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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary 3 9-1-1 Access and Communications 9-1-1 … you don’t think about it until you need it, but when you need it, it had better work. —Workshop participant A common, primary challenge to rural emergency response exemplified by both the Mexican Hat and Albert Pike incidents is that of communication in general, and limited 9-1-1 access specifically. This section of the workshop summary explores these issues in more depth and examines potential strategies that integrate emergency communication and improve rural response (summarized in Box 3-1 and Box 3-2). CHALLENGES The communications challenge, as discussed by panelists in detail in the following sections, extends throughout the stages of a mass casualty incident (MCI) response and manifests in several venues. Common to all of them, however, is the challenge of interoperability. In her presentation, Dorothy Spears-Dean, the public safety communications coordinator of the Integrated Services Program for the Virginia Information Technologies Agency, clarified that compatible technology is only a part of interoperability. In the case of the Mexican Hat incident (see Chapter 2), for instance, it was necessary that all of the responding ambulances, coming from as far away as 250 miles, have technology that could easily communicate with each other; but technological coordination is a manifestation of successful interoperability on a regional and state level. “[Interoperability] … is more fundamental than the technology. It boils down to the policy issue,” claims Spears-Dean. Interoperable policy, in turn, is created from strong local and regional policymaking coalitions. It requires coalition-building across traditional jurisdictions to ensure an en-
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary BOX 3-1 Suggested Challenges Facing 9-1-1 Centers Areas without any 9-1-1 service Areas without wireless coverage Ability to receive and respond to text and interactive video calls, and multimedia data Ability to locate callers, both: Discerning the geographic location or street address of the caller Responders finding the site of the incident (missing street signs, standardized 9-1-1 house numbers versus rural delivery addresses) Funding Availability Restrictions on the use of grant funding Recruiting and retaining qualified dispatchers Ability to provide emergency medical dispatch (prearrival instructions) Ability to provide backup and overflow capacity such that calls can be transferred between PSAPs Unfamiliarity with or fear of technology Systems redundancy in the same physical space (e.g., primary and backup phone trunks run along the same highway; may both be rendered inoperable at the same time) BOX 3-2 Suggestions for Overcoming the Challenges In implementing Next Generation 9-1-1: Central or state authorities can provide technological and operational guidance, and funding to localities based on individual needs and current capabilities. Federal programs can provide best practices for communication projects. Granting agencies need to have a common vision that promotes interoperable standards and guidelines. States’ roles: Leverage centralized resources and existing communication assets. Plan with the end in mind. Assume a coordinating role, assist in promoting and supporting regional initiatives through public-private partnerships: Proactive outreach to those that could share expertise and resources. Form strategic alliances with those that could provide support. Maintain a “brokering role” between local needs and federal opportunities. Promote cross-jurisdiction interoperability of policy, technology, and funding. Establish minimum capabilities and equal access to service for all states and all constituents, regardless of local communications platform. Collaborate with local communities to reduce and address legal and regulatory barriers they might face in implementing Next Generation 9-1-1.
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary tire region plans for and responds to MCIs with the same strategies, expectations, and language plan. Inclusive pre-planning and practice exercises, engaging representatives of local 9-1-1 services to state administrators, are the only way to achieve this type of cooperation, says Spears-Dean. Policy interoperability should strive to be comprehensive, encompassing issues of technology, resource dispersion, and the dedication of funding in the context of an entire region’s or state’s ability to respond to an MCI. The strategies offered by those in attendance, detailed below, aim to resolve challenges of inconsistent communications coverage and available technological expertise through creatively leveraging new and existing technology, and increasing policy interoperability with a leadership role for the states and federal government. Inconsistencies in Cell Phone Service Emergency medical services (EMS) awareness that an incident has occurred is the first link in the response chain, and for rural America, it is one of the most challenging obstacles to future improvement. The importance of cell phone service to emergency response is undisputed: one-third to one-half of all 9-1-1 calls are made from a wireless phone. Yet, noted Booz Allen Hamilton lead associate John Chiaramonte, there are about 125 counties across the United States, primarily in the frontier areas, that do not currently provide enhanced 9-1-1 (E911) services. In these areas only basic 9-1-1 service is available, without location or caller phone number information; in some cases no 9-1-1 service is available. This issue of inadequate or unavailable 9-1-1 services is compounded by the absence of redundant communications systems. Often, even where redundancies exist, they are confined to the same physical space as the primary system, like primary and backup phone trucks located along the same stretch of highway. Limited effectiveness of the backup results from the fact that both primary and secondary systems can be inactivated simultaneously. Wireless coverage is concentrated in populated areas. About 90 percent of the 3,135 counties in the United States have some sort of phase II wireless, which has the ability to locate a wireless caller using either handset-based global positioning system (GPS) information, or network-based triangulation services using cell phones, tower locations, and wireless signal strength. There are about 6,100 9-1-1 centers or public safety answering points (PSAPs), across the United States. All of these centers are facing at least some issues associated with coverage, access, technology, funding, recruiting and retaining qualified staff, and the ability to provide emergency medical dispatch. Chiaramonte noted that in rural areas these issues are magnified.
