The Metropolitan Medical Response System

Oct. 3, 2008
The system, which serves 127 of the largest jurisdictions in the country, is built upon a template that can be adjusted to fit large and small communities.

The Metropolitan Medical Response System (MMRS) traces its origin to the Metropolitan Medical Strike Team (MMST) concept created by the Washington D.C. Metropolitan Area in 1995. The MMST was a joint effort by Washington D.C., Arlington County in Virginia and Prince George's and Montgomery Counties in Maryland.

The MMST was primarily a glorified hazardous materials team designed to respond to a terrorist event involving weapons of mass destruction. Based on the success of the MMST, a similar team was formed in order to defend against a possible terrorist attack at the 1996 Summer Olympics in Atlanta.

The MMRS was created in 1996 primarily in response to the Alfred P. Murrah Federal Building bombing in Oklahoma City and the Sarin gas attack in Tokyo, both of which occurred in 1995. Also playing a part in the decision was the first attack on the World Trade Center in 1993. A series of Congressional actions in the late 1990's laid the groundwork for the MMRS as it is known today. The original authorization for the program came from Public Law 104-201, National Defense Authorization Act for Fiscal Year 1997.

Funding the System
The Secretary of Defense was mandated to enhance the capabilities of the nation's first responders and to support improvements to their programs by the Defense Against Weapons of Mass Destruction Act of 1996. The Nunn-Lugar-Domenici Amendment to the National Defense Authorization Act for Fiscal Year 1997 authorized funding for "medical strike teams". These medical strike teams evolved into the current MMRS program. There are currently 127 MMRS jurisdictions across the country. The program is funded by Congress every year with current funding of approximately $30 million. This has been reduced from the initial allocation of $50 million.

Funds for the MMRS are distributed through the states where they are located. DHS allows up to 5 percent of the total allocation to be used for management and administrative needs. DHS also encourages the individual states to pass the entire allocation to the MMRS, but the state may retain up to 20 percent of the allocation in order to fund strategy assessments and capability integration projects between the state and the MMRS.

The Meat of the Team
The First Responder community is generally thought to consist of fire, law enforcement and emergency medical services (EMS) personnel. The MMRS takes these traditional first responders and adds a public health and hazardous materials component in taking an all hazards approach to mitigating a large scale incident. While the MMRS was initially designed to counter a terrorist event, it can also deal with any large scale mass casualty event such as a natural disaster or a large scale building collapse.

The system currently covers 127 of the largest jurisdictions in the country, leaving many jurisdictions at risk. The template can be adjusted to fit large and small communities. In fact, the MMRS was not designed to be a one size fits all solution. Individual jurisdictions are actively encouraged to tailor it to their individual needs in order to make it more effective. Regionalization is also encouraged. The MMRS is designed for high population areas. This does not necessarily mean large cities only. Several areas throughout the country have a MMRS based on a region as opposed to a single jurisdictional entity.

Federal disaster planning suggests that all jurisdictions be prepared to be self sufficient for 48 to 72 hours after an event occurs, be it a terrorist attack or a natural disaster. While federal assets will be on the way as soon as they are requested, it will take time for federal teams to marshal their staffing and resources and deploy to the incident site. While the response to Hurricane Katrina immediately comes to mind, even events that saw federal response teams on the ground quickly (Murrah Federal Building, September 11 attacks, etc.) took at best several hours to arrive on scene. The MMRS is designed to assist local agencies with mitigating the incident prior to the arrival of federal assets.

The current organization of the system makes it more than just a glorified hazardous materials team. It is a multi-discipline response force designed to take an all hazards approach to hazard mitigation as opposed to the more traditional fire/police/EMS model. The MMRS includes an integrated medical response system. This includes not only governmental EMS providers, but private EMS providers as well. The additional units owned by private ambulance companies will be needed to handle the surge in patients that a terrorist attack or natural disaster will entail. The integrated response model also includes public health departments and hospitals as well.

