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National Association of State Emergency Medical Services Officials/ National Association of EMS Physicians

Resource Document - December 13, 2002

Domestic Terrorism: Issues of Preparedness Purpose:

This resource document addresses key EMS issues and components, which are required for the EMS preparedness and response to acts of domestic terrorism. At the present time, EMS systems are in jeopardy of "falling between the cracks" of federal initiatives for assuring the terrorism preparedness of public safety (fire and police) and public health. This document identifies the critical EMS resources that require immediate attention at state and territorial levels nationwide to assure the safety of EMS responders and strengthen their ability to respond effectively to acts of terrorism.


The National Association of Emergency Medical Services Officials (NASEMSO) is an organization of state EMS directors and physician medical directors from each of the 50 states and the U.S. territories. State EMS directors are responsible for the development and oversight of EMS and trauma systems at the state level, and for the regulation of EMS. NASEMSO provides vision and leadership in the development and improvement of EMS systems and national EMS policy.

The National Association of EMS Physicians (NAEMSP) is an organization of physicians and other professionals who provide leadership and foster excellence in out-of-hospital emergency medical services. The membership of NAEMSP represents the medical community in assuring the quality of medical care provided by EMS systems.

EMS systems provide the emergency health care response, treatment, and transportation to any person with an acute medical or traumatic problem. EMS represents the intersection of public safety and public health. This role requires EMS to respond to emergencies as a first responder in the public safety role, such as on September 11th, as well as integrate with the health care system, as a medical care provider.

We must learn from past terrorist events and be prepared for the future. This document serves to point out issues of concern within the EMS community and to describe the priorities for the funding and development of this critical EMS infrastructure across the country. The delivery of EMS takes many forms including private for-profit, private non-profit, fire based, hospital based, etc. Some organizations provide emergency medical care and transportation by ambulance, while others provide emergency care at a scene and then transfer the patient care to a ground or air ambulance crew for transport. Irrespective of configuration, all EMS organizations are part of an integrated EMS system of care. While current federal initiatives are beginning to address the needs of some EMS provider organizations, the needs of EMS systems have not yet been addressed.

EMS is currently challenged on a day-to-day basis to balance the level of care needed within each community given the available resources, including personnel, and training required for providing service. Each of the items described below are important for EMS to deliver needed services in the event of an act of terrorism. Funding is required not only for initial resources, but also to create an infrastructure of domestic preparedness, which will be a long-term component of the ongoing operations of an EMS system.

Support for EMS systems occurs at national levels, state levels, and local levels. To the extent possible, the level where funding is necessary has been identified. This document represents a work in progress and will be updated as federal support becomes available or as the details of need can be more precisely described.

EMS Systems

Planning, coordination, infrastructure, and mutual aid

EMS systems must integrate and collaborate with the relevant partners on issues of domestic terrorism preparedness. This collaboration must cross the public/private sectors, branches of government, and political jurisdictions of friends and competitors. Effective planning must take place beginning at the local level and continuing seamlessly to state and national levels. Plans must include provisions for mutual aid in anticipation of events that will outstrip local resources. EMS brings significant resources to bear for leadership in planning and coordination. Systems collectively have an existing work force of medically trained responders as an essential resource.

EMS systems are neutral with respect to a local choice of EMS provider type. EMS must integrate with public health departments, fire services, hospitals, training institutions, and other agencies in a collaborative and positive manner. Funding for this should be part of the infrastructure within each state for EMS disaster preparedness, including plans, operational protocols, policies and procedures. A dedicated position within each state office of EMS is required to establish and coordinate this process.

Funds needed: $28,000,000

$500,000 per state and territory

These funds will support:

At least one EMS planning/coordination specialist for each state

Support for a planning process to assure appropriate EMS involvement in all aspects of state level terrorism preparedness

Communications of plans from the state EMS level to local EMS providers

Purpose: This funding will allow state EMS offices to be represented in state level terrorism planning efforts and to facilitate the distribution of state plans to local EMS agencies. It will provide a personnel resource to assist with local EMS planning initiatives.

Medical Direction

Physician emergency medical directors are an essential component of EMS systems. They provide medical leadership, oversight, coordination, access to best practices, and research in order to assure the best possible EMS system for our patients. EMS medical direction requires political, administrative, and financial support to achieve these goals. Critical issues for EMS Medical Direction are: standardized planning and treatment protocols; local, regional, state, and national coordination of best practices; education and training for EMS personnel and EMS physicians; evaluation of data and assistance with EMS resource allocation; and quality management of the state EMS system. With the integration of EMS systems, hospitals, and trauma systems, medical direction is also needed at the regional level for many states as well.

