Presented to 35 th IFPA - Fletcher Conference DoD Medical Support to Civil Authorities UNCLASSIFIED Lloyd E. Dodd, Brig Gen Command Surgeon NORAD-USNORTHCOM

Presented to 35th IFPA - Fletcher Conference

DoD Medical Support to Civil Authorities

UNCLASSIFIED

Lloyd E. Dodd, Brig GenCommand SurgeonNORAD-USNORTHCOMPeterson AFB, CO 80914

29 Oct 04

[[email protected]](719) 554-8153 (DSN 692-Fax -7227

2

Overview

• DoD’s role and USNORTHCOM mission

• A bit about the N-NC SG’s office

• Medical concept of operations (CONOPS) and guiding principles for DoD support

• Way ahead

3

DoD Areas of Responsibility

4

USNORTHCOM’s MissionUSNORTHCOM’s Mission

• Conduct operations to deter, prevent, and defeat threats and aggression aimed at the United States, its territories, and interests within the assigned area of responsibility; and,

• As directed by the President or Secretary of Defense, provide military assistance to civil authorities including consequence management operations

Deter…Prevent…Defeat…Mitigate

5

Commander’s Intent

• There is no difference between war and peace in this AOR…we are at war every day

• We must continue to improve the system every day…lives depend on it– Failure to advance the ball is not an option

• A key to success is building relationships

Gen Eberhart, May 03 USNORTHCOMIOC: 1 Oct 02

FOC: 11 Sep 03

6

Role of Medics…Our PD

• Advise NORAD-USNORTHCOM CC and staff on all medical issues…with broad interpretation of “medical”

• Anticipate, as much as possible, threats of disasters, natural or otherwise

• Forge plans and relationships before the event– Understand and provide key support to components– SG role in the deter, prevent, defeat phase– Pre-event consequence management planning

• Coordinating DoD medical response during and after event as requested by local, state, and other federal agencies

– Within DoD and across all agency boundaries– Full range of consequence management

• Attend to the health and welfare of the people in the commands• Make the system better every day

7

Vision

Preserve and protect the health of the force, their families, and the communities we serve.

8

NC Principles (HD/HS)• Policy from Pentagon; doctrine, CONOPs, planning at NC• In civil support role: local state PFA DoD…usually• DoD (NC) only participates when requested…

– And authorized, including Immediate Response, EXORDs, (?) CIRS– DoD flies wing to the Primary Federal Agency ( formerly LFA)

• Layered, tiered, flexible response• Sometimes we move beds; sometimes we move patients• Regionalizaton approach to multiple/pandemic events• Should emphasize DoD’s natural roles, skills and structures• Cannot purchase resources that do not directly support our primary

warfighting mission• Pre-event planning and relationship building are required

USNORTHCOM must maintain significant situational awareness, & be able to mobilize a wide spectrum of rapid

responses.

9

Cap

ab

ilit

ies

and

Res

ou

rces

Lo

wH

igh

Layered Response Concept

Metropolitan Medical Response Systems

State Response

Local Response, Municipal and County

Minimal Low Medium High Severe

Categories of Escalating Health Threats

Regional Response

National Response

10

Cap

ab

ilit

ies

and

Res

ou

rces

Lo

wH

igh

How DoD Fits In


State Response


Time

Regional Response

National Response

“Normal” DoD Response

4-6 Days

11

Cap

ab

ilit

ies

and

Res

ou

rces

Lo

wH

igh

How DoD Fits In


State Response


Time

Immediate Response Authorities

Hours

Regional Response

National Response


4-6 Days

12

Cap

ab

ilit

ies

and

Res

ou

rces

Lo

wH

igh

How DoD Fits In


State Response


Time


Hours

Regional Response

National Response

Standing EXORD(s)


4-6 Days

13

Cap

ab

ilit

ies

and

Res

ou

rces

Lo

wH

igh

How DoD Fits In


State Response


Time


Catastrophic Incident Response Supplement

Hours Hours-1 Day

Regional Response

National Response

Standing EXORD(s)


4-6 Days

14

Cap

ab

ilit

ies

and

Res

ou

rces

Lo

wH

igh

How DoD Fits In


State Response


Friendly Forces

Immediate Response Authorities“Normal” DoD Response

GuardSAD, Title 32 SAD, Title 32 SAD, Titles 32, 10

Regional Response

National Response

Standing EXORD(s)

Catastrophic Incident Response Supplement

15

Types of DoD AssistanceSubject matter experts

Physicians, nurses, med techsLab and lab personnel

Respiratory and other techsBeds…facilities

EquipmentBlood and pharmaceuticals

Public health teamsVaccination/med distribution teams

Patient movementManpower

Single expert to 10s of thousands of troops and more, but…

16

Limitations to DoD Support• Resource competitive environment• Often takes time…maybe days (or worse)