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary Paul Patrick, director of the Bureau of EMS and Preparedness in the State of Utah Department of Health spoke in this session as a representative of the National Association of State EMS Officials (NASEMSO). Patrick reiterated that it is not known how the first 9-1-1 call received from the Mexican Hat incident got through, who called, or from where. Without this critical information a dispatcher cannot start activating emergency resources. Patrick recalled Larson’s comment that after the bus incident the contested cell phone tower was installed, and likened it to what happened with the railroad industry; how many times did an automobile-train accident have to occur before there was a crossing placed or a bridge built over the railroad tracks? How may Mexican Hat-type incidents will it take to enhance communications? These issues are not isolated in one state or even several, Patrick said. They are nationwide. Available Technology, Unavailable Technical Know-How Unfamiliarity with or fear of technology is a real issue. Patrick said that it was his understanding that the bus that crashed in Mexican Hat had a satellite notification system installed, but that it was apparently not operational. He went on to insist that regulations need to be established to ensure that not only is the necessary technology available, but that it is installed and operated properly. Aaron Reinert, executive director of the Lakes Region EMS, a rural ambulance service in Minnesota about an hour north of Minneapolis-St. Paul, offered another startling example. While the absence of a dedicated and flexible federal grant mechanism for EMS was highlighted by many workshop participants as a significant barrier, Reinert’s example illustrated the specific need to ensure that existing funds are compatible with both governmental and nongovernmental organizations. He described Minnesota’s robust 800 megahertz communication system, an effective but expensive behemoth: a single portable radio costs $2,500. For the most remote ambulance services, the equivalent model costs $5,000 per ambulance. Under a federal grant, Reinert’s county received 160 of these $2,500 radios, theoretically enough to distribute one to each emergency responder. Yet none are used. Why? Reinert’s EMS service, which responds to all of the county’s 9-1-1 calls, is a nonprofit, non-governmental EMS organization, and it is therefore prevented by the grant guidelines from using any of the provided radios. So to this day, Reinert said, the radios sit in a closet unused. Existing Alternatives to Traditional 9-1-1 Calls Reinert’s example demonstrated that leveraging existing resources to bolster EMS communications during an MCI might prove more reasonable,
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary in the short term, than seeking new funding sources in this global climate of recession. As communications technology advances, many people are now communicating solely by e-mail and texting, and in some cases they assume they can text 9-1-1. Patrick proposed a rigorous demonstration project to assess the value and effectiveness of programs that identify alternative methods to communicate with 9-1-1 emergency services. This type of program, he said, would prove worthwhile for the general public and the EMS community alike. If the system had been capable, in theory a text to a 9-1-1 center in San Juan County, with its short-burst message, might have gotten through when a completed cell phone connection could not. Yet, a participant cautioned that reliance on commercial cell phone technology, via calls or text messages, might be misguided: service infrastructure cannot be guaranteed by local governments, it does not assure EMS priority in an MCI, and the existing capacity is likely to be overwhelmed during an MCI, causing a cessation of all service. Rick Jones, Operations Issues Director for the National Emergency Number Association (NENA), noted that video emergency medical dispatch is on the horizon as well, yet only about half of the 9-1-1 centers in this country are capable of performing emergency medical dispatch at all (i.e., providing medical information and prearrival instructions over the phone to the caller). Johns Isfort, director of Business Development and Physician Services at Marcum and Wallace Memorial Hospital in Kentucky, characterized 9-1-1 dispatch services as undependable in providing responders with any prearrival instructions. He explained that in Kentucky, all fulltime personnel for communications centers are required to attend a 4-week training course covering public safety, communications, police, fire, EMS, and parts of the incident command system, the criminal justice information system, and emergency medical dispatch. However, employees who are not full time are not required to attend this, and as there is a long waiting list for this course, often the personnel staffing the communications centers in rural areas have not had any formal training. In addition to the potential to text message 9-1-1, Reinert noted the potential benefits of broadband communications such as voice over Internet Protocol (VoIP) and popular, no-cost Internet applications such as Skype. (Currently Skype does not support calls to emergency numbers.) Ambulances could be equipped with broadband for communications, data collection, and remote patient care technology (e.g., telemedicine). Broadband could also provide a platform for automatic vehicle location. Reinert noted that this would not necessarily be expensive. One would need a basic unit, which costs about $2,500, a data card, and service for about $20 a month. Anywhere that an ambulance traveled, it would have an Internet connection (assuming there is broadband in that area, which is an obstacle in its