General George Patton once said that plans are only good until the first shot is fired in combat. While this may be true, adequate planning must be done in order to anticipate how an incident will develop and what resources will be required to mitigate it. The MMRS includes detailed systemic and operational plans. In a large scale incident, many of these resources will come from other jurisdictions, including those at the state and federal levels. Failure to plan beforehand will lead to a delay in the request and arrival of these much needed resources after the incident occurs.

The MMRS trains responders at all levels. Prior to the events of September 11, fire departments handled fires and hazardous materials. EMS providers dealt with sick and injured patients and law enforcement dealt with crime and the "bad guys". Cross training is a much needed commodity in the current threat environment that the MMRS operates under.

Police and EMS personnel are receiving training in chemically protective clothing and respiratory protection. Fire and law enforcement personnel are learning more about the signs and symptoms of a chemical/biological attack and how to deliver chemical antidotes, such as the Mark I kit. Fire and EMS personnel are gaining access to much needed intelligence about what to look for regarding suspicious persons, bomb-making materials and more. All of this cross training can be coordinated through the local MMRS.

MMRS Has Provided New Equipment
Specialized response equipment is also provided by the MMRS. Before September 11, many hazardous materials teams did not carry any weapons of mass destruction (WMD) related equipment and those that did utilized surplus military equipment. For example, the Greensboro, NC, Fire Department's (GFD) Hazmat team's WMD capability consisted of only M8 Paper, M9 Tape and M246 kits. Thanks to MMRS funding, not only has the GFD Hazmat Team received more sophisticated detection equipment, but every piece of apparatus in the fleet carries a Canberra Ultra Radiac Radiation Meter. Without MMRS funding, this would not have been possible. MMRS funding has also purchased the same monitors for Guilford County, NC, EMS transport units and chemical protective clothing for the Greensboro Police Department's Special Response Team and Explosive Ordnance Disposal Team.

Specialized medical equipment and pharmaceutical caches are a major component of the MMRS as one would gather from its name. There is no requirement for what the specialized medical equipment is to be, as long as it comes from a rather extensive list of approved items. This gives each jurisdiction the latitude to plan for individual needs as opposed to having preconceived needs thrust upon it. Medical equipment may be tailored towards a WMD terrorist event or a natural disaster. In most cases, it is a combination of both for a multi-use, all-hazards approach.

For example, mass decontamination tents may be used for the decontamination of victims of a chemical weapons attack or for short-term sheltering of displaced people due to a natural disaster. The pharmaceutical caches are tailored more towards a chemical or biological attack. The drugs may be stored in a readily accessible location for ease of security and distribution or distributed throughout the jurisdiction. In Guilford County all EMS units carry enough Mark I kits to treat 30 people. In the Greensboro Fire Department, each piece of apparatus carries enough Mark I kits to treat the entire crew assigned to the unit.

Planning for Increased Medical Needs
Any mass casualty event, be it a natural disaster or a terrorist attack, will strain the transport and treatment capabilities of any jurisdiction. While MMRS funding cannot be used for the purchase of transport units, it can be used for planning activities on a regional basis. No jurisdiction maintains a spare fleet of transport units waiting to be used for a mass casualty incident.

Mutual aid from surrounding jurisdictions will be necessary in order to provide the additional units to transport the hundreds or thousands of victims that may be present. The only way to line up these resources ahead of time is to plan. The planning process may include meetings, conference calls, table-top exercises, full-scale functional exercises and legal documents such as memoranda of agreement or understanding.

Treatment capabilities of the jurisdiction are also addressed. Treatment includes that provided by first responders in addition to that provided by hospitals. The planning process can help to identify not only the treatment needs, but also the training necessary to provide the treatment. Doctors, nurses and paramedics are well versed in dealing with cardiac events, diabetic emergencies and routine traumas resulting from accidents because they occur on a daily basis. How many of the aforementioned personnel have experience in dealing with the management of chemical/biological casualties? Unless they have previous military experience or have attended training courses sponsored by the military, Department of Justice or Department of Homeland Security, the answer is probably very few. The MMRS addresses this concern by providing the tools and funding necessary to enhance the treatment capabilities of the jurisdiction.