– Today, still evolving internal DoD Cold War structures and processes

• Public perceptions– Military “takeover” and mistrust of government– GIs all trigger-happy and default to brute force– “We’re the Pros from Dover” complex – Potential lack of technical sophistication– Lack of common culture, language, systems

• There is a cost

17

National Guard• Guard has the lead in homeland security and is actively

restructuring to optimize response capabilities• Every congressional district has a Guard asset• WMD-Civil Support Teams (CSTs) growing in concept and

capabilities– 23 person team can diagnose and recommend Rx– 33 now; soon to have at least one per state

• CBIRF-like Enhanced Response Force Package (CERF-P)– Up to 120 people– 12 now; soon to have at least one per state

• Expeditionary Medicine (EMEDs) team per FEMA region• Regional medical planners being put in place• At least two major regional exercises per year

18

HURRICANE/TYPHOONHURRICANE/TYPHOON

EXPLOSIONEXPLOSION

VOLCANIC ERUPTIONVOLCANIC ERUPTION

RADIOLOGICAL EVENTRADIOLOGICAL EVENT

SNOWSTORM/SEVERE SNOWSTORM/SEVERE FREEZEFREEZE

DROUGHTDROUGHT

TORNADOTORNADO

POSTAL WORK STOPPAGE POSTAL WORK STOPPAGE EPIDEMICSEPIDEMICS

TERRORISMTERRORISM

INSURRECTIONINSURRECTION

CIVIL DISTURBANCECIVIL DISTURBANCE

EARTHQUAKEEARTHQUAKE

FIREFIRE

FLOODFLOOD

COUNTER-NARCOTICSCOUNTER-NARCOTICS

OIL SPILLOIL SPILL

POTUS/VPOTUS/FLOTUSPOTUS/VPOTUS/FLOTUS

SUPPORTSUPPORT

Defense Support of Civilian AgenciesDefense Support of Civilian Agencies

SUNAMI/TIDAL WAVESUNAMI/TIDAL WAVE

METEOR IMPACTMETEOR IMPACT

LANDSLIDE/MUDSLIDELANDSLIDE/MUDSLIDE

CHEMICAL HAZARD CHEMICAL HAZARD

SPACE DEBRIS IMPACTSPACE DEBRIS IMPACT

ANIMAL DISEASEANIMAL DISEASE

MASS IMMIGRATIONMASS IMMIGRATION

NSSEsNSSEs

19

Dodd Sermonizing• Within DoD, planning must be across components and functions in

open, outcome-oriented manner– Collaboration must involve Reserve and Guard– Focus on faster, smarter, better integrated processes

• Improve inter-agency and federal-state mutual understanding, communication, and collaboration

• Planning at municipal, county, state, and regional levels must continue…vertically and horizontally

• International public health planning a must• Exercise at all levels…start with tabletops• Public-private interactions must improve• Re-invigorate and support public health infrastructures• Individual and family planning and volunteering

20

Bottom Line

• Bad guys are actively planning bad things today• DoD has a potential role (with plusses and minuses)

– DoD resources might range from one SME to multiple medical TFs

• This will only work well if we all work together– Progress is being made within DoD and at the IA level– Progress is being made at the state and community levels

• Our obligations are legal, ethical and moral• If we do our job right, a lot of people will live that might not

otherwise• We might not have a lot of time!

21

22

Getting to a PDD

Event

DoD Entities RespondUnder Immediate

Authorities

POTUS signs PDD

DHS tracks and makes recommendationsNC’s DWC tracks

TAG and NGB tracks

SCO appointed

Economy Act Stafford ActSome Agency HeadsCan Execute per prior authority and HSPD 5

Gov formally asks for aid

PFA, PFO and FCOappointed

EMO

CIRS?

23

Assembling the Players

Event


Authorities

POTUS signs PDD



DFO establishedwith FCO, SCO,DCO (& DCE)

NC designates TSB/CC as DLO or DCO

JRMPO rolls into DFO

PFO cell (JFO?)

POTUS HHS

DoDFed IA/IIMG

CDC ERT

SERT

CONUSAsFORSCOM

NC

JFCOMJS

FEST

DEST

S/R/EPLOsServices

OCs…OCs…OCs….

DOS

WMD-CST

IIMG

CERT

FIRST

DHSHSOC

24

Once PDD in Effect

Event


Authorities

POTUS signs PDD



FCO

PFO DHHSNC/DoD

DCO

Bounds of tasking?Resources on site?