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary own right). The task is to ensure that there is broadband in the most rural parts of the nation. Moving forward, Reinert encouraged a review of the data available through databases such as the National EMS Information System (NEMSIS) and the development of metrics that can be used to help direct exiting resources to the right places. A Role for the Federal Government Governments, federal, state, and local, also have a role in facilitating technology development and use. Technology is an answer, DeTienne said, but it is not the only answer. Technology can be a foundation for metrics, training and education, integration of systems, and regionalization. Throughout the workshop, many participants emphasized telecommunications, as a component of rural MCI response, is in desperate need of improvement to ensure reliability; such improvements will potentially benefit both public and private partnerships. A role for government is to help remove barriers to diverse partnerships, for example by updating 9-1-1 laws originally written for traditional telecommunications systems to allow for implementation of Next Generation 9-1-1. Jones pointed out that regardless of who manages 9-1-1 at the local level, be it by law enforcement, fire, EMS, emergency management, or a combination, it is important to actively include the 9-1-1 authority in any state and regional planning efforts. Because 9-1-1 is diverse across states and territories, Jones recommended contacting state chapters of National Emergency Number Association and the Association of Public Safety Communications Officials, to help identify the people who represent and can speak for, local 9-1-1 administrators. Telemedicine is another component of telecommunications that, coupled with broadband, is a powerful tool for rural and frontier first responders and EMS. Jones also drew attention to the 2-1-1, 5-1-1, 7-1-1, and 8-1-1 systems that are now available in many areas. These systems route to services such as poison control or mental health/suicide hotlines, or travel and traffic information. These other “N-1-1” numbers are staffed by trained people that can serve as valuable resources during an MCI. Jones suggested that commercial vehicles ought to be equipped with software and technology that enables onboard communications devices to automatically search across platforms for emergency communications. For example, a vehicle would search for cell phone signals, then available radio frequencies, satellite, Wi-Fi, and so on, until it made a successful connection. Associate chief medical officer at the Office of Health Affairs at DHS Mike Zanker asserted that the technology for communication in remote areas exists, but it is underutilized because of a lack of incentives
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary for the private sector to bring these technologies to rural and frontier areas. Regarding the issue of bringing privately held technology to rural response units, Zanker admits that perhaps a government middleman might be useful to standardize, and perhaps even subsidize, such technology exchanges. IMPROVING RESPONSE Jenny Hansen, CEO of Strategic Partnerships Incorporated, provides contract services to governments for large-scale public safety telecommunications projects. “We live where we live, and we enjoy it,” she said. Rural residents do not want to replicate New York City, but they should not have to settle for the status quo just because they live in rural areas. Hansen has been working to establish minimum capabilities and equal access for everyone across Montana, putting together a public safety services bureau and taking inventory of what resources exist, and to whom they belong, in the state. No one can afford a complete replacement of communications equipment, she noted. Legacy equipment, to a certain degree, has to move forward into the future and not to obsolescence. Collaboration Means Better Communication Based on her 30 years experience in public safety communications, Hansen observed that the technology is there and basic funding is available. The challenge is to find the right collaborative relationships, both public and private. It is about the politics, the people, and the willingness to break down some of the walls that have been in place for so many years. Hansen commented that in Montana, success in improving communications was wrought from introducing neighboring organizations and entities to each other and then pursuing various levels of public-private partnerships, taking an inventory of resources at every level. Start with the end result in mind she suggested. Make sure, for example, that resources spent on infrastructure prepare for the future instead of trying to treat the past. As an example of a partnership, Hansen cited a relationship brokered between the Burlington Northern and Santa Fe railroads. The railroad has a lot of real estate, and a lot of infrastructure including Wi-Fi, and both were amenable to working out an agreement to share that infrastructure. Integral to the agreement was a categorization of the roles and responsibilities of each organization in planning for and responding to what-if scenarios. The critical infrastructure within a jurisdiction is going to be different from the neighboring county, and the neighboring state. As such, Hansen said a regional concept is needed, especially when considering funding mechanisms that are targeted for specific purposes.
