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Show noted during the TOPOFF exercise, "No one knew what a JIC (Joint Information Center), a JOC (Joint Operations Center), or DMORT (Disaster Mortuary Assistance Team) were." (Inglesby. Grossman & O'Toole, 2000) EOCs (Emergency Operation Centers) may be established at federal, state and local levels. These centers are structured to coordinate responses, but communication problems between EOCs and medical organizations will occur if appropriate procedures have not been developed before the event. Cell phones may be of assistance in communicating with responders, with other agencies, and within facilities, but systems have become overloaded during emergencies (Garrett, Ma-gruder & Molgaard, 2000). "HAM" radio systems have proven valuable in many disasters. Dedicated 800 MHz radios for on-scene or other medical communications can be helpful, but consideration should be given to making them secure. Otherwise, people and the media overhearing the communications may misinterpret reports and spread mis-information that could hamper response efforts and create panic. Those involved in making radio transmissions should be trained in basic radio discipline, so information to and from medical units or other responding agencies can be transmitted concisely and accurately. Hospitals may also consider incorporating the use of hand held radios or satellite phones to augment cell phones. This equipment may be particularly useful for all inpatient units, enabling the Command Center to more easily assess needs, available resources and better direct the hospital response. It is also important to recognize the need to have contact points for the media (CDC, 2000). Although a public information officer or media spokesperson may provide some information, media representatives typically will want to speak to health professionals when a major event with casualties or fatalities occurs. Designating one or more health professionals as media contact person(s) can help assure appropriate information is provided and aid in reducing interruptions of other providers. Providing basic training in media interviewing can be of significant help to the designated representative(s). Additionally, those in this role must be versed in the provisions of the Health Insurance Portability Account Act of 1996. This expertise will help prevent inadvertent compromise of the new patient confidentiality requirements. COORDINATION Health organizations will require assistance from multiple agencies when a disaster occurs. It is important that planners coordinate with these other agencies before an event occurs, and then include contact with the organizations during exercises (Moser, et al., 2001). If requirements have not been coordinated before the event necessary help may not be available. For example, calling the police department to assist in controlling a crowd of several hundred wanting decontamination will result in limited, if any, aid without prior coordination. A terrorism event adds additional concerns in that the FBI and police departments will be involved. Specific requirements, including chain of custody and obtaining the names and addresses of victims, will occur as part of the criminal investigation. Laboratory results of patients who have been exposed to chemical or biological agent may be valuable to the investigation or used as evidence. Hospitals must work with their local FBI constituents to develop a procedure for obtaining and relaying this information expediently, so the investigation is not delayed, but continue their ethical and legal responsibilities of protecting patient's rights. Establishing contacts with these groups before an event, and agreeing on procedures that will be followed, will help prevent prob- lems in the midst of responding to the emergency. Failing to coordinate effectively can lead to major difficulties, as illustrated by the reported disagreements between the New York City fire and police departments that are now being resolved (Baker, 2002). These disagreements over areas of responsibility were noted in the late 1990s and were still present as recently as December 2001 (Baker, 2002). Depending on the scope of activities of the organization, coordination may be required with such federal activities as the Strategic National Stockpile or the National Disaster Medical System. Since public heath agencies will play major roles in any disaster or terrorism situation, prior coordination between treatment facilities and public health organizations is essential. Signed agreements documenting expected support are preferable to verbal "understandings". Coordination is also necessary to meet the heavy logistical demands that an event will generate (Moser, et al., 2001). Re-supply of pharmaceuticals, general supplies (including beds, linens, gowns, masks, gloves, foot coverings, decontamination materials, and similar items), equipment (including respirators and personal protective equipment), and food and laundry services will be required. Ascertaining before the event what resup-plies are available locally will be particularly important since there may be delays in obtaining shipments from more distant locations. In addition to logistics, it is necessary to coordinate sources of assistance for additional staff and support personnel, especially if prolonged 24/7 activities are required. A number of cities have coordinated plans among all hospitals to provide support if one facility is overwhelmed. However, the experience in New York during 9/11 confirmed earlier observations that, in a disaster, patients tend to go the hospitals they know best (Miller, 2003). This response can result in severe overloading of a facility and require transport of individuals to other facilities. In addition to coordinating with health facilities to accept patients, it may be necessary to coordinate with non-health care facilities to accept stable "overflow" patients. Naturally, plans for command and control, communications, staffing and resup-ply of overflow facilities have to be coordinated in advance of sending patients to the off-site locations. Similarly, planning should consider alternate sites if it becomes necessary to evacuate the primary facility. Terrorism events may produce large numbers of "worried well" individuals who come to treatment facilities requesting evaluation, decontamination, prophylactic treatment, or treatment for symptoms that are attributed to an exposure even though no exposure actually occurred (Miller, 2003). During the 1995 sarin attack in Tokyo, there were 11 deaths, but over 5,000 individuals sought emergency medical evaluations. Of these, 74% had no identifiable clinical injury (Macintyre, Christopher, et. al. 2000). Identifying and separating individuals requiring only psychological support from those needing immediate medical attention will help optimize the triage process. PRACTICING PLANS An apparently well-constructed plan that delineates response plans may be useless unless it is practiced. Practice must be realistic, involve all who would be responsible for the multiple actions required, and be done frequently enough so that staff and support personnel know their responsibilities and how to accomplish them. "Table top" exercises, although useful, cannot replace regular, "real" field exercises as a means to acquaint those in health organization with their roles and responsibilities. Rare "down times" in an organization provide the opportunity for face-to-face meetings with representatives of the agencies 22 Utah's Health: An Annual Review Volume DC |