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Responding to IED attacks: Improving EMS for violent mass casualty incidents

This post is co-authored by Scott Somers and Raphael M. Barishansky.

Since 9/11, firearms have accounted for 95 percent of all deaths from domestic terrorism. While IEDs remain relatively rare in the U.S. when compared with armed attack, the Boston Marathon bombing (2013) and the recent explosions in Manhattan and New Jersey (2016) warn of a growing domestic threat. Both tactics produce mass trauma casualties.

Advances in battlefield trauma care and medical technology during the wars in Iraq and Afghanistan resulted in a sharp reduction in preventable deaths in those conflicts. First-responder combat medics and corpsmen are better trained and equipped to address bullet and shrapnel wounds.

Law enforcement agencies have also adapted their tactics for violent mass casualty incidents. After the Columbine High School Shooting, police departments adopted a more aggressive response in which officers immediately pursue and neutralize an aggressor rather than waiting for a SWAT team. This change was supported by significant enhancements in officer training and equipment.

By comparison, the emergency medical services (EMS) response to violent mass casualty incidents has been slower to adapt. EMS curricula, standards and policies still largely dictate that field EMS providers wait until police mitigate the threat before entering to treat victims. While EMS responders wait for a secure scene, the injured are not receiving care resulting in potentially preventable trauma-related disability and death. Critics point to the Aurora theater shooting to suggest that some lives might have been saved had a more proactive emergency medical response procedure been in place.

To be fair, the need for better field EMS response has not gone unaddressed. Guidelines from the DHS Office of Health Affairs, US Fire Administration, and Interagency Board are just a few examples of resources developed for medical first responders. And law enforcement has begun training officers in Tactical Combat Casualty Care. But greater Federal leadership is needed to support training and equipping local, regional, and tribal field EMS providers for violent mass casualty response.

The White House should set an explicit goal. The National Academy of Science will soon recommend that the White House set a national aim of achieving zero preventable deaths after injury and minimizing trauma-related disability. Reducing morbidity and mortality among violent incident casualties would be a logical component of this goal. However, the current national Counter IED strategy makes no mention of either field EMS or the trauma care system.

The Federal Interagency Committee on EMS (FICEMS) should take the lead. A significant barrier to coordinating preparedness in the pre-hospital arena is that EMS sits at the crossroads of public health, health care, and public safety. There is no designated lead federal agency for EMS. As a consequence, the federal government has not set standards for EMS performance in the homeland security mission and some EMS provider types have received as little as four percent of DHS preparedness funding.

Congress mandated creation of the FICEMS to ensure interaction among Federal agencies in support of EMS and 9-1-1 systems. Its mission is to coordinate projects across the Federal government.

Improving field EMS interaction and interoperability during violent mass casualty incidents must be a high-priority initiative for FICEMS. FICEMS is also well-positioned to establish a cross-disciplinary effort to collect, analyze and validate best practices for pre-hospital and hospital-based response to violent mass casualty incidents, from bystander actions to field treatments and surgical care. FICEMS must also advocate among its members for proper funding for integration of all EMS provider types into the homeland security mission.

The FDA must be a partner in this process. Innovations from military medicine, such as redesigned tourniquets and utilization of hemostatic agents, have helped save lives. These treatments are supported by a large body of uncontrolled clinical evidence. FICEMS and the FDA should facilitate prehospital inclusion in randomized controlled trials of innovative trauma care.

Scott Somers, Ph.D., is a CCHS senior fellow with over 20 years in emergency medical services. He was formerly a member of the National EMS Advisory Council.

Raphael M. Barishansky, MPH, MS, CPM, is a CCHS senior fellow with over 20 years of experience in emergency medical services and public health preparedness.

Protecting 911 call centers from cyber threats: Federal action needed

The growing threat of cyber attacks on 9-1-1 call centers, also known as public safety access points or PSAPs, has become a serious homeland security concern. PSAPs are the public’s vital link to life saving emergency services. As of March 2015, there are some 5,906 primary and secondary PSAPs in the United States, to which 240 million calls are made to 9-1-1 each year. The next generation of public safety communications will be even more reliant on information technology.

Existing narrowband, circuit switched 9-1-1 networks carry only voice and very limited data, so PSAPs have focused largely on preventing Telephony Denial-of-Service attacks. Advancements in Next Generation IP-based systems and emerging mobile technologies increase the threat of infiltration and exploitation of emergency communications systems. Next Generation 9-1-1 (NG911) systems will be a “network of networks” providing connectivity between PSAPs regionally and nationally. As these systems become connected to the Internet, public safety communications will be increasingly vulnerable to the same threats as other IP networks.

