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Wednesday, March 1, 2006

Improving The Next Response

John Croft

Johnny Delgado closed out last August with four of the most frustrating days of his career. As head of a "strike team" of five emergency medical services (EMS) helicopters based in Florida, Delgado and 50 other volunteers to support those helicopters--pilots, nurses, medics, mechanics-- were prepped and ready to fly within 24 hr. to the Mississippi Delta to rescue victims of Hurricane Katrina, which had just hammered the coast. All he needed was a green light from the federal government.

His frustration grew in parallel with the mounting number of emails he received from hospitals in the storm's path asking for help evacuating patients. A program director for Baptist Health Air Transport in Miami at the time, he received close to 400 such requests during the wait. "The first two days, they were flying fast and furious," Delgado said. "Most air transport services are made up of nurses and paramedics--people of action. You've got a dollar waiting on a dime when stuff like that happens."

Meanwhile in Lafayette, La., 120 mi. west of New Orleans, Mike Sonnier may have been looking for the kind of expertise Delgado was offering. As air services coordinator for Acadian Ambulance, an air/ground medical transport provider in southwest Louisiana, Sonnier and 45 employees were working 18-hr. days ramping up the civilian helicopter response for the entire state of Louisiana. Acadian had been selected to manage the job by the Federal Emergency Management Agency (FEMA) the morning the storm hit--Aug. 29. Sonnier said he got offers for helicopter support "from all over," but he had never heard of the Florida strike teams.

That communications chasm highlights much that went right and much that went wrong in the confusing hours and days that followed a storm landfall that could have an overall, multi-state economic impact topping $100 billion. On the positive side, the rotorcraft response again displayed the resilience and ingenuity mustered by the aviation community, both civilian and military, in the aftermath of a disaster. On the negative side, the overall response was ad hoc.

"Coordination was slow, or didn't occur at all, in terms of additional available assets that could have been brought into the area," said Matt Zuccaro, president of the Helicopter Assn. International. "It's not a matter of saying someone's at fault," he added, allowing that the sheer magnitude of the destruction almost put the event in a first-time response category, like Sept. 11. Regardless, Zuccaro said "we need to make to make sure we're prepared and have a response ready."

Rhett Flater, executive director of the American Helicopter Society International, said the Katrina response made it clear helicopters must be integrated into regional and national disaster planning well-before those plans are needed. "In the U.S., if there's a need for helicopters, it's done on a very local basis," he said. While he agreed that the civil and military sectors are quick to step up to help, he said, "Helicopters from public and private sources, working a particular problem ad hoc are not as effective as they would be with an overall planning strategy." He cited Japan's national emergency response plans, which include helicopters and even landing sites on Tokyo's tallest buildings, as a possible model for the U.S.

A look at the actions of Delgado and Sonnier during those four fateful days in late August does much to explain the points that Zuccaro and Flater are emphasizing.

As "primary provider" of helicopter and ground transport services in southwest Louisiana, Acadian was the go-to service for hospitals needing to move or evacuate patients. Under previously prepared plans, Sonnier said, it began pre-evacuation efforts two days before the hurricane hit. The move was not at all unusual; the company said it generally sees at least one significant evacuation per hurricane season.

Starting Aug. 27, Sonnier said, Acadian went into New Orleans and transported more than a dozen patients on ventilators out of the area. He said the plans were developed by each hospital and are not part of a statewide plan. When and if the patient transfer volume becomes too high, Acadian would call the state's Emergency Operations Center (EOC) in Baton Rouge to ask for more help.

The night before the storm hit, Sonnier received a phone call from an FAA contracts officer in Texas, giving Acadian a contract in advance for transport services. Acadian has a fleet of seven EMS helicopters. FEMA had asked the FAA to assist in gathering transport assets that might be needed to evacuate hospitals and shelters after the storm. Within hours, Acadian's role was greatly expanded, however. The morning the hurricane hit, Sonnier said, the state EOC--in discussions with the FAA--offered Acadian the job of coordinating the entire civilian response. Sonnier said reimbursement for responders would be covered by the FAA contract; more would be available if Acadian needed it.

Finding help was not difficult. "We got requests that came in to our communications center from all over," Sonnier said. The closer the operator, the more likely their services would be needed. Of those who called to help, he said, there was never any mention from them of getting reimbursed.

