Welcome, everyone. We'll begin in just a moment. We're allowing the residents and other registrants of this webinar to join the webinar. Welcome. Okay, welcome everyone. To be respectful of everybody's time, including the panelists and the attendees, I'll go ahead and get started. My name is Anita Balan. I'm the ACPM Director of Residency Engagement and Development, and we are thrilled to offer you these series of webinars that Dr. Miriam Alexander will explain shortly. Just to cover a couple of housekeeping things, this webinar will be recorded, and ACPM will be happy to send instructions as to how this recording can be accessed by current preventive medicine residents. We will post the evaluation survey on the chat towards the end of the webinar. Please take a few minutes to complete the evaluation survey, and it will also be sent to the attendees. This is a pilot, so your, you know, your evaluation feedback would be very useful for us. Our featured speaker and lecturer today, Dr. Barnett, will be covering the answers, doing the Q&A session towards the end. So please pose all of the questions in the Q&A box, and we will hold off for the final 10 minutes for the Q&A session. With that, Dr. Alexander, floor is yours. Hi, good afternoon, or good evening for those of you. I'm very excited to bring this project to fruition. This is a project that has been long in the making, and the idea behind this always was to be able to provide residents across the country and other preventive medicine physicians the opportunity to cover topics that are important for a preventive medicine physician to know that they might not have been able to get in their own education. And what we've done is we have multiple purposes in picking these topics. Most importantly, there are topics that really need to be known by preventive medicine physicians, but also there are topics that program directors need to be able to evaluate their residents on. So what we've got planned is a series of 12 and 13 webinars that will be delivered over the next, say, four to five months. And we're going to then have on May 5th at the annual ACPM conference, a half a day of skill-based workshops only for residents. And it'll give you an opportunity to meet some of the people you may have talked with over these webinars, but also really an opportunity to begin to meet preventive medicine physicians from around the country who will then be your colleagues for the rest of your career. I can't tell you how important that has been for me in my 30 years in preventive medicine, meeting the PrevMed residents who were my compatriots when I was a PrevMed resident. And in those skill-based workshops, we're actually going to take real world examples, things probably that will have happened within a month before May 5th, and really utilize the material that we've learned over these 12 webinars series. And we're hoping eventually to turn these into a CME that ACPM can offer to all of our membership and to all other physicians, and really to the whole public health community who want to hear clearly from people who are experts in the field, but also who really are PrevMed physicians themselves, who really understand the knowledge and skills we need to do. I'd like to thank very much Dr. Mills, who worked with me on this development, and most importantly, Anita Bailin and Cara Molinari, who have been tirelessly working from a staff perspective. Next slide, please. As I mentioned, we will be fulfilling requirements that will allow the residents to meet their requirements, program directors to check the boxes of the milestones, and actually provide and cover the material that residents need to know for the exam, both for the PM and the OCMED and aerospace for the morning part of their exam. Go ahead, please. And here are the topics, and you can take a look at some of these at your leisure, but Dr. Barnett, who I'll introduce to you in one moment, is going to do our first two sessions, followed by other names that you'll see on the next couple of slides, many of who are PDs themselves or have been, all who have experience in their expert areas, but who are really PM docs at heart. And then I think finally, can you go on to the next slide, which is just another lecture. I told you about the workshops here, the other topics we're going to cover, all things you really need to know for the boards, you also need to have experience with. And the last slide I think I have here for you is how I'd like to encourage everyone to attend. And we will not be allowing residents to attend the workshops. If they haven't attended the webinars, please complete the surveys that you'll get after these. And we have an ACPM community forum that is going to be launched later this fall, where we hope we'll be able to have a robust discussion. And please come to the PM meeting. And I think finally, we are ready to introduce Dan Barnett. Dan's going to mainly introduce himself, but let me tell you that Dan was one of my star residents when I was a PM director at Hopkins. Dan very early on found a passion in the field of public health surveillance and teaching. He continues both of those today and he really is par excellence, a superb person to begin today's lecture and next times as well. Dan, take it away. Thank you so much, Dr. Alexander. And Dr. Alexander has been a true mentor to me throughout my career. And I'm really excited about the opportunity to present the first two webinars in this exciting series. So what we're going to talk about in this webinar is the Incident Command System or ICS. A couple of things I want to focus on this afternoon or tonight, depending on your time zone, are operational aspects of the Incident Command System and regulatory and related perspectives. Just by way of background, I'm a professor in Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. As Dr. Alexander mentioned, I'm a graduate of the Johns Hopkins Preventive Medicine Residency Program. And I continue to do actual, actually each summer a preparedness module for the Johns Hopkins General Preventive Medicine and Occupational Medicine Residence. So this is a topic that is near and dear to my heart and I think is very relevant regardless of your career path in med preventive medicine or aerospace medicine. So next slide. Just very briefly, these are the learning objectives and I promise not to do PowerPoint karaoke tonight. We've got a lot of material to cover. I will highlight on each slide the key things that are important for you to, I think, take home with you. But this will be my one exception where I will read it item by item. So we'd like for you to be able to describe the