Assistant Chief, Bureau of Medicine and Surgery (MED 02)
An attack against an installation using a Weapon of Mass Destruction would undoubtedly
be a devastating event. If that weapon were a biological pathogen, Military Health
Services commanders might be faced with a catastrophe not seen in the United States
since the Spanish Influenza epidemic of 1918.
In this four-part mini-seminar, participants will be exposed to the many and complex
issues that would be faced by the supporting healthcare system if such an event occurred.
Following a realistic scenario at a typical military installation, in which the consequences
of such an attack will progress at an alarming rate, subject matter experts will address
challenges of – and potential solutions to– this low probability but high severity event.
Participants will be afforded the opportunity at the completion of these presentations to
comment or ask questions of the panelists.
PRESENTATION SPEAKER TIME ABSTRACT
Introduction Steve Hart 0930-0940 <Page No.>
CAPT MC USN
BUMED (MED 02)
Scenario “Attack on Onslow” Vince Musashe 0940-1000 2
CAPT MSC USN
Weapons of Mass Destruction in the Jerry Mothershead 1000-1020 4
21st Century: Military Medicine and CDR MC USN
the Imperative of Homeland Defense NEHC
Healthcare Operations in the Wake Randy Culpepper 1030-1050 5
of a Bioterrorism Attack CDR MC USN
New JCAHO Standards: Disaster Robert Darling 1050-1110 6
Management CDR MC USN
CAMH Standards: Emergency 7
Speaker Biographies 9
Attack on Onslow
CAPT Vince Musashe, MSC, USN
In the News…
(Sunday Times) SADDAM PUTS ARMY ON ALERT TO
LONDON (JANUARY 7) Saddam Hussein showed that his grip on power was as firm
as ever yesterday. He marked Iraq's army day by making a defiant televised address to the
nation and establishing a new command headquarters for a special military force to
support the Palestine revolt against Israel if necessary, write Uzi Mahnaimi and Jon
The Hamorabi tank division of the elite Republican Guard has been moved from its
permanent barracks to the new headquarters at Al-Rabtah, west of Baghdad, where it is
on 24-hour standby.
The Iraqi headquarters and Saddam's promise to support the Palestinian uprising -
reaffirmed in yesterday's speech - are being closely monitored by Israel. It is expected
that heavy Iraqi armour would join Syria in any regional war against Israel. Ehud Barak,
the Israeli prime minister, predicts that such a war will break out if the Palestinian
question is not settled peacefully.
"The Iraqis have done it in the past - in 1973 - and there is no reason why they would not
do it again," said Professor Amtazia Baram, a leading Israeli expert on Saddam and
adviser to Israeli military intelligence.
However, the Israeli military is more concerned about a possible low-altitude attack by
Iraqi warplanes carrying chemical weapons than an armoured attack. Saddam's televised
address, glorifying the Iraqi army, appeared finally to have put to rest opposition claims
that he had suffered a serious stroke last weekend. The 63-year-old president appeared
healthy and robust in a dark brown suit and tie as he delivered his speech, marking the
80th anniversary of Iraq's armed forces.
(VNN) BUSH WEIGHS SENDING TROOPS TO ISRAEL
WASHINGTON, DC (JANUARY 22) High level government sources, speaking on the
condition of anonymity, confirmed today that President George W. Bush, in his first
week in office, is considering sending up to 20,000 armed military personnel to
Jerusalem in the wake of the latest Palestinian rocket attacks on the Holy City.
On Tuesday, five Israeli soldiers, and thirty Palestinians, were killed during an Israeli raid
on a north end apartment complex. A spokesperson for Palestinian Authority President
Yasser Arafat claims the attack was a bungled assassination attempt, directed by the
Mossad, Israel’s Secret Service. Israeli Prime Minister Ehud Barak has denied that
claim. In retaliation, Palestinian guerrillas destroyed four Israeli Police Stations in
occupied territory. No deaths have been reported. Arafat had just returned from a trip to
Baghdad to drum up more Arab support for the Palestinian positions.
Chief Palestinian negotiator Saeb Erakat stated no peace deal would be reached before
Barak faces re-election on February 6th, and predicted further significant deterioration in
negotiations if Barak loses to the hard-line opposition Likud leader Ariel Sharon. "We
don't believe a deal is doable at this time,” said Erakat.
Israeli peace envoy Gilead Sher stated that the key issue facing the two sides is the “Right
of Return” – the Palestinian demand that all Palestinian families -- and their descendants -
who were forced to leave what is now Israel when the Jewish state was founded in 1948
be allowed to return. “This is not negotiable,” said Sher.
A U.S. National Security spokesman said Bush is considering a variety of options, and
would make a decision on US intervention "within 2 to 3 weeks."
