Partnership for Preparedness
By C. Everett Koop, M.D.
Surgeon General and Deputy Assistant Secretary for Health
Keynote Address to the National MAST Conference
Spokane, Washington
April 21, 1983
(Greetings to hosts, guests)
I'm delighted to be here today, not only to participate in this national conference, but also to give recognition to 10 years of outstanding service to the nation by both civilian and military personnel involved in the "MAST" effort.
You have a full program before you at this meeting and there are a number of specific areas that need your best thinking. But I would like to remind you that this kind of enterprise -- this partnership of the uniformed services and civilian organizations, joined to save lives -- is the exception not the rule in the world today.
The newspapers and the television news programs offer us examples every day of the oppression of a people by its own military. The military tradition could be an honorable one. It can be devoted to the saving of lives . . . of communities . . . of whole civilizations. Uniforms can identify those people who live by such a tradition.
I think we have that here in the United States. And I think that this conference -- and the "MAST" program itself -- are specific examples of the military tradition as its life-saving best.
I've done some traveling in my time. Before joining the government I had visited four continents and I talked with physicians and nurses and technicians in many countries. In many places -- not all, certainly -- but in many places it was quite clear to me that these professionals in the art and science of healing were often occupied in patching together the terrible wrongs done by their own fellow citizens in uniform.
This year we can look back upon a decade of service to the American people . . . service in which the uniformed services -- their personnel and their equipment -- were joined in a partnership of mercy with their civilian counterparts in medicine and transportation. The "MAST" program is uniquely American for many reasons: its breadth of coverage . . . the number of personnel involved . . . the versatility of the equipment used . . . and the extraordinary success rate: 2,500 patients transported last year, nearly 29,000 patients transported since the record-keeping began back in 1970.
But the truly unique aspect of the "MAST" program, the aspect that reveals it as a fundamentally American program, is the use of our country's Armed Forces for an essentially humane, life-saving activity.
I will not gloss over the difficulties . . . the losses of life incurred during the missions of mercy. And today it is my honor and privilege to give recognition to the supreme sacrifice given by the four-member crew of an Army helicopter out of Ft. Carson, Colorado, killed while saving a civilian climber southwest of Lake George. We will speak of that later. But for now, let it be said that there can be no greater heroism, no finer hour for the human spirit, than when one human being ventures his or her life to save the life of another.
We don't want that to happen . . . we all pray that it will not happen. But when those occasions have indeed occurred, the personnel of our Armed Services have made the tough but heroic decisions . . . they've made those decisions without a lot of public agonizing. The decisions have been private . . . they've been swift . . . and they've been right.
The people of the United States owe a profound debt of gratitude to the personnel involved in the "MAST" program -- military and civilian alike -- but we need to make special note of the devotion to the saving of human life that has been exhibited by our uniformed personnel. As a citizen and as a physician, I am proud to know you are there.
It would be a mistake, however, to see the "MAST" program as an isolated example of cooperation between military and civilian emergency services. It is not. I would say that it is among our best examples and it is without a doubt, from the viewpoint of service to our citizens, is among our most successful examples. The "MAST" program is also a prototype for us to use when we look about and consider the other emergency needs of the country.
In the next few minutes, I'd like to sketch out some of the ways the cooperative spirit of "MAST" is being expanded or emulated. Most of you are aware, I'm sure, of the Air Ambulance Guidelines produced jointly by the National Highway Traffic Safety Administration and the Commission on Emergency Medical Services of the American Medical Association. That document has been out for about two years and has been of immeasurable help to institutions and communities entering the age of emergency medical evacuation by air.
Of more recent vintage and with more widespread implications, however, is the "Civilian-Military Contingency Hospital System." That's terrible mouthful, so I will refer to it by a slight squish of its acronym: I'll call it "CHIMSUS" (C.M.C.H.S.).
The concept behind this system is easy enough to understand. Our government took a look at our experience during the Vietnam War and also looked around the world since then. What if we were to become engaged in another major conflict beyond our shores? How well could be transport are wounded back to the continental United States and give them proper treatment?
As the planners began to work through the logistical problems, it soon became clear that the military hospital system by itself would not be enough. Indeed, we already had learned that lesson during the Vietnam War.