Most states have little or no current funding for a state EMS medical director. Even fewer states have funding for a regionalized structure of medical direction. Funding of a full time state EMS medical director with the necessary administrative support requires $250,000/state per year. Regionalized medical direction would cost an additional $150,000/state per year in states with significant geography.

Funds needed: $17,900,000

$250,000 for each state and territory to support a state EMS Medical Director

$150,000 for 25 states to support regional medical direction activities

These funds will support:

Physician involvement in the oversight of EMS care provided to patients including those from terrorist events

Physician involvement in the system design of how terrorist patients can best be cared for

Physician resources for EMS training and education activities related to terrorism

Purpose: EMS represents the intersection of public health and public safety. Without committed physician involvement, EMS cannot assure that patients will receive proper care at the right place in an appropriate time frame.

Workforce Development

Personnel shortfalls exist across the country with respect to EMS services. In many states EMS is heavily dependent upon volunteer personnel. A national effort on the part of Congress to promote EMS as a career, and to address recruitment and retention by providing $52,400,000 dollars in assistance for EMS educational scholarships and recruitment programs. The National Highway Traffic Safety Administration (NHTSA) has played a central role in supporting the development of sustainable EMS systems of care at state levels and should be tasked with assisting states in the development of recruitment and retention resource materials.

Funds needed: $52,400,000

These funds will support:

$5,000 scholarships for 10,000 individuals enrolling in EMS training

$25,000 for each state and territory to implement a statewide recruitment and retention program

$1,000,000 to NHTSA to coordinate the design and distribution of national resource materials for EMS recruitment and retention

Purpose: Expenditures in this category will assist states and ultimately local communities in assuring the adequacy of their EMS workforce.

Education and Exercises

Educational programs for domestic preparedness is needed throughout the country for EMS personnel, administrators, and local medical directors. Most EMTs have little or no formal training in response to acts of terrorism. Funding is needed to provide for standardized course content, travel, and materials for this large-scale effort. This terrorism training must also become part of the initial training curriculum for all EMS personnel. Once planning and training have occurred, exercises must be conducted on a periodic basis. The exercises will serve to identify opportunities to improve the system plans, allow personnel to practice their skills, and test preparedness.

Funds needed: $85,000,000

These funds will support:

$1,000,000 to NHTSA for updating terrorism related content in the national standard EMS curricula.

$500,000 to each state and territorial EMS office to support the integration of medically appropriate awareness level training for EMS personnel into initial and continuing education programs.

$500,000 to each state and territorial EMS office to support the delivery of specialized programs on the EMS management of nuclear, biological and chemical terrorism incidents.

$500,000 to each state and territorial EMS office to support exercises.

Purpose: Training is a key to EMS preparedness. Funding in this section will support the inclusion of relevant material into initial EMS training programs. It will also support the delivery of specialized training for current EMS providers and periodic exercises.

Protective Equipment

The purpose of EMS personal protective equipment (PPE) is often quite different from the PPE necessary for firefighting or hazardous materials response. As an example, self contained breathing apparatus (SCBA) is the standard of respiratory protection for operations in environments with smoke or other harmful gasses. SCBA is not practical or necessary for most EMS activities other than initial rescues and decontamination. EMS respiratory protection is more commonly necessary to prevent the transmission of disease through airborne exposures. Barrier clothing for EMS personnel is generally lighter than what is required for firefighting and is commonly made to be disposable. Funding should be provided for the relevant personal protective equipment so that EMS personnel can be protected in the line of duty.

Funds needed: $28,000,000

These funds will support:

$ 1000 per EMS vehicle (500 per state average) to state and territorial EMS offices to purchase and distribute standardized protective equipment packages for EMS providers that do not already have this protection available.

Purpose: Funding in this category is to support states in assisting local EMS organizations to close an existing gap in personal protection for their personnel. Equipment supported here is for basic respiratory protection and other PPE that will enable EMS providers to retreat from hazardous environments and transport patients after they have been grossly decontaminated at hazardous emergency scenes.


EMS systems will be a part of the first response to any biological or chemical attack. Antidotes and medications appropriate for the identified agent must be available for EMS at the time of the initial response. This requires prescription drugs, to be stocked on ambulances and other EMS response vehicles for use by protocol on the EMS workers, fire, police, patients, and other response personnel.

Funds needed: $14,000,000

$500 per EMS vehicle (500 per state average) to state and territorial EMS offices to support the purchase of emergency pharmaceuticals.

These funds will support:

Purchase of essential pharmaceuticals for the initial scene management of specific biologic and chemical exposures

Purpose: Funding in this category is to supply EMS responders with a relatively small quantity of the necessary pharmaceutical supplies to be prepared for an initial response that may involve exposure to the responders as well as other patients. Purchases here are separate from the national pharmaceutical stockpile program and other federal initiatives that may provide vaccinations to health care workers in advance of terrorist strikes.

