Chapter Two
The Basics of Emergency Response

President Dwight D. Eisenhower once remarked: "Plans are useless, but planning is indispensable."²⁵ Eisenhower, who had served as supreme commander of Allied forces in World War II, was referring to military battles when he made that comment. Military commanders routinely draw up detailed battle plans before engaging an enemy force, even though no battle ever goes exactly as planned. Surprises from enemy forces, equipment malfunctions, human error, and the general chaos of combat simply make it impossible to formulate a perfect battle plan. Nevertheless planning is essential. Using the accumulated wisdom gained from previous battles and wars, along with whatever (usually limited and imperfect) information is available about the enemy, good military commanders try to ensure that their troops are prepared to deal with the inevitable surprises of battle.

Homeland security efforts follow a similar approach, particularly the efforts that are being made to prepare for a possible future terrorist attack on U.S. soil. Terrorists have to their advantage the element of surprise. It is likely that there will be little or no prior warning of when, where, or how the next attack will occur. As in conventional warfare, the unpredictable nature of terrorism underscores the importance of planning even as it makes formulating a perfect attack-response plan impossible.

Terrorism and Emergency Response

The United States has relatively little experience in dealing with terrorist attacks; indeed, few American civilians were familiar with the concept of "homeland security" before the September 2001 attacks. The two major terrorist attacks prior to September 11 were the bombing of the basement of New York City's World Trade Center in February 1993, in which 6 people were killed, and the bombing of the Alfred P. Murrah Federal Building in downtown Oklahoma City in April 1995, in which 168 were killed. Homeland security planners are able to draw on the lessons that were learned in responding to these attacks as well as the attacks of September 11.

However, while the firefighters, police officers, and medical workers who responded to these terrorist attacks had, for the most part, little experience in responding to terrorist threats, these first responders were trained to deal with a wide variety of potential disasters of both natural and human origin. The planning and procedures that these cities had in

place for general emergencies served them well when they were confronted with a terrorist attack. The challenge is to incorporate the possibility of a terrorist attack into these broader plans meant for dealing with emergencies such as fire, earthquake, explosion, or flood.

By placing U.S. terrorism-response plans in a broader context, homeland security planners take advantage of the fact that most cities are already familiar with the basic steps that must be taken in response to a disaster. As a report on homeland security from Harvard University's John F. Kennedy School of Government explains, cities' attack-response plans should not try to reinvent the wheel:

There is no benefit, and potentially much harm, in adopting new programs when old ones will do. Although the terrorism threat is evolving continuously, many of the existing practices and policies of first responders can be utilized to assist in homeland security.²⁶

The existing practices and policies the report refers to center around several areas that are key to emergency response regardless of the type of emergency. In very broad terms these areas are communications, mass medical care, protective actions, and recovery.

Communication is one of the most important—and most overlooked—elements of emergency response. There are two critical types of communication that must be preserved in the event of a terrorist attack: (1) the ability of public officials to inform the public, and (2) the ability of first responders to communicate with each other in order to coordinate their efforts.

Informing the Public

The first type of communication—informing the public—is vital to avoid panic. FEMA explains that:

Terrorism is designed to be catastrophic. The intent of a terrorist attack is to cause maximum destruction of lives and property; create chaos, confusion, and public panic; and stress local, State, and Federal response resources. Accurate and timely information, disseminated to the public and media immediately and often over the course of the response, is vital to minimize accomplishment of these terrorist objectives.²⁷

An effective emergency-response plan must therefore address how emergency information will be disseminated to the public.

