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NEWS | Aug. 7, 2006

Air National Guard Medical Service tackles critical surge capacity shortfall

By Sgt. Jim Greenhill National Guard Bureau

SNOWBIRD, Utah - The Air National Guard Medical Service is filling a critical need that many Americans may not even be aware exists.

It’s called “surge capacity” or “surge capability,” and it’s the ability of hospitals and first responders to cope with a sudden influx of patients caused by a natural disaster such as a deadly hurricane, disease such as pandemic bird flu or manmade calamity such as a terrorist attack.

The problem: There isn’t much of it.

“We have no critical care surge capacity in this country,” said Col. (Dr.) Randall Falk, the National Guard Bureau’s air surgeon. “The problem is illustrated best by Sept. 11.

“When the Pentagon was attacked there were 10 staffed critical care beds that were open and available in the National Capital Region. Had more people been injured or sick - as they would be with the pandemic flu - we would have overwhelmed that 10-bed surge capability immediately.”

Among the National Guard’s answers to the critical surge shortage are the self-supporting EMEDS that’s been domestically battle-proven by Hurricane Katrina and the medical elements of CERFPs.

EMEDS stands for Expeditionary Medical Support. CERFP stands for CBRNE (Chemical, Biological, Radiological, Nuclear or High-Yield Explosive) Enhanced Response Force Package.

Both were on display during an exercise at Readiness Frontiers 2006, an Air National Guard Medical Service conference held at Snowbird Ski & Summer Resort July 27 through Aug. 7.

“We’re one of the relatively few providers of surge capability that cities and states can look to,” said Col. (Dr.) Chip Riggins, incoming air surgeon.

EMEDS is a package that includes everything needed to screen, treat and release to other facilities for longer-term care people with injuries from trivial to traumatic.

“The EMEDS is the most flexible, most mobile, most agile medical system seen in the history of mankind,” Falk said.

Enhanced EMEDS packages - called “EMEDS plus 10” or “EMEDS plus 25” - include up to 25 critical care beds.

“We felt that the EMEDS capability would provide some of that support,” Falk said. “We can’t make up for all the requirements. It’s not the only answer, but it certainly is a very strong answer.”

An EMEDS used in a civilian setting buys time while other facilities are ramped up, Falk said. “We hope that with the critical care capability we have with EMEDS, that we’ll be able to provide at least initial surge capability to be able to help some more people than we’re currently able to help in the managed care environment we live in today,” he said.

CERFP: field hospital capacity like nothing else

The medical element of a CERFP - staffed jointly by Air and Army Guard - is similar to an EMEDS and can be expanded to same. It can be deployed alone without the rest of the CERFP if needed.

The CERFP can respond rapidly, activated with a governor’s phone call to a state adjutant general and be on the ground in six hours. They can respond outside their own state, though a governor could decline a request if faced with a pressing emergency of his own.

“A military asset used to be almost impossible to get to, to call up,” said Lt. Col. Theresa Votinelli, field commander of Missouri’s CERFP, which exercised at Readiness Frontiers 2006. “And then the civil support teams came where you had a very easy call-up. The governor could pick up the phone, and they’re out within four hours. Now this provides the same thing on the medical side.”

Sgt. 1st Class Matt Sandbothe is noncommissioned officer in charge of operations and training for the Missouri CERFP. “We have the capacity to be able to quickly take people in and get them out without overflowing local hospitals,” Sandbothe said.

The CERFP can include a surgical suite.

“That gives us a field capacity that nobody else on the civilian side has,” said Maj. Bill Beck, a member of the 149th Medical Group who responded to Hurricane Katrina.

The Air National Guard Medical Service goal is to stand up an EMEDS plus 25 in each of the 10 Federal Emergency Management Agency regions, Falk said.

Experiences such as 9/11 and Hurricane Katrina have increased support. “Congress is now very interested in supporting us with equipment,” Falk said.

For the Air Guard Medical Service, filling surge capacity has been a force preserver. “We’ve retained our forces and our strength based on our ability to support the nation and provide this surge capacity,” Falk said.