DoD on siteexecutes

MA #

NC

JDOMS

MA #

No

Yes

SecDef/ASD (HD) NC/JFCOM

LegalityLethalityRisk ImpactCostAppropriatenessReadiness

Mission analysis

Coordinates

Approves/Signs EXORD Sources as necessary

JRMPO, EPLOs, ESF8…

SCO

DHS

FORSCOM/Services

JS

ServicesJFCOM

NGB

ARF

25

Suppose It’s Really Big…

Event


Authorities


POTUS signs PDD


FCO

PFO DHS

JRMPO, EPLOs, ESF8…

DCO

JTF-CS

TF-East

TF-West

NORTHCOM

1st ArmyFORSCOM

NC

SecDef/ASD (HD)

NC/JFCOM/NGB

SCOServices

JDOMS

CONUSAs also have significant C2 role in regional events

JTF/CC

5th Army

ARF

26

In Simplified Summary…<F

unct

ion

>

Emergency Services DispatchMedical Military/ Civilian

Emergency Rooms, EOCs, &Hospitals

Military/ Civilian First RespondersOn-Scene Commander/ DCG StaffCivilian Incident Command Center

Local Government(Municipal & County Emergency

Operations Centers)

Does the VictimRequire a Level of CareGreater Than What is

Available?

Victim/ Observer NotifiesEMS System of ImmediateEmergency Care Needs

Victim/ Observer NotifiesEMS System of ImmediateEmergency Care Needs

EMS DispatchReceives Notificationfrom Victim/ Observer

EMS DispatchReceives Notificationfrom Victim/ Observer

EMS Dispatch NotifiesControl Centers via

Prescribed ReportingProcedures

EMS Dispatch NotifiesControl Centers via

Prescribed ReportingProcedures

Medical Military/Civilian Emergency

Rooms ReceiveNotification from EMS

Dispatch

Medical Military/Civilian Emergency

Rooms ReceiveNotification from EMS

Dispatch

Coordinate the Activities ofSupport Teams at theMedical and AlternateTreatment Facilities

Coordinate the Activities ofSupport Teams at theMedical and AlternateTreatment Facilities

EOC DeterminesAdditional Response

Capabilities & DispatchesAdditional Medical Assets

to the Scene of the Incident

EOC DeterminesAdditional Response

Capabilities & DispatchesAdditional Medical Assets

to the Scene of the Incident

OSC Establishes IncidentBoundaries upon Arrival atAccident Site and Manages

Incident Following ICSProtocols

OSC Establishes IncidentBoundaries upon Arrival atAccident Site and Manages

Incident Following ICSProtocols

Is the Request forAssistance Validated?

Medical EOCs NotifyChains of Command/County Emergency

Management Center ofActions Taken in Support

of Incident Response

Medical EOCs NotifyChains of Command/County Emergency

Management Center ofActions Taken in Support

of Incident Response

Information Receivedfrom Multiple Control

Centers and theOn-Scene

Commander

Information Receivedfrom Multiple Control

Centers and theOn-Scene

Commander

First RespondersNotified of Incident &Receive Instructions

to Proceed to theIncident Site

First RespondersNotified of Incident &Receive Instructionsto Proceed to the

Incident Site

State Government(Emergency Operations Center)

Victim/ Observer

On-Scene CommanderCoordinates ResponderActivities at the Scene &

Keeps Local EOCInformed

On-Scene CommanderCoordinates ResponderActivities at the Scene &

Keeps Local EOCInformed

Conduct Hot Zone Triage& Treatment

Gross Decon

Conduct Hot Zone Triage& Treatment

Gross Decon

Military OSC & DCGStaff/ Civilian ICS

Members Notified toAssemble at the

Established Staging Area

Military OSC & DCGStaff/ Civilian ICS

Members Notified toAssemble at the

Established Staging Area

Determine EmergencyCare

Needs, Identify AdditionalResources Needed

OSC & DCG StaffBriefed on Situation

En-route to theAccident Site

OSC & DCG StaffBriefed on Situation

En-route to theAccident Site

YES YES

Federal Government

Response Process for Known CBRNE Contamination

Do FirstResponders

Need AdditionalResourcesOn-Scene?