We took an inventory of beds that could be released immediately for military wounded -- beds in the military hospital system and a portion of the beds in the VA system -- and that inventory became the nucleus of the contingency pool hospital beds, the basis of the "CHIMSUS."
But to reach the plateau of 50,000 beds, we had to appeal to the civilian hospital community to volunteer a portion of their capacity. That has been done, the facilities and staffs have been identified, and a "Contingency Hospital System," made up of facilities that are currently under either military or civilian control, is now in place.
Naturally, we are not speaking merely of the physical facilities . . . the beds, the rooms and words, or the buildings. We're speaking of total arrangements of care in this country -- facilities and personnel -- they could handle upwards of 50,000 returned wounded at any one time.
Let me add a further word about the civilian capacity. As I indicated a moment ago, the hospitals in the system have volunteered to participate. It has never been necessary to conscript a hospital into participation and I don't believe we'll ever have to. The responses of the civilian hospital community has been excellent throughout the development of "CHIMSUS."
In addition, the bed capacity and support services identified for the contingency system are otherwise fully available for the hospital's use. No beds are put in moth balls or literally kept in reserve until we are struck by natural disaster or become embroiled in a conventional war. Instead, their beds and facilities that are in normal use until mobilized under "CHIMSUS," when they would be quickly cleared to receive casualties.
By the way, "CHIMSUS" is not an expression of faith that in any future conflict or emergency we would anticipate no more than 50,000 feel the casualties at any one time. That would be very foolish thing to predict.
There is, of course, a triage system in the field during wartime. There are emergency field stations, field hospitals of the "MASH" or "MESH" variety, or the smaller "Air Transportable Hospital" of U.S. Air Force. These would handle a portion of the patient load closer to the military theater, outside the United States. Hence, it seemed possible and desirable to talk about a stateside hospital-level reserve of 50,000 beds to take care the serious casualties to be flown here from the field.
The "CHIMSUS" is in place and identified. It goes without saying that we hope we never have to activate the system. But it is there, if and when it is needed.
Since the 1950s, this country has been concerned about caring for its own people in a time of national emergency. We've gone through the planning for civil defense and civil preparedness and we've learned quite a bit from them. Those experiences have helped us better understand the kinds of problems we are successfully handling with "MAST" and, more recently, with "CHIMSUS."
Is there yet another arena in which emergency preparedness and civilian-military cooperation are important? Yes, there is. It is a new concept, one you may have heard of, but a concept that will become more and prominent in the months and years ahead. In a way, given its antecedents, this new concept is truly "an idea whose time has come." It is called the "National Disaster Medical System."
Until now, we have looked upon natural or man-made disasters as having a geographically discrete location. Medical evacuation programs, such as "MAST," our local or sub-regional. To all intents and purposes, the territory to be covered equals the maximum search-and-rescue range of a helicopter.
The "CHIMSUS" system is more far-flung, but it's mission is still limited in terms of total potential users of the system. Also, the anticipated patient load has a combat military profile, and we have had enough experience in military medicine to anticipate the kinds of medicine we need to practice, if we had to activate the "CHIMSUS" system of care.
However, each year a large number of Americans are at risk because of the major natural disaster -- fire, flood, snow, or hurricane. These are frightening enough and stun the imagination when they take place. But what about any one of these getting fully out-of-control for enough time to risk the lives of upwards of 100,000 people? What about the occurrence of a catastrophe that is still anticipated and is truly awesome in its potential for havoc: that is, an earthquake along the San Andreas fault in California or almost anywhere else in that state just to our south?
Not long ago, the Federal Emergency Management Agency wondered aloud about our ability to handle such an earthquake or anything similar in scale. In its report, the agency concluded that "The nation is essentially unprepared for the catastrophic earthquake (the probability of greater than 50 percent) that must be expected in California in the next three decades . . . " The FEMA staff went on to say that "federal, state, and local officials agree that preparations are woefully inadequate to cope with the damage and casualties from a catastrophic earthquake."
Having come to that conclusion, what with the agency to do next? Fortunately, the FEMA is authorized by law to assume leadership in these kinds of matters and it has. The result is what we now call the "National Disaster Medical System." It is a natural outgrowth of the "MAST" and "CHIMSUS" experiences.