The mass media—primarily television and radio—are the most reliable and productive ways for first responders and government officials to inform the public. Maintaining good relationships with the media is a regular part of state and local emergency management offices' operations. "With 24-hour news," writes Frances Edward-Winslow, director of emergency preparedness for the city of San Jose, California, "it is possible to provide life-saving information to many

community members in a short period of time, and often in multiple languages."²⁸

This was certainly the case on September 11, 2001. While the media reported on a few false alarms in the first few hours of the coverage that day, for the most part the nation's television and radio networks kept the public informed and helped avert panic. The major television networks covered the attacks around the clock, and many cable networks suspended their own programming in favor of covering the developments in New York City and Washington, D.C. In the weeks and months after the attacks, some pundits criticized cable news channels for their nonstop postattack coverage of September 11. However, most agreed that, on the day of the attack, they provided a major public service. "Journalists are first responders," asserts Randy Atkins, a senior media relations officer for the National Academy of Engineering. "Not only do they sometimes get to the scene first, but they are the only ones focused on and able to describe the level of risk to the public. They can save lives through the efficient delivery of good information."²⁹

Many news agencies developed emergency-response plans to help reporters respond to possible future attacks. Newspapers and magazines such as USA Today and U.S. News & World Report have contingency plans to meet at backup newsrooms in the event that access to their main offices is disrupted. Journalists' safety is also a concern. "WNBC-TV in New York has outfitted most of its news vehicles with nuclear, biological, and chemical kits that contain protective body suits, gas masks, gloves, booties, tape, and water," reports Rachel Smolkin in American Journalism Review, and "CBS News, based in midtown Manhattan, has provided protective body suits, gas masks and escape hoods, as well as training in their use, to crews, producers and correspondents in major U.S. cities."³⁰

Communication Among First Responders

The second type of key emergency communication—first responders keeping each other informed and coordinating their efforts—is one of the greatest challenges facing emergency-response planners. Public policy professor Viktor Mayer-Schönberger provides a vivid illustration of the challenges faced by law enforcement officers and other emergency personnel who responded to the April 1999 Columbine High School shootings, in which two students shot fifteen students and teachers and wounded dozens more. During that disaster, first responders did not know how many attackers they faced or what the attackers' goals were. Screaming students were fleeing the school; others were wounded and needed medical attention. Mayer-Schönberger writes:

Yet as it turned out, the biggest challenge on that Tuesday afternoon was not battling the two attackers…. The biggest challenge was coordinating heavily armed and ready-to-fire police forces from half a dozen sheriff's offices and twenty area police departments, forty-six ambulances, and two helicopters from twelve fire and EMS agencies, as well as personnel from a number of state and federal agencies.³¹

The problem, explains Mayer-Schönberger, was fundamentally a technical one. Different agencies—local police, state police, firefighters, and others—each used different radio systems. The cellular phone network became over-loaded as hundreds of journalists and first responders converged on the scene. Responders essentially had no way of communicating other than face-to-face. "The real miracle of Columbine High," says Mayer-Schönberger, "is that nobody else got killed because of the complete communications breakdown, either through friendly fire or uncoordinated agency activity."³²

Similar communications breakdowns occurred during the 1993 World Trade Center bombing, the 1995 Oklahoma City bombing, and the September 11 attacks. In Manhattan on September 11, for example, intercommunication between police made them aware of some dangers that firefighters were not. More effective communications systems could have saved lives. As Dale Craig reported in the Journal of Counterterrorism and Homeland Security:

Police helicopters circling the World Trade Center on September 11th, for example, could see that the first tower was on the brink of collapse. While those in the helicopter could communicate with police units on the ground they were unable to talk directly to the firemen and others inside the building to warn them of the impending catastrophe.³³

And in Washington, D.C., emergency workers from ten different jurisdictions arrived to help victims of the attack on the Pentagon—but because they used different radio frequencies, their efforts were initially marred by confusion and delay. Ultimately, says Arlington County fire chief, Edward P. Plaugher: "We relied on communications technology perfected by the ancient Greeks: carrying messages on foot."³⁴

Each of these incidents demonstrated the need for inter-operability—the linking of communications networks among different emergency agencies. By 2003 most cities and towns still did not have fully interoperable communications systems

because of the high costs involved in implementing them. "According to some estimates," reports Craig, "it would cost up to $500 million for a major metropolitan area like Los Angeles to convert all of the current radios used by its fire, police, and emergency workers to a single network."³⁵

A wide variety of solutions has been proposed to make first responders' communications systems interoperable, some involving satellite uplinks, digital radio systems, cellular phone carriers, and wireless computer networks. In addition to cost a major challenge is getting so many different emergency units to adopt a common set of technologies and protocols that would help them to act in concert. Homeland security officials agree that universally accepted operability standards and equipment are needed, but such standards may take years to implement.