(Jacksonville Daily News) MARINES HOST FIREWORKS
Camp Lejeune (JANUARY 19) The Marine Corps Base Morale, Welfare, and
Recreation Department will host a gala fireworks display at 9 p.m. on February 19th at the
Main Parade Ground. The fireworks will cap a day of festivities beginning with a parade
through downtown Jacksonville in honor of All President’s Day. All Camp Lejeune
activities are open to the public. See this weekend’s Family Section for further details
Weapons of Mass Destruction in the 21st Century:
Military Medicine And the Imperative of Homeland Defense
CDR Jerry Mothershead, MC, USN
For any given community, disasters are rare, although in the aggregate, they occur
frequently. Most disasters in the United States have been of a category referred to as
multi-casualty incidents. These pale in comparison to those in other parts of the world.
Terrorism and technology make for a very bad combination. The recent attack on the
USS Cole in Yemen challenges the conventional wisdom that terrorists will only go after
the so-called “soft targets.” Of all “Weapons of Mass Destruction,” or WMD, biological
attacks pose the most serious threat - they are the most difficult for which to plan, and,
will result in a prolonged event, lasting up to several months. They result in little physical
destruction, but exact a heavy toll on health and lives. As such, the medical community
will find itself in the lead of disaster response, as opposed to its usual supporting role.
Very little was done to protect and defend the civilian population from such events until a
number of high visibility events moved the possibility of such incidents from the realm of
fiction to reality. Over the past 5 years, close to $50B has been spent, and numerous
organizations are involved, in improving our defensive posture. Still, our national
program remains sub-optimal. This is true for the federal government, and is true for the
Department of Defense (DoD).
There are three circumstances short of actual combat in which the Military Health System
(MHS) may find itself responding to incidents involving WMDs:
An attack or incident at a military installation;
In assisting local communities under the “immediate response clause” of current DoD
As part of a federal response under the Stafford Act (domestic) or at the request of the
State Department (foreign).
The Secretary of Defense will shortly submit a report to Congress on our preparedness to
respond to incidents involving WMDs on military installations. The MHS is crucial to
any effective WMD response, but is only one element of the overall DoD capability. If
DoD and the services are to be adequately prepared, there are some fundamental changes
in the “system” that must take place:
Organizational oversight must be simplified and streamlined, at all levels;
Response standards must be developed;
Response capabilities must be realistically evaluated and improved upon, at all levels;
Training requirements must be defined, refined and expanded; and
Funding, requested and received, must reflect this mission.
Healthcare Operations in the Wake of a Bioterrorism Attack
CDR Randy Culpepper, MC, USN
There are a number of things that healthcare system commanders can do to reduce the
effects of a bioterrorist attack. Some must be accomplished prior to the attack if they are
to be effective. These include:
Developing and maintaining a surveillance system to improve early detection of an
outbreak or disease complex that might be indicative of an attack.
Maintaining a high index of suspicion among healthcare providers and preventive
Enhancing existing disaster plans through partnerships with community healthcare
resources, using such models as the Mobile Metropolitan Response System
development program, sponsored by the Office of Emergency preparedness of the
Department of Health and Human Services.
Frequent testing and evaluation of developed disaster plans.
In the event of a bioterrorist attack on an installation, several critical tasks must be
accomplished during the initial several hours to days to reduce death and disability.
Although State and Federal resources will be able to extend and sustain operations, many
of these tasks will have to be started prior to arrival of these additional resources:
Protect the healthcare system and staff first. Little can be done for the victims if first
responders –who in a bioterrorist incident will be the medical community – fall victim
Contain the spread of the disease. Actions to identify the population at risk, provide
primary preventive interventions, and reduce further incidence of secondary or
continued spread are mandatory.
Expand the capacity of the existing healthcare system and resources to manage the
surge of patients that the attack will produce.
Address the psychological implications and consequences of the attack. Many
anxious but uninfected individuals will seek evaluation and treatment during the
initial phase of the disaster. Many members of the community, including healthcare
workers, will suffer long-term psychological sequellae if not adequately treated at
time of presentation.
Handling the dead. It is unlikely that in the short term, detection and surveillance
systems will reach the sophistication required to prevent all casualties, and many
potential bioagents have a high mortality, even with treatment. Few communities are
prepared to address a surge of fatalities, especially if special handling precautions are
Dealing with the media. The media can be a friend or a foe, but, if an attack occurs,
they will come.
