All disasters, regardless of scope or scale, occur at the local level. Most of these incidences can be managed at the local level using local resources. When the resources required to manage a disaster exceeds the capacity of resources available at the local level, the incident commander will contact state government for support. Large disasters often will grow from a locally managed event through regional and state responses to a federal response. As more services are brought to the scene of an incident, the responders face a variety of challenges. These challenges include communications, resource allocation, leadership, and governance between agencies that rarely work together. These challenges are aggravated by working in a stressful and a time-sensitive situation. Managing disasters begins with planning and training. Local responders must establish regular disaster drills which include all government and private entities that may be involved in a disaster. The incident commanders and the command staff must be aware of regional, state, and federal assets available to assist in large-scale disasters.
Over the past decade, the number of large-scale incidents has increased in both severity and scale. With this increase in events, many local and state responders face a growing crisis of navigating the various state and federal agencies responsible for coming to the aid of local emergency response agencies. In the post-911 landscape, the president of the United States ordered, by presidential directive, that the federal government improve its capabilities of preventing and responding to large-scale incidents that may overwhelm local and state responders. This directive allowed local, state, and federal responders to create a framework that all responders could use to manage incidents and resource requests.
The on-scene incident commander may request additional regional and state support. Special weapons and tactics (SWAT) teams, hazardous materials (HAZMAT) teams, surrounding county emergency management services (EMS), fire, law enforcement, and regional medical staff are available to assist when called upon.
State's governors may call various assets to aid responders. The governor may elect to activate portions or the entirety of the states National Guard. National Guard troops may assist with responses from large-scale emergency medical incidents to chemical, biological, radiological, nuclear, and explosives (CBRNE) and search and rescue teams.
At the federal level, a variety of support services are available to assist responders in mitigating and responding to incidents.
The National Incident Management System (NIMS) and the Incident Command System (ICS) were created to help local and state agencies (ICS) and the federal responders (NIMS) speak the same language when responding to incidents. This framework allowed local agencies to request federal help when the local needs overwhelm the capabilities of the responders.
The Healthcare Preparedness Program and Healthcare Coalitions were established to unify efforts between local, state, and federal agencies. These coalitions allowed responders from all areas of healthcare to come together to discuss capabilities, needs and vulnerabilities and response and recovery plans. The Assistant Secretary for Preparedness and Response (ASPR) established funding for the coalitions to purchase equipment and for the training of responders that directly align with the needs of the coalitions. These purchases range from education to direct response equipment, including communications and patient care equipment. They also addressed challenges with the integration of services into a local, regional, and state response frameworks to speed response times.
The Federal Government also can assist local responders with the direct mobilization of teams from across the country.
The Department of Health and Human Services, Assistant Secretary for Preparedness and Response (ASPR) also created the ASPR TRACIE Information Exchange for all Healthcare Emergency Preparedness and Response partners. The TRACIE system allows registered users to connect with other response partners and to take part in relevant conversations about actual or pending threats to healthcare systems, share plans and information to create best practice items. The ASPR TRACIE system also allows responders to disseminate After-Action Reports (AARs) to a wide-ranging group of responders and other allied healthcare providers in a near real-time environment.
In the same vein as the ASPR TRACIE system, the Department of Homeland Security created the Homeland Security Information Network (HSIN). This network allows users to send alerts and notifications, situational updates and other documents of interest to other users. While this system is secured by the Department of Homeland Security, users with the appropriate levels of access can request compartmentalized access to specific sections of need. Some of these sections include emergency medical services, emergency management, a critical infrastructure, state, and local jurisdictional sites.
The Coast Guard may be called upon for search and rescue, security, to establish safe zones for first responders and victims, and for law enforcement of disaster areas.
The American Red Cross works with federal, state, and local providers to provide relief from human suffering, protect life, and improve health for victims of disasters. They help plan for disasters and provide basic living requirements to those in need.
Clinically, each disaster or large-scale event differs from the next and responders must be ready to shift from one priority assignment to another. While many of these events are relatively straightforward and may be handled with local resources those events that affect large populations or populations of medically fragile patients, require more assets, support, and resources. Responders, both locally and at the state levels, must consider the recovery efforts to any event of significance and must begin acquiring resources that will be needed as quickly as possible. One mostly overlooked piece of recovery is Critical Incident Stress Management that allows responders to focus on their mental health and wellbeing after an incident has occurred. With continued, multi-level coordination efforts aimed at practice and patient care, local Incident Commanders may access state and federal assets. Finally, all disasters should include an After Action review process to identify opportunities for improving response to future events and providers should be offered stress management counseling.