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary Preparing for Next Generation 9-1-1: Local Versus State and Federal Stakeholders The current 9-1-1 system is designed around 20th-century telephone technology that is not capable of transmitting data, text, images, or video. Efforts are underway to establish the Next Generation 9-1-1 system that will define the systems architecture needed to enable digital multimedia 9-1-1 communications. Jones stressed that it is extremely important for EMS to be actively involved in the implementation of Next Generation 9-1-1. Associations are collaborating at the national level, but there needs to be more regional discussion within states and across borders. He emphasized how important it is for rural communities to work together to ensure their needs are met during the development and implementation of Next Generation 9-1-1. As Public Safety Communications Coordinator for the Integrated Services Program of the Virginia Information Technologies Agency, Dorothy Spears-Dean is the state 9-1-1 director and the manager for all state-managed radio assets in Virginia. She sees herself as a broker between local needs and federal opportunities. Spears-Dean emphasized the importance of states developing a strategic plan to leverage centralized resources and existing communication assets. It will be expensive to move to Next Generation 9-1-1, and successful planning involves both proactive outreach to those that could share expertise and resources, and strategic alliances with those that could provide funding. Similarly, a participant noted that local communities should balance the priorities of investing in Next Generation 9-1-1 and augmenting traditional land mobile radio systems. One participant suggested that this can be accomplished by focusing on interoperability, national standards coordination, and by effectively integrating broadband to be able to bring technological advances to the field. Before communications technology can be addressed, representatives from all stakeholders must come to the table to address interoperability, with regard to funding, and legal and regulatory policy. It is important that jurisdictions, cities, and counties develop coordinated and integrated 9-1-1 policies. Localities will determine the standards that work for their local populations, she said, but service needs to be ubiquitous. Localities will look to the state for guidance and support, and to the federal government for a consistent voice on best practices. Federal funding of demonstration projects in rural communities would help ensure that the needs of rural communities are fully considered.
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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary THEMES IDENTIFIED BY WORKSHOP PARTICIPANTS Access to 9-1-1, whether by landline or wireless phone, is not universal. John Chiaramonte suggested there are a number of technological solutions that exist today, and others that are in development, that could improve EMS response to rural MCIs. Examples include but are not limited to satellite phones with GPS and portable locator beacons using satellite technology. Today, around 90 percent of the U.S. population carries a cell phone. For areas that do have wireless service, phase II wireless and mobile phones with GPS chips can provide the geographic location of the caller better than systems basing location information on the cell tower that picked up the call. To ensure technological compatibility, it was noted that phase II enhanced 9-1-1 needs to be universal across the more than 6,000 PSAPs and 9-1-1 centers across the United States. Several participants pointed out that the ability to share communications infrastructure between private and public entities needs to be considered, as well as the use of devices that can locate and operate across cellular, Wi-Fi, and satellite networks, depending on what is available at the time of need. Technological advancements, like Next Generation 9-1-1, have the potential to bring multiple resources together across large areas, provide backup and overflow capabilities for PSAPs, and support 9-1-1 access for deaf, hearing impaired, and special needs individuals. Next Generation 9-1-1 will also have the ability to share images and video. Yet participants observed the need for rural communities to strike a balance between investing in such Next Generation 9-1-1 technology, and improving the use of traditional land mobile radio systems. One participant suggested that this can be accomplished by focusing on interoperability, national standards coordination, and by effectively integrating broadband to be able to bring technological advances to the field. Beyond technology and hardware, Spears-Dean held that the human component of communications requires both collaboration and cooperation among public and private stakeholders. As the link to police, fire, EMS, and emergency management, the 9-1-1 system is the first “first responder” on the scene. The local 9-1-1 authority or PSAP representatives should therefore be included in planning and exercises. In addition, public expectation can similarly be managed through education and participation in demonstrations and exercises. Workshop chair Robert Bass reiterated that EMS and 9-1-1 should be considered an essential government service, and funded and supported accordingly.
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