NG911 will allow our growingly wireless society to access 9-1-1 through texting and mobile apps, as well as send images, videos, emails, and other documents…any of which could contain embedded viruses that rapidly infect the network. First responders are also making greater use of data and cloud computing. Sensitive public safety information stored on the cloud such as emergency medical patient care reports and police body camera video could become targets for cyber hacking.

Unfortunately, information sharing across all levels of government and the private sector is lacking, often leaving local public safety blind to the latest threats to public safety cyber infrastructure. PSAPs may not be aware of steps that should be taken to mitigate emerging threats to networks.

Ultimately, the primary responsibility for protecting critical NG911 infrastructure lies with PSAP owners and operators themselves. But the federal government has a crucial facilitative role to play in public safety cyber security, which includes:

  • Protecting critical infrastructure. DHS has begun collaborating with public safety sector stakeholders to address cyber security implications of information and communications technology through the National Infrastructure Protection Plan. DHS must continually engage NG911 and Nationwide Public Safety Broadband Network officials to create sector-specific plans within the NIPP framework.
  • Providing forums where industry stakeholders can engage in risk assessment and mitigation. The federal government needs to work with public safety agencies, and engage private communications and cloud service providers, to ensure the security of critical infrastructure from cyber threats. Use of models for information sharing, such as the Multi-State Information Sharing and Analysis Center (MS-ISAC), must be encouraged.
  • Providing tools for prevention and intervention. The federal government should disseminate cyber intrusion, detection, and prevention tools to public safety partners, and be permitted, when required, to provide assistance to localities and other entities in addressing and repairing damages from a major cyber-attack and for advice on building better defenses.
  • Improving information sharing. The multiple cybersecurity information sharing bills currently being considered in the House and Senate would require federal agencies to develop and promulgate procedures to promote the timely sharing of cyber security threats to prevent or mitigate adverse effects. Congress must work to pass legislation that removes existing impediments and improves incentives for information sharing, while also safeguarding the civil liberties and privacy of citizens.

Scott Somers is a senior fellow with the GW Center for Cyber and Homeland Security and sits on the Center’s Preparedness and Infrastructure Resilience task force. He previously served on the FirstNet Public Safety Advisory Council and SAFECOM Executive Committee.

The Ebola Jet Set

In a recent Vanity Fair magazine, there was an article about the early “Jet Set” who traveled the world on the new Boeing 707 jetliner. In those days, the jet was a miracle knocking off nearly 5 hours of transit time from America to Europe. It was expensive to take and only the rich and glamorous could afford it. People wore their best clothes and were served five course meals, says the author of the article. Oh those were the better days – if you were rich.

As anyone who has flown in the past few years can tell you, that era is but a dream. On the other hand, we can now travel the world in less than 24 hours. The Taj Mahal or Monrovia, Liberia can replace the site of my cat sitting in my window in front of my desk in McLean, Virginia in a day. A miracle and a problem. Welcome to the age of the Ebola Jet Set.

In this world, people and their problems can also move around in 24 hours. Terrorist can move about with relative ease. We know that and have taken actions to deal with the problem.

But, diseases, like Ebola, can also spread world wide in a matter of days. So, we have seen in recent weeks that what happens in West Africa can arrive in Dallas, Texas in no time flat. And, thus again, the definition of Homeland Security expands.

Whatever the missed opportunities from the World Health Organization (WHO) and the Centers for Disease Control (CDC) and whatever other health related initials there are out; rarely does a small fever stop anyone from traveling. Being prepared to deal with type of thing is going to take some getting used to by Americans who are already irritated by long and intrusive TSA lines. The Japanese do health screens on the way in to their country. Maybe we need to do the same.

The news media hype and distortion for ratings is not helping inform the public to say the least. And watching the Administration struggle with a response is hardly awe-inspiring. What is really upsetting, however, is after both SARS and H1N1 influenza, our medical establishment is not prepared around the country to deal with mass infectious disease.

Simply put, while international cooperation is nice as is a competent WHO, we need to boost that capability within the U.S. regionally to deal with infectious disease – not just as NIH headquarters in DC. Hospitals and medical centers have not been at the forefront of homeland security efforts and it is now showing.

The early warning reporting system also needs to be strengthened recognizing that people being people do not go wandering into a medical facility unless they think they are sick. The earlier detection among doctors and public awareness is crucial.

So, welcome to the Ebola Jet Set. The nature of travel time today makes it near impossible to stop. And Americans must understand and be prepared as part of our total homeland security effort to deal with it.