal information only when an EMS provider assesses for it.

Planners should also note that use of volunteer victims presents a liability concern for the sponsoring jurisdiction and ensure these individuals are covered by insurance policies should they be injured or killed in the exercise. "Victims" should generally sign a waiver of liability and exercise administrators should provide for their comfort and safety with dedicated victim controllers, food, water and restroom facilities. An appropriate number of actor controllers should be recruited to give direction to and ensure the safety of this group. The victims should be protected from any dangerous actions by responders and monitored for the effects of environmental conditions, such as extremes of heat or cold.

Safety is paramount in any type of exercise. Possible hazards should be anticipated ahead of time and addressed. For example, cold weather conditions warrant supplies of blankets to protect victims, while hot weather requires provision of water and sunscreen. Controllers should watch for, and correct, hazards throughout the exercise, such as patients carried on stretchers or backboards without straps. For any large exercise, a dedicated ambulance should stand by for actual emergencies at the exercise itself and a code word should be developed to indicate that such a problem is a real emergency and not part of the scenario.

Follow-Up Activities

Following any exercise, controllers, evaluators and key responders, such as agency leaders, should participate in a facilitated debriefing session. Here, observations can be shared and suggestions for improvement discussed. The exercise planning group should capture this information in an after-action report, to be shared with all those involved in the exercise. Such a report documents the exercise and determines follow-up actions to be taken by agencies in terms of training, revised procedures, equipment acquisitions or additional exercises. It is also important to complete any exercise documentation required by FEMA, state offices of emergency management or local agencies, in order that the community be recognized for engaging in appropriate exercises.

To be effective, an after-action report must be accepted as accurate by all stakeholders and contain appropriate, operationally workable and politically feasible recommendations to address those challenges identified in the exercise. The "sandwich" principle works well here, with appropriate credit being given for those areas of the response that went well and carefully chosen words discussing problems encountered. Following delivery, it becomes incumbent upon the administration of each participating agency to utilize the after-action report in determining strategies for improving its responses.

As an example, following an exercise involving an industrial accident, evaluators might identify a shortcoming in terms of an EMS agency's ability to manage contaminated patients. Thus, one of the items in the after-action report would be an objective description of this problem and a suggested solution:

Observation: Following their initial entry into the hot zone, hazmat personnel subsequently extricated approximately a dozen patients potentially contaminated by hydrogen fluoride to decon. Several patients required immediate intervention for life-threatening problems, including airway compromise and traumatic injuries. Springfield EMS provided excellent and appropriate advanced life support care to these individuals following their decontamination, but these interventions were delayed by the inability to deliver care in the decontamination corridor.

Recommendation: The EMS agency should consider cross-training a group of paramedics as hazardous-materials technicians and providing additional training in the clinical management of hazardous-materials exposures. Given appropriate personal protective equipment and other supplies, these individuals could provide lifesaving care, such as airway management, ventilation, trauma care and administration of antidotes to contaminated patients while they are undergoing decontamination.

Other key issues that an after-action report might address with this scenario could include the interface between EMS and the hazmat team, adequacy of medications and supply stockpiles, patient tracking and communication with hospitals. Concrete, workable recommendations prove most helpful, so long as the authors present them tactfully enough that they do not alienate the audience. Ideally, an after-action report becomes the blueprint for improvement in the agency or agencies involved in the exercise.

Conclusion

Mass-casualty exercises offer EMS agencies myriad opportunities to test their responses to large-scale incidents. Whether agency-specific or community-wide, a disaster exercise facilitates the assessment of plans, training and equipment. A well-designed and well-executed exercise allows an agency or community to train with uncommon scenarios and determine needs for increased preparedness. The after-action report following the exercise can present a plan for improvement, and follow-up exercises allow continued assessment and fine-tuning of policies, plans and procedures. The largest jurisdictions in the United States have benefited greatly from federally funded exercises, and smaller communities can also enjoy excellent results by employing similar techniques for exercise design and administration.

Bibliography

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