FEMA Emergency Support Functions (ESF) provide a concept of operations, procedures, and structures to achieve needed coordination of essential functions and response objectives in an incident. Developed into 15 categories that align governmental and private sector agencies that provide specific services, a lead agency is designated for each. There are several ESFs that apply to emergency management for the EMS physician. Each is listed below with a brief description.
FEMA can deploy assets and capabilities through ESFs into an area in anticipation of an approaching storm or event that is expected to cause a significant impact and result. This coordination through ESFs allows FEMA to position Federal support for a quick response, though actual assistance cannot normally be provided until the Governor requests and receives a Presidential major disaster or emergency declaration. This “leaning forward” or prepositioning of assets is now the model for predicted events.
ESF 4 “provides Federal support for the detection and suppression of wildland, rural, and urban fires resulting from or occurring coincidentally with an incident requiring a coordinated Federal response.”11 The Department of Agriculture/Forest Service is the lead agency, supported by the Departments of Commerce, Defense, Homeland Security, Interior, State and the Environmental Protection Agency. The physician role has several foci: medical clearance for service, provider rehabilitation, and hazardous materials threat assessment and chemical impact from an incident. Understanding the Incident Command System is essential since this is the management model of the fire service. Many types of technical rescue teams that benefit from physician involvement are provided out of the fire service. Confined space, high angle, building collapse, urban search and rescue, and hazardous materials are several; medical oversight and on-scene support are critical components for safe, effective operations. Anticipating the high heat, high stress, variable weather conditions, hazards and the impact upon personnel, victims, and the community places the physician at the heart of medical preparedness.
Understanding the National Fire Protection Agency (NFPA) 1600 Standards on Disaster/Emergency Management and Business Continuity Programs12 combine both the clinical care aspects of the physician role with the management understanding of the larger picture of emergency management. Adopted by the Department of Homeland Security as the national preparedness standard, NFPA 1600 established a common set of criteria for disaster, emergency management, and business continuity programs in both public and private sectors.
ESF 6—MASS CARE, EMERGENCY ASSISTANCE, HOUSING, AND HUMAN SERVICES
ESF 6 “coordinates the delivery of Federal mass care, emergency assistance, housing and human services when local, tribal, and State response and recovery needs exceed their capability.”13
DHS/FEMA is the ESF coordinator as well as the lead agency. Every state designates a lead agency; that agency works with the governor. Supporting Federal agencies include the Departments of Agriculture, Defense, Health and Human Services, Housing and Urban Development, Interior, Justice, Labor, Transportation, Treasury, Veterans Affairs, as well as the Social Security Administration, Small Business Administration, US Postal Service, American Red Cross, and several other NGOs.
Of the four ESF six components, the EMS physician is most likely to be involved in “mass care.” That portion includes emergency first aid for victims as well as sheltering, feeding, and collecting/distribution of information on victims to family members. The Annex specifically mentions that the sheltering and medical needs of special needs populations are included. Health care providers may also be called upon to provide ongoing care for those in the shelters. Although the EM/EMS physician probably will not be involved in the evacuation of nursing home patients, he or she may be one of the medical care providers for them before or after they are relocated. The physician may be requested to coordinate and provide input on process and resource needs and use during these events. Understanding the mutual aid agreements and assistance plans regionally, intrastate, and interstate is very helpful when managing evacuation and sheltering needs.
ESF 8 - PUBLIC HEALTH AND MEDICAL SERVICES
This is the largest of the ESFs that are likely to involve the EMS physician. The purpose includes “responding to medical needs associated with mental health, behavioral health, and substance abuse considerations of incident victims and response workers.” It also covers “the medical needs of members of the ‘at risk' or ‘special needs' population described in the Pandemic and All-Hazards Preparedness Act and in the National Response Framework (NRF) Glossary, respectively.”14 The Department of Health and Human Services (HHS) serves as both ESF Coordinator and Primary Agency. HHS does this through the Office of the Assistant Secretary for Preparedness and Response (ASPR). Supporting agencies include the Departments of Agriculture, Commerce, Defense, Energy, Homeland Security, Interior, Justice, State, Transportation and Veterans Affairs as well as the Environmental Protection Agency, General Services Administration, US Postal Service, and American Red Cross.