Data and Information System Surveillance

Complete EMS data is missing at the regional and state level in over 90% of the states. Data is an important component to a coordinated EMS response and surveillance system. EMS will be the initial contact in the majority, if not all chemical, nuclear, or biological events. EMS data systems can monitor the patient population that EMS serves for signs of biological outbreaks. This data can be compared to the day-to-day normal trends to determine if an outbreak has occurred and where it is located within a community. EMS data is also critical from a resource utilization perspective. The ability to know what resources are available in a timely manner, with respect to equipment, personnel, and expertise is essential. Real-time EMS data must be collected at the local level and provided to the state EMS offices to integrate with local and state public health initiatives.

Funds needed: $84 million

These funds will support:

An average of $1.5 million per state and territory to provide the necessary hardware, software, and technical expertise to establish functional EMS data and information systems in each state and territory.

Specific needs will vary from state to state.

Purpose: EMS data may provide the first identification of an evolving terrorism event. Funding in this category will allow states to establish EMS information systems and link them with other public health disease surveillance.

Trauma System

The state offices of EMS are typically the home of and regulatory authority for state trauma systems, which began to be developed in the early 1970s. Integration of the trauma system and EMS is a critical link to a systematic approach to domestic terrorism preparedness. Optimal management of injuries from a terrorist event is dependent upon the existence of the same system of trauma care that handles patients from car crashes, falls, fires, violence and other mechanisms. Trauma systems in most states are struggling at this time due to a variety of resource issues including patient volume, a lack of qualified specialty personnel, and finances. Funding is needed nationally to begin the process of incorporating trauma centers into state plans for networked domestic terrorism preparedness. This funding will not address the current problems trauma centers experience on a daily basis, nor does it provide funding for hospital preparedness to management a terrorism event. The funding does create the infrastructure for coordination, data collection, and implementation of the trauma care system within the states, and on an interstate level as necessary.

Funds needed: $112,000,000

$2,000,000 (average) to state and territorial EMS offices to establish trauma systems

These funds will support:

Trauma system planning and coordination

Protocol and policy development

Trauma registry implementation

Establishment of a quality improvement process

Purpose: Preparedness to deal with injuries from acts of terrorism begins with the foundation of a functional trauma system. The organization and planning of a trauma care system involves the coordination of available pre-hospital and in-hospital resources. While many states have begun the process of developing their trauma systems, most have significant work remaining.


September 11th as well as other disasters have revealed the significant weakness each state or municipality has with respect to communications systems. Standard telephone, cellular telephone, and other routine communications systems become overwhelmed. Redundant, secure, and exclusive radio and other communications systems are required for effective EMS communications during a disaster or crisis event. The need to link EMS communications with other public safety and healthcare resources is vital. The Unified Command Suite developed by the National Guard and deployed in 22 areas nationwide is one approach to this issue. Funding for one of these mobile communication terminals for each state is a start in correcting this significant weakness.

Also, the general communications infrastructure for EMS and public safety is aging. Many rural areas have never achieved adequate systems to communicate within EMS, much less, within a larger conglomerate of organizations during a terrorist event. Funding is needed initially to provide a state-by-state assessment and target critical improvements while identifying additional needs which would require additional funding in later years.

Funds needed: $40,500,000

28,000,000 for state and territorial EMS offices nationwide to perform comprehensive EMS communications needs assessments and develop communications plans.

12,500,000 ($500,000 average for 25 states or territories) for the purchase of mobile command suites to support on site operations.

These funds will support:

An identification of EMS communications needs in each state and territory

Mobile command suites for areas that do not currently have access to this technology

Purpose: Communications has been a historical challenge in the management of significant mass casualty or disaster events. EMS communications in many states is using outdated technology that cannot link with other response partners. Assessments and plans must be created to address communications needs in light of anticipated responses. Mobile command suites will make an immediate improvement for operations at major incidents.

The Worried Well

Since September 11th, a significant proportion of EMS services nationwide have expended time and resources responding to "feared" events of terrorism, such as anthrax letters or chemical events. Even hoax events significantly tax day-to-day EMS system operations. Protocols, policies and procedures are necessary to identify when EMS truly required and when these events can be dealt with using fewer EMS resources. Alternative treatment centers must be identified; data collection, hazard identification, and reporting methods must be put into place. Funding for this initiative must be included in the Infrastructure of the EMS system and is included in the medical direction, information systems, and planning components described above.

Total EMS Need- $461,800,000

Additional funding is needed on an ongoing basis to support this initiative and infrastructure.