rationale and utility of something called the National Incident Management System. The National Incident Management System is actually the umbrella under which the Incident Command System is housed and I'll explain that today. We'll talk about the basic organizational structure of the Incident Command System and its components. We'll talk about the relevance of the National Incident Management System and Incident Command System principles to public health emergencies and disasters. We'll do some contrasts of terminology between unified command and area command. All these terms may be unfamiliar at first but we'll make it user-friendly. We'll talk about essential facilities that are used in the context of incident management including with Incident Command Systems and we'll describe the relevance and it's a bit in some ways of a teaser to a subsequent module that is in the series about risk communication. So Incident Command and specifically the National Incident Management System umbrella is relevant for public health crisis risk communication. Next slide please. So let me begin by talking about the umbrella because I think it's important to understand the broader architecture, this umbrella piece which is the National Incident Management System and again the Incident Command System is an element underneath the umbrella of the National Incident Management System. So what is National Incident Management System or NIMS? Next slide please. So the National Incident Management System is a relatively new umbrella and by that I mean and as I'll mention in the upcoming slide it's only about 21 years old to be exact. It was founded or created as part of Homeland Security Presidential Directive number five under the George W. Bush administration and when you think about the history very briefly this was after September 11th and after the anthrax mailings that occurred in the United States and so that and other events led to the creation of the Department of Homeland Security which was the largest reorganization of government since the FDR era. So this is important because we need to think about the National Incident Management System as an umbrella that applies regardless of jurisdiction whether you're in terms of city, county or state and regardless of what city, county or state you're in. These are standardized concepts. Next slide. So just by way of background. So the National Incident Management System has a variety of important features that are necessary to appreciate and among them is that, among them are that they are, the National Incident Management System is standardized so and it's based on a principle that all disasters begin locally. So you've heard the expression all politics are local. Well, all disasters begin locally. So regardless of the scale whether it's a public health infectious disease crisis or a natural weather related disaster the response to an incident should be led at the lowest jurisdictional level. So for example, if it's an infectious disease event the National Incident Management System framework comports in such a way that the lead agency should be for example, the local health department. If it were an explosion or a radiological emergency chances are that the lead agency should be the local fire department. So again, it should be led at the most local driven level with state and federal resources added to the local mix to facilitate response. The other term that I wanna highlight very briefly is the term interoperability. You can see that highlighted in bold here. We've learned through unfortunate case studies including Hurricane Katrina that there have been a number of instances in disaster response where state and local agencies literally have been on different or incompatible radio frequencies. That unfortunately occurred during Hurricane Katrina and that will absolutely undermine any chance of a successful disaster response. So the term interoperability means for example that my wavelength of two-way radio is compatible with the wavelength of my colleague's two-way radio in response. And as I mentioned, the origin of this umbrella was in 2003 with the Homeland Security Presidential Directive number five. Very importantly on the right side you'll see some three key principles but I wanna highlight one in particular. This is a bit paradoxical but one of the rules of the National Incident Management System is you're not supposed to use acronyms. But people say NIMS all the time. So the reason I say that is because I'd be committing a training malpractice to not mention the acronyms because despite the rules of avoiding acronyms we see them all the time in the context of Incident Command System which is often referred to as ICS and NIMS which is often, or National Incident Management System which is referred often to as NIMS. Next slide. So let's talk about some of the greatest strengths of the National Incident Management System. One of which is its flexibility. So as an umbrella concept which we'll describe in more detail, it is useful for events large and small in scale. Whether across what we call the all hazards model. And you can see the phrase all hazards on the right side of this slide. What that means is it's a system that is relevant regardless of the type of event. Whether it's an intentionally caused event, whether it's a naturally occurring event and regardless of the nature of the event. Whether it's weather related, infectious disease related or otherwise. And in the center I want to highlight again that it promotes standardization. One of the challenges that we see for example is that local law enforcement agencies often use different codes to refer to the same thing. So for example a 1040 might be a homicide in one jurisdiction and a 1080 might be a homicide same event in a different jurisdiction for a different law enforcement agency. The beauty of the National Incident Management System is it promotes standardized terminology so you don't have a tower of Babel effect in which different agencies are literally cross talking across each other because they're using different terminologies that mean different things to the respective agencies. Next slide. So we want to think about the National Incident Management System through a few important lenses. One is that through use of the National Incident Management System we can be better prepared as a country. And as a country I don't mean just at the federal level, I mean NIMS applies as well as we discussed just now as at the state and local levels too. So the idea is we want to be able to use NIMS to prevent, mitigate and respond to and recover from emergencies and disasters and NIMS allows us to