Mass Medical Care

In the meantime one thing that is certain is that in the event of an attack, many people will need basic emergency medical services (EMS). One of the first things that any emergency-response plan must address is how to provide EMS as quickly as possible to those who need it. For smaller-scale emergencies, medical services are generally provided by paramedics and emergency medical technicians (EMTs) who treat victims at the scene and during transport to local hospitals via ground or air ambulances. Emergency care is then provided according to the hospital's normal procedures. Throughout the country variations on this general system have been tested by countless automobile crashes, fires, and other emergencies.

The main concern is that a terrorist attack could overwhelm a community's EMS capabilities. For small-scale terrorist incidents, conventional EMS is likely to be adequate. If a car bomb injured dozens of people, for example, the EMS response, at the scene and at the hospital, might not be very different than for a serious traffic accident. Likewise EMS resources in New York City and Washington, D.C., were able to respond effectively to the September 11 attacks. (The

extreme violence of the World Trade Center collapse left relatively few survivors with serious injuries.)

Homeland security experts warn, however, that normal EMS procedures could be inadequate for large-scale terrorist attacks. Few physicians have handled true disasters—incidents in which hundreds or thousands of people with severe or unique injuries strain available medical resources. "A true mass casualty situation is not like your typical Saturday night influx of multiple casualties into an urban trauma center," cautions Eric R. Frykberg, a surgeon at the University of Florida. "There are certain things you have to change in your approach, and it's important for surgeons and trauma experts to be aware of that."³⁶

When Resources Are Overwhelmed

One concern is that a hospital's resources could be overwhelmed fairly quickly. Since the early 1990s, in order to curb the rising costs of health care, hospitals have been working to reduce unnecessary spending. The result is that many hospitals have enough resources to handle day-to-day operations but not much more. "Hospital emergency departments are now commonly filled to capacity during daily operations and must divert even critically ill emergency cases,"³⁷ writes a group of physicians for UF News.

The most common solution to what emergency medical planners refer to as "surges" in demand for medical services is to divert patients to other hospitals. An effective emergency-response plan designates not just which hospitals are to be the main destinations for attack victims, but also the network of hospitals and trauma centers that will serve as secondary destinations for EMS personnel.

But in a large-scale attack, an entire area's medical resources could be quickly overwhelmed. Over the course of hours and days, victims can be transported to out-of-area medical facilities, and agencies such as the Red Cross can set up mass-care facilities to supplement area medical services. But in the crucial first minutes and hours after an attack, medical first responders must change their normal approach. As Frykberg explains:

Typically, in everyday medical care, everyone who's injured goes to the hospital, and we use our maximum resources on each patient…. The challenge in a mass casualty situ ation is in keeping most patients out of the hospital, not bringing them in. A change in mindset has to occur. Otherwise it will overwhelm the hospital's ability to sort out the relatively few injuries that need major treatment from the tremendous number that don't. If you don't handle it properly, existing evidence clearly shows this can lead to unnecessary loss of lives.³⁸

This process of sorting victims by immediacy of treatment needed is known as triage. In triage EMS personnel must quickly decide which victims need first aid immediately and which can wait, which victims should be first to be taken to the hospital, and which patients can be saved and which cannot. Such life-and-death decisions are more associated with wartime battlefields than with civilian emergencies, and in fact homeland security planners may look to the military for lessons in how to deal with massive casualties.