Medical EmergencyOperations Center (MOC)

is Activated

Medical EmergencyOperations Center (MOC)

is Activated

Transport toHospital forTreatment

Transport toHospital forTreatment

Victim/ ObserverAssesses Incident

Victim/ ObserverAssesses Incident

Emergency RoomNotified by FirstResponders of

AdditionalRequirements

Emergency RoomNotified by FirstResponders of

AdditionalRequirements

YES

First Responders NotifyER of Additional

Assistance/ Advise &Remains On-Site

First Responders NotifyER of Additional

Assistance/ Advise &Remains On-Site

NO

Notifies StateEmergency OperationsCenter and Issues aFormal Request for

Assistance

Notifies StateEmergency OperationsCenter and Issues aFormal Request for

Assistance

USNORTHCOM

Do Sufficient ResourcesExist to Manage the

Incident?

YES

State EOC ReceivesNotification from

County RequestingAssistance

State EOC ReceivesNotification from

County RequestingAssistance

Do Sufficient ResourcesExist to Manage the

Incident?

YES

Governor Issues a FormalRequest for Assistance(RFA) to the President/Secretary of Homeland

Security

Governor Issues a FormalRequest for Assistance(RFA) to the President/Secretary of Homeland

Security

Office of EmergencyPreparedness, DHSValidates Request

from State andAdvises POTUS on

the Situation

Office of EmergencyPreparedness, DHSValidates Request

from State andAdvises POTUS on

the Situation

Federal and StateCoordinating

Officers Notified ofActivation (FCO &

SCO)

Federal and StateCoordinating

Officers Notified ofActivation (FCO &

SCO)

Disaster Field Office(Emergency Support Function 8)

Notified of DisasterField OfficeActivation


FEMA Establishes theDisaster Field Office in

the Affected Region

FEMA Establishes theDisaster Field Office in

the Affected Region

Provide CoordinatedAssistance

to Supplement StateResources

Disaster Field OfficeIdentifies SupportRequirement forConsequenceManagement

Disaster Field OfficeIdentifies SupportRequirement forConsequenceManagement

JRMPs Deployed toAugment the DefenseCoordinating Element

Section in Support of theDCO

JRMPs Deployed toAugment the DefenseCoordinating Element

Section in Support of theDCO

Receives Tasking toAccept OperationalControl of ForcesFrom Supporting

CINCs, Services, &DoD Agencies

Receives Tasking toAccept OperationalControl of ForcesFrom Supporting

CINCs, Services, &DoD Agencies

Is There Evidence ofKnown Contamination?

NO

Hospital/ PatientTreatment

Hospital/ PatientTreatment

Further Triage/ Treatment& Communication to

Medical EOC for MoreSupport

Intensive Decon

Further Triage/ Treatment& Communication to

Medical EOC for MoreSupport

Intensive Decon

Treat & ObserveCasualties

Treat & ObserveCasualtiesEstablish Casualty

Collection Point(s)

Establish CasualtyCollection Point(s)

Transport to Hospital &Alternate Treatment

Facilities

Transport to Hospital &Alternate Treatment

FacilitiesProcess Casualties thruDecon Release Site

Process Casualties thruDecon Release Site

Manage Incident via ICSWhile

Keeping State EOC Informed

Have CasualtiesBeen Evacuated to aMedical Treatment

Facility?

YES

Local EOC StandsDown

Local EOC StandsDown

State EOC ManagesSituation

While Keeping DHSInformed About the

Situation

Have CasualtiesBeen Evacuated to aMedical Treatment

Facility?

State EOC StandsDown

State EOC StandsDown

Victim TreatedOn-Site or at

Home

Victim TreatedOn-Site or at

HomeEMS Involvement

Terminated

EMS InvolvementTerminated

ER Determines InitialResponse Capability from

within ER &Dispatches Team

ER Determines InitialResponse Capability from

within ER &Dispatches Team

Proposed Response Process for Suspected Covert CBRNE/WMD Contamination

Victim is a Self-Presenter

Victim is a Self-Presenter

HMO/ Doctors’s OfficeObtains Specimen for

Analysis

HMO/ Doctors’s OfficeObtains Specimen for

Analysis

Hospital EmergencyDepartments ObtainSpecimen for Analysis

Hospital EmergencyDepartments ObtainSpecimen for Analysis

Public Clinic ObtainsSpecimen for Analysis

Public Clinic ObtainsSpecimen for Analysis

Does Lab TestingReveal Evidence of Rare

Disease or PuzzlingSigns & Symptoms?