New JCAHO Standards: Disaster Management
CDR Rob Darling, MC, USN
Historically JCAHO standards relating to emergency management, disaster planning and
preparation have been listed under the section titled the Environment of Care (EC)
Standards. In prior years, these standards focused mainly on the internal safety of the
Health Care (HC) facility, with a statement of requirement of a disaster plan. Practically
void of the facility's role or integration into a community response plan, JCAHO was
woefully behind in tasking HC facilities to prepare or educate their staff for response to
"all hazards" events, or integrate with the emergency management community as a viable
player with a crucial role in ensuring a successful community response.
The revisions to the EC standards are a significant move on the part of the JCAHO, and
very welcomed by those concerned over the relative lack of preparation and disinterest in
emergency planning and preparation on the part of healthcare systems. With so many
other concerns and challenges facing them, emergency and disaster preparation and
planning have typically been viewed as things that warrant attention only in times of
Most revisions related to emergency management went into effect July 1, 1999. EC
standards related to Emergency Management, Hazardous Materials, and Tabletop Drills
became effective January 1, 2001. JCAHO usually looks for a "track record" of
performance toward these changes over the prior year (at least 4 months for facilities
seeking accreditation for the first time).
Of the EC standards, 4 experienced significant revision that involves emergency
management. The details of these new standards and the ramifications of the revisions
will be discussed:
EC.2.9. Drills are regularly conducted to test emergency preparedness.
EC.2.10. Fire drills are conducted regularly.
EC.2.14. Utility systems are maintained, tested, and inspected.
EC.1.6. * A plan addresses emergency management. The standard prescribes new,
specific requirements of hospital disaster planning processes as well.
*This standard, and JCAHO intent, is appended on pages 7-8.
Standard EC.1.6. A plan addresses emergency management.
Intent of EC.1.6
The emergency management plan describes how the organization will establish and maintain a
program to ensure effective response to disasters [see note 1] or emergencies affecting the
environment of care. The plan should address four phases of emergency management activities:
mitigation, preparedness, response, and recovery. [See note 2]
The plan provides processes for
a. Identifying specific procedures in response to a variety of disasters based on a hazard
vulnerability analysis [see note 3] performed by the organization;
b. Initiating the plan (including a description of how, when, and by whom the plan is
c. Defining and, when appropriate, integrating the organization’s role with community-wide
emergency response agencies (including the identification of who is in charge of what
activities and when they are in charge) to promote inter-operability between the health
care organization and the community;
d. Notifying external authorities of emergencies;
e. Notifying personnel when emergency response measures are initiated;
f. Identifying personnel during emergencies;
g. Assigning available personnel in emergencies to cover all necessary staff positions;
h. Managing the following during emergencies and disasters:
Patient activities including scheduling, modification, discontinuation of services, control
of patient information, and patient transportation;
Staff activities (e.g., housing, transportation, and incident stress debriefing);
Logistics of critical supplies (e.g., pharmaceuticals, medical supplies, food supplies, linen
supplies, water supplies);
Security (e.g. access, crowd control, traffic control); and
Interaction with the news media.
i. Evacuating the entire facility (both horizontally and, when applicable, vertically) when
the environment cannot support adequate patient care and treatment;
j. Establishing an alternative care site when the environment cannot support adequate
patient care including processes that address (when appropriate)
Management of patient necessities (e.g., medications, medical records) to and from the
alternative care site;
Patient tracking to and from the alternative care site;
Inter-facility communication between the organization and the alternative care site;
Transportation of patients, staff, and equipment to the alternative care site; and
k. Continuing and/or re-establishing operations following a disaster.
The plan identifies
l. An alternative means of meeting essential building utility needs (e.g., electricity, water,
ventilation, fuel sources, and medical gas and vacuum system, etc.) when the
organization is designated by its emergency preparedness plan to provide continuous
service during a disaster or emergency;
m. Backup internal and external communication systems in the event of failure during
disasters and emergencies;
n. Facilities for radioactive or chemical isolation and decontamination; and
o. Alternate roles and responsibilities of personnel during emergencies, including who they
report to within a command structure that is consistent with that used by the local
The plan establishes
p. An orientation and education program for personnel who participate in implementing the
emergency management plan. Education addresses
1. Specific roles and responsibilities during emergencies;
2. The information and skills required to perform duties during emergencies;
3. The backup communication system used during disasters and emergencies; and
4. How supplies and equipment are obtained during disasters or emergencies;
q. Ongoing monitoring of performance regarding actual or potential risk related to one or
more of the following:
1. Staff knowledge and skills;
2. Level of staff participation;
3. Monitoring and inspection activities;
4. Emergency and incident reporting; or
5. Inspection, preventive maintenance, and testing equipment; and
r. How an annual evaluation of the emergency preparedness safety management plan’s
objectives, scope, performance, and effectiveness will occur.