Twelve capability focus areas are identified as missions of the MMRS and are divided among the many disciplines present in the planning process. The surge capacity of local hospitals is sometimes addressed by the media during particularly bad flu seasons. Surge capacity will become critical after a natural disaster or terrorist event. The surge encompasses not only the strain placed on transport units, but the lack of hospital beds available for the victims requiring treatment. Strengthening the medical surge involves the planning for additional transport units, activating federal assets such as mobile hospitals and planning for transport of victims to hospitals outside of the original impact area.

Strengthening mass prophylaxis ensures that the jurisdiction has access to the drugs necessary to treat infected persons or to vaccinate a large segment of the population should such action become necessary. The local pharmaceutical cache is considered to be a supplement to the national stockpile as opposed to being a replacement for it. The cache can be used for the general population or for first responders. Responders may be treated first due to their mission critical nature.

WMD detection, response and decontamination capabilities enhance the capabilities of all disciplines within the MMRS. In order to determine treatment modalities, health care professionals must know what the victims have been exposed to. Advances in technology give this capability to first responders in ways that were not available to them just 10 years ago. Local hazmat teams can detect a wide range of chemical warfare agents and some biological agents with a good probability of success. Response capabilities are enhanced not only by increased detection abilities, but also through increased availability of chemical protective equipment and training where first responders can actually attend courses where scenarios involve such chemical agents as VX and Sarin.

Hazardous materials teams have been concerned about decontamination since the first entry teams began going down range with the inception of fire department hazmat teams in the 1970's. The Sarin gas attack in Tokyo demonstrated a need for mass decontamination needs. Hazmat teams have been prepared to decontaminate their own personnel and possibly a few victims, but not a large number of casualties. This capability belonged to the military. After the Tokyo attack, hazmat teams began looking at the means to effectively decontaminate large numbers of ambulatory and non-ambulatory patients. MMRS decontamination capabilities include specially designed decontamination trailers, tents and showers. Local jurisdictions are free to devise their own mass decontamination strategies as opposed to having to comply with a mandatory federal template.

Communications and Interoperability
Interoperability between agencies is imperative during the response to a terrorist event or natural disaster. There are several means that the MMRS utilizes to accomplish this goal. Communications was, is and always will be a concern on incidents where agencies from multiple jurisdictions are operating. This problem can be solved in a number of ways. Plain talk and the elimination of 10 codes ensure that everyone understands what is being said. Planning also ensures that radios are compatible with each other or the necessary patches can be made through the communication centers.

Information sharing is an area that has been getting more attention. Fire and EMS agencies must have access to information being collected by law enforcement and intelligence agencies. Joint Information Centers and Joint Operations Centers, as mandated by the National Incident Management System (NIMS), address this issue.

Regionalization not only allows for better allocation of resources but also increases interoperability as well. Regionalization has allowed smaller jurisdictions to join together and qualify for the same MMRS funding that larger jurisdictions, such as New York and Los Angeles, have access to. Regionalization is a win-win situation for all jurisdictions involved. Interoperability is immediately enhanced as soon as the jurisdictions agree to enter into the MMRS agreement. The planning has already begun as soon as the agreement is signed. As long as egos and inter-discipline rivalries can be left at the door, interoperability can only get better.

All paramedics and EMT's receive training in pre-hospital treatment and triage when they receive their initial training. This training falls short in dealing with a true mass casualty event because it generally deals with major auto accidents dealing with 10 to 20 patients. MMRS brings training to the jurisdictions that deal with triaging hundreds of patients at once. By learning how to deal with this surge in patients, pre-hospital treatment immediately improves.

Jurisdictions along the East and Gulf Coasts of the United States are familiar with evacuations and sheltering evacuees due to hurricanes. (Hurricane Katrina is considered an anomaly here.) In other jurisdictions, the Red Cross is routinely relied upon to handle shelters set up to handle evacuees from fires and smaller natural disasters such as tornadoes. The MMRS takes this a step farther by training and planning for sheltering thousands of evacuees instead of just a few hundred.