Information ReceivedBy Epidemiology

DepartmentRegarding Initial

Positive Identificationof CBRNE/ WMDContamination

Information ReceivedBy Epidemiology

DepartmentRegarding Initial

Positive Identificationof CBRNE/ WMDContamination

Information ReceivedFrom County

Regarding InitialPositive Identification

of CBRNE/ WMDContamination

Information ReceivedFrom County

Regarding InitialPositive Identification

of CBRNE/ WMDContamination

ReceivesNotification fromJDOMS RegardingEstablishment of a

Disaster Field Office

ReceivesNotification fromJDOMS RegardingEstablishment of a

Disaster Field Office

Deploys a DCO & DCEunder command ofUSNORTHCOM inSupport of FEMA

Deploys a DCO & DCEunder command ofUSNORTHCOM inSupport of FEMA

Receives Requestfrom 1st/ 5th Army for

CapabilityFulfillment

Receives Requestfrom 1st/ 5th Army for

CapabilityFulfillment

Mobilize Capability tothe JTF-CS Commander

Mobilize Capability tothe JTF-CS Commander

Governor Notifies FederalGovernment of Initial

Positive Identification ofCBRNE/ WMD

Contamination and Issuesa Formal RFA to FEMA

Governor Notifies FederalGovernment of Initial

Positive Identification ofCBRNE/ WMD

Contamination and Issuesa Formal RFA to FEMA

Notifies StateEmergency OperationsCenter of Initial Positive

Identification ofCBRNE/ WMDContamination

Notifies StateEmergency OperationsCenter of Initial Positive

Identification ofCBRNE/ WMDContamination

Is a PresidentialDeclaration of

Disaster Issued?

YES

NO

YES

NONO NO NO

NO

YES

NO

LOCAL & METROPOLITAN STATE FEDERAL

USNORTHCOMExercises Command &

Control via Three TieredOptions

USNORTHCOMExercises Command &

Control via Three TieredOptions

DCO ApprovesCapabilities Identification& Prepares the Requestfor Assistance (RFA) for

FEMA

DCO ApprovesCapabilities Identification& Prepares the Requestfor Assistance (RFA) for

FEMA

FEMA Submits InitialRFA for DoD Support

Thru JDOMS

FEMA Submits InitialRFA for DoD Support

Thru JDOMS



Tasks USJFCOM toProvide DCO and DCE

Tasks USJFCOM toProvide DCO and DCE

ASD/ HD ReceivesRFA & Validates

ASD/ HD ReceivesRFA & Validates

A USNORTHCOM Systems View - Medical Management of a Mass Casualty/ Public Health Disaster

Minimal : Influenza, food borne illnesses, endemic B. PlagueLow: Anthrax,

P. PlagueMedium: Pandemic Influenza High: Smallpox Severe: Bio-Engineered Agent

Is MilitaryAssistance Needed?

YES

NO YES

Forces Command(FORSCOM)

Notified to Preparefor Mobilization in

Support ofOperations

Notified to Preparefor Mobilization in

Support ofOperations

Conducts MilitaryOperations In Support ofthe Unified Commander

Conducts MilitaryOperations In Support ofthe Unified Commander

JFACCJFLCCJFMCC

Provides Command &Control

During Operations

Have OperationsTerminated?

YES

Redeploy &Transfer Forces

Back toSupportingCombatant

Commanders &Services

Redeploy &Transfer Forces

Back toSupportingCombatant

Commanders &Services

Tasks Services toTransfer Operational

Control of DoDPersonnel & EquipmentProviding Support to the

Unified Commander

Tasks Services toTransfer Operational

Control of DoDPersonnel & EquipmentProviding Support to the

Unified Commander

NO

Notified of Need toIdentify

Organizations thatCan FulfillCapabilitiesRequirement

Notified of Need toIdentify

Organizations thatCan FulfillCapabilitiesRequirement

Is FederalAssistance Still

Needed?

YES

Disaster FieldOffice Stands

Down

Disaster FieldOffice Stands

Down

NO

Legend

JDOMS TranslatesGuidance from the

SecDef into OperationalOrders

JDOMS TranslatesGuidance from the

SecDef into OperationalOrders

ProcessBeginningor Ending

ProcessBeginningor Ending

Pre-DefinedAction

Pre-DefinedAction

Recurring Process

DecisionInformationInput

InformationInput

YES

References:DoD Directive 3025.1 DTD 15 Jan 93DoD Directive 3025.1-M/ DTD 2 Jun 94DoD Directive 3025.15/ DTD 18 Feb 97Deputy Secretary of Defense Implementation Memorandum/ DTD 25 Mar 03The President’s Federal Response Plan (FRP) Jan 03, interim changeStafford Act, as amended, 42 USC 5121/ Sep 98Economy Act, 31 USC 1535/ Jan 96Joint Publication 3-26, Second Draft 11 Sep 03USNORTHCOM SG HLS Executive Course Presentation

Documents

Presented to 35 th IFPA - Fletcher Conference DoD Medical Support to Civil Authorities UNCLASSIFIED Lloyd E. Dodd, Brig Gen Command Surgeon NORAD-USNORTHCOM