1. Disaster is a natural or man-made event that significantly disrupts the environment of
care, such as damage to the organization’s building(s) and grounds due to severe
windstorms, tornadoes, hurricanes, or earthquakes. Also, an event that disrupts care and
treatment, such as loss of utilities (power, water, telephones) due to floods, civil
disturbances, accidents, or emergencies within the organization or in the surrounding
community. Disasters are sometimes referred to as “potential injury creating events” (i.e.,
2. Mitigation activities are those a health care organization undertakes in attempting to
lessen the severity and impact a potential disaster or emergency may have on its
operation while preparedness activities are those an organization undertakes to build
capacity and identify resources that may be utilized should a disaster or emergency occur
3. Hazard vulnerability analysis is the identification of hazards and the direct and indirect
effect these hazards may have on the health care organization.
Vincent W. Musashe, Captain, Medical Service Corps, United States Navy
CAPT Musashe is currently the Deputy Director, Medical Resources, Plans and Policy
Division on the OPNAV staff. He is board certified in Aerospace Physiology and has
spent the last 21 years working within operational medicine. He has completed the
Marine Corps Command and Staff Non-Resident Program and is a graduate of the Armed
Forces Staff College. Prior to coming to OPNAV, he was assigned to United States
Atlantic Command with duty at U.S. Army Forces Command, Fort McPherson, Georgia
where he served as the Chief Medical Mobilization Officer and Program Manager for the
Joint Regional Medical Planning Program, tasked with providing Department of Defense
medical liaison officers for interagency support in domestic disaster response operations.
During that timeframe, he was assigned to the Domestic Plans Branch and was
responsible for USACOM medical support for all domestic events. He provided medical
support for the Training Readiness Oversight mission for the certification of the current
Weapons of Mass Destruction Civil Support Teams. He was instrumental in the
incorporation of weapons of mass destruction training into the existing Department of
Defense Emergency Preparedness Course and is a past Course Director. CAPT Musashe
has been an invited speaker at many national and local disaster preparedness conferences.
Jerry L. Mothershead, Commander, Medical Corps, US Navy
CDR Mothershead is currently the Special Projects Officer for Chemical, Biological,
Radiological, and Environmental Defense at the Navy Environmental Health Center. He
is board certified in Emergency Medicine, and is the Surgeon General's Specialty Leader
for Prehospital Care and Emergency Medical Services. He has had various and extensive
experience in operational medicine, including humanitarian assistance operations and
combat support of Special Operations Forces during Operation Desert Storm. He is a
member of the National EMS Committee of the American College of Emergency
Physicians, the National Association of EMS Physicians Standards and Practice
Committee, and the Federal Interagency Committee on EMS, and has served as
consultant to or as a member of several DoD and national committees on emergency
operations and emergency medical services. He has authored numerous articles on
emergency medical services and disaster management, and is a requested national
speaker and lecturer on these topics.
Randall Culpepper, Commander, Medical Corps, US Navy
CDR Culpepper is currently stationed at the U.S. Army Medical Research Institute of
Infectious Diseases at Fort Detrick, Maryland. He is Head of Epidemiology and
Bioterrorism Surveillance and Assistant Head of the Operational Medicine Department.
He lectures and consults extensively on the medical management of biological warfare
and terrorism casualties and represents the United States in various NATO and allied
government organizations for biological warfare medical defense. He is board certified in
General Preventive Medicine and Public Health and has a Master's degree in Public
Health. Previous duty assignments have included Head, Occupational Health/Preventive
Medicine, Naval Hospital Great Lakes; Officer in Charge, Navy Environmental and
Preventive Medicine Unit 7 in Italy; and Head of Quality Management, Naval Hospital
Robert Darling, Commander, Medical Corps, US Navy
CDR Darling serves as Flight Surgeon and Medical Director of the Aeromedical Isolation
Team and Containment Care Unit at the US Army Medical Research Institute of
Infectious Diseases. Dr. Darling is a graduate of the Uniformed Services University of
the Health Sciences. He is board certified in Emergency Medicine and is a designated
Naval Flight Surgeon. He has academic appointments in Emergency Medicine at the
University of Maryland, the George Washington University School of Medicine and the
USUHS. Military tours of duty have included Carrier Air Wing Eight (CVW-8), the US
Naval Academy, and Naval Hospital Camp Pendleton, California. He was the first
emergency physician ever selected to serve the President of the United States as White
House Physician, from 1996 through 1999. He worked closely with the United States
Secret Service and other federal agencies, and was responsible for training medical staff
in various aspects of emergency medical response. Dr. Darling spearheaded the White
House Medical Unit’s efforts to defend against threats posed by weapons of mass
destruction, specifically chemical and biological weapons.