The Katrina response - the first real-world use of a National Guard CERFP -- proved the concept, Beck said.

The team first went to New Orleans International Airport, where they saw several hundred nursing home and special needs patients among more than 1,000 total people.

Then it was on to the Convention Center.

“We were part of that mass medevac,” Beck said. “We medically screened over 5,000 people and evacuated them.”

That happened in just 10 hours at the Convention Center. The CERFP team - originally 22 or 23 strong - was augmented by New Orleans Emergency Medical Service and additional outside medics, he said.

After the first two phases, the team then supported the members of the military relief operation in the weeks that followed, he said.

“The National Guard was front-and-center with two full-up EMEDS facilities,” Falk said. “We had 17,000 patient contacts. It was a rainbow coalition of medical forces from across the nation.”

The EMEDS concept has been proven on the active duty side during recent conflicts, Falk said - and Guard members have augmented active duty EMEDS, increasing their experience.

“The techniques used today in the overseas front have resulted in a survivability rate of 92 percent,” Falk said. “That is, if a wounded Citizen-Soldier or Airman reaches a medic with a pulse, he or she has a 92 percent chance of recovery.”

During the Vietnam War, that chance was in the 70 percent range. “It’s a leap forward with EMEDS technology, and with other medical technology,” Falk said. “This war has seen us not needing, not requiring a theater hospital more forward than Lundstuhl, Germany.”

The inference: If the active duty’s overseas EMEDS capability can be this successful in the war zone, the National Guard’s domestic EMEDS capability can be decisive for the homeland. “I’m extremely enthusiastic about this,” Falk said.

Falk calls Kansas’ adjutant general (TAG) “the daddy TAG of the EMEDS” for the enthusiasm with which Maj. Gen. Todd Bunting embraced the concept. Kansas is the only state to pay for an EMEDS with a specific line item in the state budget.

“We like the EMEDS mission,” Bunting said, explaining that Kansas’ central location and experiences like hospital-wrecking tornadoes and hospital-closing snowstorms and floods motivated his state.

“The surge capacity for the nation in most public safety environments is the National Guard,” said Bunting. “That’s why you have the National Guard. EMEDS is a classic National Guard mission, and I’m excited to get it to the point where every state has this mission.”

Where did the surge capacity crisis come from?

“We had a large surge capability many years ago in this nation,” Falk said. “But with managed care and the development of the realities of medical politics, we don’t have that surge capability anymore.”

Col. (Dr. and Brig. Gen.-select) John D. Owen is Missouri’s state air surgeon and a civilian doctor. “The hospital facilities of the United States have contracted due to cost concerns,” he explained. “They have the facilities needed for their anticipated short-term needs. An intensive care unit needs to be manned and operated at a level that will be nearly full for economic concerns. That eliminates surge capacity.”

Doctors say that other ingredients in the surge capacity shortfall are losses of hospital beds due to social changes over the past two decades in where people die (at home or in a hospice instead of in a hospital) and how they receive post surgical care (as an outpatient rather than in hospital). Other factors include a state reluctance to permit hospitals additional beds - the numbers are state regulated. But the bottom line is money, doctors say.

“It’s like cars sitting on a car lot,” said Brian Garrett, Utah’s director of Emergency Medical Services. “They’re not going to let [hospital beds] sit there. Our hospitals are at capacity every day just doing the general business of healthcare for our citizens. They are at capacity all the time.”

Although a crisis - such as a Utah earthquake - could prompt hospitals to discharge patients faster and cancel elective procedures, Garrett said they’d face immediate strain.

“You have the actually sick and injured coming in as well as the worried,” he said. “The out of state resources - particularly the Guard - bring a huge capacity to us to be able to deal with the surge capacity.”

Said Falk, the air surgeon, “It’s a seamless capability, whether it’s deployed here in the United States in response to an earthquake, hurricane or manmade disaster, [or] to the wartime theater in Afghanistan, Iraq or anywhere that’s required.”