EMS physicians and Emergency Medicine physicians who serve in a military reserve unit may find themselves as part of a Department of Defense deployment for casualty clearing, staging, and treatment. Likewise, those who are members of the Medical Reserve Corps may be called upon to assist State, tribal, and local public health and other medical personnel. EM physicians on staff at NDMS-affiliated hospitals may be part of emergency department receiving teams for disaster victims transported to their areas. Emergency physicians with training in psychological first aid or critical incident stress management could assist if HHS asks for assistance from partner organizations. Finally, ESF 8 can deploy National Medical Response Teams to assist with victim decontamination, surge response, etc. Emergency medicine physicians are often part of those teams. For more about the potential for physician involvement, see “Roles of EM / EMS Physician in Emergency Management” below.
ESF 9—SEARCH AND RESCUE (SAR)
The purpose of ESF 9 is to rapidly deploy “Federal SAR resources to provide lifesaving assistance to State, tribal and local authorities, to include local SAR Coordinators and Mission Coordinators, when there is an actual or anticipated request for Federal SAR assistance.”15
Operational involvement may involve structural collapse, maritime/coastal/waterborne or land scenarios. FEMA is the ESF Coordinator. Other primary agencies include the US Coast Guard, the Department of the Interior/National Park Service, and the Department of Defense. Support agencies include the Departments of Agriculture, Commerce, Health and Human Services, Justice, Labor, Transportation as well as NASA and the US Agency for International Development.
The primary agency for each type of SAR depends on the setting. DHS/FEMA takes the lead for structural collapse urban search and rescue— US&R. DHS/US Coast Guard is responsible for maritime/coastal/waterborne events. For land SAR, responsibility resides with the Department of the Interior/National Park Service and Department of Defense.
Currently there are 28 US&R task forces distributed throughout the US. The goal is 6 hours from notification of need to departure. All teams are prepared to be self-sufficient at the site for 3 days. Personnel categories include search, rescue, medical, and technical.16 Nationwide, many EMS physicians serve on urban search and rescue teams as medical providers in support of other team members who find and rescue victims. They provide care both for team members and patients.
ESF 11 may not seem to impact the health and medical community until it is viewed in these terms: “nutrition assistance, response to animal/plant diseases and pests, safety of meat, poultry, and egg products, protection of natural and cultural resources and historic properties and the safety and well-being of household pets.”17 The EMS physician may become involved with response teams that use search dogs, shelters where pets are being cared for as well as people, or events involving the consumption of contaminated meat or foods. It is important to note that the epidemiology of these events may be a shared public health, Federal Bureau of Investigation, and Department of Agriculture function.
ESF 13 PUBLIC SAFETY AND SECURITY
ESF 13 includes “force and critical infrastructure protection, security planning and technical assistance, technology support, general law enforcement assistance to both pre-incident and post-incident situations.18 The Department of Justice (DOJ) is the ESF #13 coordinator and primary agency supported by the Bureau of Alcohol, Tobacco, Firearms and Explosives, the Drug Enforcement Administration, Federal Bureau of Investigation, Office of Justice Programs, and the U.S. Marshals Service. Other support agencies include Department of Commerce, Environmental Protection Agency (Hazardous Materials evidence response teams), and the Department of Energy (nuclear/radiological incident response).
The EMS physician may become involved with tactical medicine in support of law enforcement and SWAT functions and in support of detection and investigation of chemical, biological, and radiological incidents. A primary role will be facilitating operations from the health standpoint: evaluating occupational and environmental health needs, responder safety and health, logistics and operational needs coordinated with those section chiefs, and continued training and exercises where the process of ICS is refined, strengths and weaknesses identified and addressed and specific unit objectives achieved. In some areas, the tactical physician will be cross trained in the police academy.