One offerer was Air Logistics, based nearby in New Iberia. Its president, Mike Suldo, said he called Errol Babineaux, vice president of aviation services for Acadian, directly. "I told Errol, `I'll send you helicopters every morning,'" he said. "'Use them how you need them. Don't worry about the money.'" Babineaux is the brother of Louisiana Governor Kathleen Babineaux Blanco.

"Things weren't coordinated at all at the federal level," said Suldo. "At the state level, they didn't have a plan except to turn it over to Errol."

Suldo said Air Logistics provided two or three helicopters every day for about 10 days. The company was later reimbursed. He said there were initially some concerns within management about liability, but it turned out the company's insurance policy covered such events.

By the second day after Katrina's landfall, Sonnier said, he was managing about 30 helicopters, all operating under Part 135. About that time, Acadian heard word-of-mouth that military responders had set up a landing pad, operations center and fuel depot near the Superdome, amassing hundreds of helicopters by the fourth day. Since most of the military aircraft were getting assignments from that location, Sonnier said, Acadian gave one of its coordinators a satellite phone and placed him in the military operations center to better coordinate the civilian side with the military. Acadian's main ops center was in Lafayette. "People were able to reach us there because the phones worked there," he added.

Ground communications in general were problematic. Sonnier said landline phones were busy for hours on end, though cell phones seemed to work, particularly those with text-messaging options. Satellite phones worked well once microwave relay stations were set up. In the air, communications were not a problem, thanks to AWACS aircraft brought in by the military after FAA air traffic control services went down, said Sonnier.

Of the civilian aircraft that participated, Sonnier said 95 percent were VFR-equipped and a few had night-vision goggle (NVG) capabilities. Despite the collision dangers of navigating around the powerless city at night and avoiding NVG-equipped military aircraft flying lights-out, Sonnier said, all the civilian operators flew the first two nights. "By the second night, they realized it wasn't safe to do it at night," he said.

In hindsight, Sonnier said, the response was appropriate based on the smaller scale of past events. Pre-Katrina, helicopters had primarily been used after the storm to evacuate workers hurt during the cleanup and recovery effort, since hospitals would maintain operations using backup power and stored supplies. Based on what happened with Katrina, he expects hospitals will move everyone out much earlier. "We hope there will be a plan to coordinate all that," he said. "Each individual facility has a plan, but it's not clear at what point it is activated and who gets evacuated."

For Florida, Hurricane Andrew in August 1992 was the wakeup call. Seven years later, with the help of Delgado, then president of the Florida Air Medical Assn., the state developed and implemented an integrated emergency response plan that included ground and air assets. The air medical plan includes five "strike teams," each with five aircraft, any of which must be ready to launch within 24 hr. of activation. Florida's plan has a pre-event phase in which aircraft are used to move the "sickest of the sick" from hospitals and a post-event phase in which helicopters assist in urban search and rescue and disaster medical assistance.

Delgado said the state budgets money for responders on a yearly basis in advance, asking providers to submit operating costs per day with and without fuel. (The state or federal government sometimes pre-positions fuel.) He said "most" EMS providers want to participate and operators carry their own insurance.

Delgado said strike teams have been launched about 15 times since 1999, and the largest deployment saw two teams activated following Hurricane Frances in September 2004. What's also good about Florida's plan, he said, is that hospitals know in advance to coordinate requests through the state or local EOC rather than directly to the providers they typically work with. That reduces the kind of communications melee seen after Katrina. "In Florida, we all know the first point of contract is your local EOC," said Delgado, adding that one of the 20 emergency support functions in every EOC is a health and medical coordinator, who handles hospital requests.

For such a system to work, the EOC must respond, however. Following Katrina, Delgado said hospitals had a difficult time getting any response from federally-controlled EOCs in Louisiana. Unlike Florida, Louisiana cedes control of emergency situations to Washington when a federal state of emergency is declared.

Government control appears to be at the root of Delgado's frustrating four days of waiting to launch. He said Mississippi had asked Florida directly for help, but government officials in the EOC maintained that only government agencies could respond. "We waited it out for four days, and finally said, `That's enough,'" he added.

Moving forward, Delgado and others see Florida's model as an excellent place to start if the government decides to craft a better National Response Plan. Delgado said he presented the Florida plan to congressional leaders in October and lawmakers were impressed with the "non-complexity" of it--the document is only 25 pages in length.

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