Large-scale emergency response becomes even more complicated in the event of a WMD attack involving chemical, biological, or radiological weapons. Whereas in a conventional bombing most of the destruction is limited to the initial explosion, WMD attacks can become more destructive over time as more people are exposed to the hazardous substance(s) in question.

Depending on the type of weapon, EMS personnel may need to decontaminate affected individuals in order to remove the hazardous substance from the victim and keep it from spreading to others (including the EMS personnel themselves). According to the Council on Foreign Relations, many hospitals are ill-equipped to deal with a WMD attack. "Even a [major] trauma center like Boston Medical Center, which

is certified to treat the most serious injuries around the clock, can only decontaminate about 20 patients at a time."³⁹

Decontamination procedures will vary depending on the hazardous substance in question. Exposure to radiation, for example, requires specific types of treatment, while a bioterror incident could involve infectious diseases that should be met with immunizations and possible quarantines. EMS and hospital personnel must train and prepare for each of the various responses to different WMD so they can ascertain what types of specialized treatment attack victims will need.

Decontamination is what FEMA calls a protective action—an umbrella term that refers to many different steps that first responders may take to minimize casualties at the scene of attack. While decontamination is an appropriate protective action for several types of WMD attacks, there is one protective action that could be applied to almost any major terrorist attack: evacuation.

Evacuations

On the most basic level, evacuation involves simply getting people away from danger. Small-scale evacuations are an integral part of attack response. Particularly in the event of a biological, chemical, or radiological attack, officials would almost certainly require people to evacuate the immediate area in which the hazardous substance was released. Larger-scale evacuations, however, are much more difficult. There are enormous challenges involved in evacuating all but the smallest cities in the United States.

Emergency planners can point to plenty of real-life examples that demonstrate the logistical nightmares that evacuations entail. For example, Johanna Neuman, of the Los Angeles Times, notes that: "In Florida in 1999, 2.5 million people hit the highways to escape Hurricane Floyd—at least 1 million more than authorities expected."⁴⁰ The evacuation resulted in massive traffic jams. Some motorists were stuck in their cars for ten hours on stretches of interstate that normally take two to three hours to traverse. With 2.5 million evacuees, the Hurricane Floyd evacuation was the largest in U.S. history. In comparison the Census Bureau estimates that 8 million people live in New York City (1.5 million in Manhattan alone); 3.7 million live in Los Angeles; and 2.9 million live in Chicago. Evacuating such large numbers of people in a short period of time may simply be impossible.

For an evacuation to be successful, local authorities require the cooperation of those being evacuated. As a Red Cross attack-readiness pamphlet explains: "If local authorities ask you to leave your home, they have a good reason to make this request, and you should heed the advice immediately. Listen to your radio or TV, follow the instructions of local emergency officials."⁴¹ However, there are a variety of

reasons that some people may choose not to evacuate immediately. One consideration is parents' concern for their children. For example, as Neuman asks: "If parents are instructed to head north while their children are at a school to the south, will they obey a police officer's order?"⁴² Another concern is pets. Many pet owners consider their pets family and will not leave them behind, but evacuee shelters set up by the Red Cross and other agencies often refuse to accept animals. On an individual level these concerns may seem reasonable, but on a city-wide scale individuals' personal priorities could foil authorities' efforts to orchestrate a timely evacuation.

All these potential problems mean that large-scale evacuation is an option of last resort for most cities. Nevertheless it is an option to be used in certain scenarios. According to Don Jacks of FEMA: "Evacuation is still the primary protective measure in the event of a nuclear incident."⁴³ If terrorists ever threatened to attack with a nuclear weapon—a scenario that is considered highly unlikely—evacuation might be the protective action that would save the most lives.