The NDMS -- or "NIDMUS" -- was conceived because we know the United States is vulnerable to natural disasters of major proportions. We also know that a disaster like a California earthquake can occur, which could dwarf anything we have had to face so far. The planning for "NIDMUS," therefore, was for a system capable of treating large numbers of patients injured in a major peacetime disaster, as well as treating the casualties we could incur from a major military conflict.
In terms of size, we are talking now of a system that can handle the number of patients that would otherwise overwhelm a state or regional healthcare system or, for that matter, would overwhelm the capacities of the Department of Defense in the "Civilian-Military Contingency Hospital System" -- the "CHIMSUS" -- now in place.
The present plan for a national disaster medical system is the product of much thought and much experience being channeled through what is called the "Principal Working Group on Health." This group is chaired by the Assistant Secretary for Health of the Department of Health and Human Services. Serving with us our personnel from the Department of Defense and the Veterans Administration. Assistant Secretary Edward N. Brandt, Jr.., has signed off on the current design stage and we are moving forward now to implement the full system.
Let me fill in a few more details, since I believe everyone in this room will be hearing more about "NIDMUS" in the months to come.
This plan is called a "system" because of formal, workable relationship of some kind is needed in order to accomplish three complex tasks simultaneously:
First, to provide immediate emergency assistance within a specified disaster area . . .
Second, to evacuate patients from the disaster area to designated locations elsewhere in the United States . . .
And third, to coordinate federal and state aid, interstate aid, and public and private aid.
The first task would most likely be carried out by medical assistance teams made up of emergency medical personnel from a variety of cooperating agencies in both the public and private sectors. They would move right into the disaster area, dispense medical supplies and provide emergency treatment in the field to the extent possible, and identify those casualties that need to be cleared out of the area.
Personnel who were involved in "MAST" operations would represent in their areas a reliable core of local experience and expertise. Team members would need to be trained to provide first aid, field rescue, and casualty clearing services under worst-case circumstances.
The second task is to evacuate patients coming through the casualty clearing process. At this point it is essential for everyone involved to know the capabilities and capacities of local transport -- road, air, or rail -- and also to know the receiving point elsewhere in the nation. Naturally, one would need to know those transportation and reception facilities that were not disrupted by the disaster itself.
Generally speaking, the preferred reception points would be the hospital-members of the "CHIMSUS" system in 48 metropolitan areas, plus hospitals in another 30 or so major metropolitan areas. Each metropolitan area should have available at least 2,500 acute care beds in facilities that offer such services as surgery, post-op, intensive care, x-ray, blood banking, and so on. In the planning thus far, the "NIDMUS" staff estimates that at least 100,000 beds should become available, once the system was complete and activated.
The third task is a very complicated one of monitoring the number of patients being evacuated to which areas . . . knowing where a patient overload is building up or where facilities are being overlooked and underutilized . . . and making sure that scarce human and material resources are not being duplicated at one reception site, while another site gets less than what it needs to function.
Effectively accomplishing this third task rests almost entirely upon the maintenance of constant and error-free communications. The parties involved in the communications network would be located at the disaster site, at casualty clearing points, at the controls of Aero-medical aircraft, as well as among government agencies and the private sector.
I am delighted with the development of this plan so far and the thoughtful reception it has received by the medical profession, our colleagues in military medicine, and responsible persons throughout federal and state government. I think the prognosis is quite good for the National Disaster Medical System to be our basic system for dealing with any large-scale disaster.
The Public Health Service is pleased to played a key role in the development of "NIDMUS." But we know the job is only at the takeoff point now. However, with a 10-year record of success shown by "MAST" as a source of inspiration -- and with "MAST" personnel ultimately involved in the national system -- we're very optimistic about the final outcome of "NIDMUS" planning.
But I will freely admit that we could not be optimistic about "NIDMUS," if we did not already have the example of the "MAST" program before us. Therefore, I would like to congratulate each of you for being a part of this important, life-saving program and for demonstrating the ability of our nation to use as human and material resources the benefit of its citizens.
Thank you for your kind invitation to join you today. And now I believe I will file the sage advice of Mrs. Anita Loos, the lady who wrote "Gentlemen Prefer Blondes." She always said, "Leave them while you're looking good." And I think I'll do just that.