The collapse of the World Trade Center and Hurricane Katrina demonstrated the best and the worst that mankind has to offer. Initial reports late on the night of September 11, 2001 indicated that there may have been as many as 12,000 fatalities. Luckily, this dropped to less than 3,000. While the military has had experience in dealing with that many casualties in one day, it hasn't happened since World War II. First responders have never had to deal with a number even remotely that large. Even the Murrah Federal Building bombing resulted in fewer fatalities than some plane crashes. Fatality management is an unfortunate occurrence that must be planned for. Morgues will be overrun, resulting in the need for temporary morgues and additional medical examiners being brought in from other jurisdictions. The MMRS addresses this through the extensive planning process.

Resource Tracking
Americans traditionally will give until it hurts. Donations poured into New York and the FDNY in the days and weeks following September 11, even though they were unsolicited. FDNY firehouses were filled to overflowing with clothing, boots, food, etc. The same was true after Hurricane Katrina. These donations must be managed properly or they will create a burden on an already overwhelmed jurisdiction. Not only must donations of money and material be managed, but individuals seeking to donate their time must be carefully managed and screened as well.

Firefighters flocked to New York to help soon after the Twin Towers collapsed. This created accountability problems for incident commanders because they could not account for all of the additional personnel streaming into Ground Zero. Volunteers would start searching an area that had already been either deemed unsafe or searched already. While their help may be needed, there must be a system for tracking volunteers and verifying that they are who they say they are and that they have the necessary training in order to accomplish the task that they have been given. The MMRS provides the model for how to accomplish this.

The MMRS is definitely a good example of taxpayers' dollars at work. The program has provided millions of dollars to local jurisdictions for the purchase of material and equipment and to provide monetary resources to facilitate the intensive planning process required to bring the objectives of the program into fruition. If not for the MMRS, local jurisdictions would have had to find the funding locally to purchase the much needed equipment. In these difficult economic times, this would be next to impossible. Jurisdictions would have to increase taxes to raise the revenue or cut funding in other areas in order to provide what the MMRS has. The other alternative would be to do without. Given the climate that first responders operate in today, this alternative simply is not feasible.

The program is not without its problems however. Like all government programs, it must be funded on a yearly basis. Funding has been cut by $20 million per year since its original allotments. This trend cannot continue. As federal programs are cut and more responsibility is transferred to the states, the states must take on the added fiscal burden of financing these programs. This leaves even less money for additional funding for responders. Something as simple at increasing fuel costs are impacting budgets nationwide. Budgets are certainly not increasing to handle the extra fuel costs, so the money must come from somewhere. It is imperative that the MMRS funding not be cut. It must be increased.

Like other federal grant programs, the MMRS has certain restrictions that tend to hamstring the jurisdictions receiving the money. MMRS funding will purchase all sorts of necessary equipment for first responders. This equipment must be stored somewhere. In some cases, the pharmaceuticals must be stored where the climate can be controlled. MMRS funding cannot be used to purchase buildings or for lease payments in order to store the necessary equipment. MMRS funding can also not be used for the purchase of apparatus to deliver the equipment to the incident scene. Apparatus purchase prices can make up a significant portion of a departments capital budget. It seems a bit unfair to provide millions of dollars in equipment to a jurisdiction, but force the jurisdiction to spend hundreds of thousands of dollars in order to purchase trucks and/or trailers to transport the equipment.

In short, the MMRS has gone a long way in preparing local jurisdictions to respond to a terrorist event or natural disaster and to be self-sufficient for the first 48 to 72 hours prior to arrival of the massive influx of federal assets.

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MARK SCHMITT, a Contributing Editor, is a firefighter with the Greensboro, NC, Fire Department and serves on their hazmat team. A 16-year veteran of the fire service, Mark started with the Rivera Beach, MD, Volunteer Fire Company and holds an Associate of Arts Degree in Fire Protection Technology from Guilford Technical Community College and a Bachelor of Science Degree in Fire Safety Engineering Technology from the University of North Carolina at Charlotte. Mark is a member of North Carolina's Hazardous Materials Regional Response Team 5 (RRT 5) and in an instructor in various topics related to hazmat and fire service operations. To read Mark's complete biography and view his archived articles, click here.

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