For security reasons most states and cities keep their evacuation plans secret. One exception is the District of Columbia that, since September 11—according to Neuman—has become a model of emergency planning: "In the event of an emergency, traffic lights are to be synchronized between Washington and its feeder suburbs in Virginia and Maryland. The city has installed 750 signs showing motorists the way out."⁴⁴

Search-and-Rescue Operations

Once the attack itself is over, the focus of emergency response shifts to recovery. For conventional attacks the critical first phase of recovery is search and rescue. Emergency workers differentiate between light and heavy search-and-rescue operations. "Light search and rescue operations are designed to provide an initial search …to locate victims with minor or no injuries and help them exit from lightly damaged [disaster areas],"⁴⁵ states a Los Angeles County fact sheet. Light search-and-rescue operations are often conducted by firefighters, but other emergency workers and even average citizens may lead or assist in light search-and-rescue efforts.

Heavy search-and-rescue operations involve locating, rescuing, and the initial medical stabilization of persons trapped in hard-to-reach spaces. Members of heavy search-and-rescue units are trained in emergency medicine and may include physicians. Members of search-and-rescue teams also possess an understanding of engineering, construction, and structural design. Such knowledge is vital in identifying both potential air pockets within collapsed buildings and parts of the buildings that may still be unstable. Canines can be part of these teams as well. In New York City after September 11, specially trained search-and-rescue dogs equipped with cameras, microphones, and infrared sensors capable of detecting body heat were used to search small air pockets for survivors.

Search equipment may include common building supplies such as concrete saws, jackhammers, drills, lumber, and rope, which are used to safely and slowly remove victims from the rubble. Other search tools are becoming increasingly high tech. As a FEMA report describes: "Snake-like cameras and fiber-optic scopes are used to locate victims trapped in rubble. Sensitive listening devices that can detect even the slightest human sound locate victims who are still alive."⁴⁶ Heavy search-and-rescue units may make use of construction vehicles if necessary, or of helicopters to provide the search team with an aerial view of the search area. Generators, lights, radios, cellular phones, and laptop computers may be used to maintain communications during a search.

Search-and-rescue units also have medical equipment and supplies available and are usually supported by a logistics section that provides the unit with the resources necessary to work around the clock—for example, cots, food and water, and cold-weather gear. The longest that earthquake victims trapped beneath collapsed buildings are known to have ever survived is thirteen days, so search-and-rescue efforts typically continue for at least two weeks.

Providing for Victims' Physical and Psychological Needs

Other recovery measures include finding food, water, and shelter for attack victims whose homes might have been destroyed. State and local governments, or organizations such as the Red Cross and the Salvation Army, may set up emergency shelters to meet these needs. The public can also play an important role here. For example, after September 11, many communities set up emergency call centers and others expanded their "211" services. People can call 211 to access health and human services information in the event of an emergency; they can also volunteer to help others. United Way president, Brian Gallagher, says that in the days after September 11, when hundreds of travelers were stranded at Hartsdale Airport in Atlanta, "Residents of Atlanta started calling 211 offering their own homes for people to stay and they were connected to people who needed help."⁴⁷

Once the physical needs of attack victims have been addressed, emergency-response officials can turn to the psychological and emotional consequences of the attack. Terrorist attacks, by their nature, traumatize more than just their immediate victims. As a report from the Harvard University John F. Kennedy School of Government notes: "While the 2001 attacks on the World Trade Center and the Pentagon resulted in thousands of deaths and physical injuries, the psychological casualties numbered in the tens to hundreds of thousands…. Indeed, these psychological effects are integral to the 'success' of terrorist actions."⁴⁸ The Red Cross includes mental health services as part of its overall efforts to help communities that have suffered a disaster.

As in every stage of emergency response, communications are critical. A well-informed public is more capable of coping with the natural fears that accompany an attack than a population that is left to guess about what threats are imminent. A continuous stream of calm, timely public information is necessary to begin managing the long-term consequences of a terrorist attack. It is at this stage that the work of emergency responders ends and the work of local, state, and national leaders begins.