do that. It allows us to establish and maintain various levels of capability. For example, there's different levels of training that come from FEMA that allow for different sort of levels of functioning among personnel in a response involving NIMS. Very importantly and I want to highlight though at the bottom of this slide, one of the things NIMS does not do and as future leaders in your field, NIMS does not tell you for example if you're a health officer how to allocate your scarce resources at your health department during an emergency or disaster. That decision is made and is incumbent upon the agency itself to determine. So there's no prescription of well you need to have this number of ambulances and they need to be allocated within your agency to such and such. That has to be determined within your agency and is an agency specific decision. Next slide. So here's the umbrella and this is kind of a visual depiction but I think it's a useful one. So the National Incident Management System umbrella which again was created in 2003 basically covers three key elements. One of which we're gonna talk about in more detail which is the Incident Command System. The Incident Command System is an old piece under this new umbrella. The Incident Command System as we'll talk about has been around since the 1970s. It originated through a program called Fire Scope which was the genesis of which was to put out wildfires in the Western United States. So it's been around for 50 years or so and through operational best practices has been refined to the version that we need to use today. So the Incident Command System is the first piece under the umbrella of NIMS. The second piece is what we call Multi-Agency Coordination Systems an example of which it could be an Emergency Operations Center. An Emergency Operations Center for example would be it often looks like Mission Control. For example there's a Maryland Emergency Management Agency where the state EOC, Emergency Operations Center resides during a disaster situation in Maryland and you have representatives from different agencies with a monitor in front of them. It doesn't have their individual names. That's one of the things we'll talk about. My name does not matter in a disaster. What you need to know is my title within the nomenclature of Incident Command. So we'll talk about that. And last but not least as relating to a future topic in this module series the National Incident Management System has rules about communicating risk in a crisis so that you have standardized risk communication modalities and messaging throughout an emergency or disaster. Next slide please. So this slide is sort of a kind of going further afield in our presentation but I wanna use it to illustrate something. So the Incident Command System which we will talk about is that first piece under the NIMS umbrella. And everyone should be familiar if you're in public health, healthcare and any other domain, allied domain you need to know the concepts underlying and the terminology very importantly of the Incident Command System. It's not the most exciting. I'm not gonna mince words about it but it's essential. And one flavor and variation, there are a number of variations of the Incident Command System and we're not gonna go into a lot of detail in the interest of time tonight but one example of a variation of Incident Command System is called Unified Command. And that is often seen when we have an event that involves multiple adjacent jurisdictions two or more affected by the same sort of relatively circumscribed event. A hazardous spill in a local reservoir for example. And you have a sort of a team of leaders co-equal who have to make determinations at that what you can see there is the Unified Command level box. And then underneath that you have Finance and Administrative section, Logistics section. Logistics actually the word that is synonymous with that in disaster literature is actually the word stuff. I know that's not the most scientific sounding word but materials and supplies are absolutely critical. Operations so this is sort of the devil in the details. Are we gonna open up a shelter at a certain time? Where is that gonna be located? Who is gonna staff it? Sort of that very granular boots on the ground detail. And last but not least Planning section. Now you may think well gosh planning shouldn't that be done before a disaster? Of course, but we also have to plan during a disaster too over what are called operational periods. And those are often 12 hours at a time or 24 hours at a time and then we update it's called the Incident Action Plan for the next operational period. So a pandemic by historic definition actually is an event that lasts two or more years. So we would have operational or operational periods for 24 hours at a time and update at the end of 24 hours for the next operational period and that's called an Incident Action Plan. So it's like a real-time planning. And by the way, the terminology we will talk about, but this is an example of a variation of incident command. Next slide. So we basically will talk more about how this allows for a response that crosses jurisdictional lines and involves leadership from police, fire, and public health, for example, all to work together, which we often need to have happen in a crisis. Next slide. Area command is another flavor of the incident command system. So again, we'll talk about the incident command system itself, but I just wanna highlight some, why this is such a relevant concept, the incident command system and its variations. Area command is particularly useful, and this is important for you to kindly remember. Area command is particularly useful for large-scale infectious disease events. And the reason is that area command is a variation of the incident command system where that is particularly conducive for events that are not site-specific. So infectious diseases do not observe geographic boundaries that are not immediately identifiable. And because of the nature of infectious diseases, there is an incubation period. So we are always, by definition, playing a game of catch-up in terms of initial recognition. Interestingly enough, the incubation periods of what CDC calls its Category A agents, the most concerning bioterrorism agents, range from hours in the case of botulinum toxin to weeks, up to 17 days in the case of smallpox. So one could present to a hospital 17 days with smallpox for signs and symptoms following initial exposure and not even know they had been exposed 17 days prior. So that presents a challenge in terms of readiness for infectious disease events. The area command is often housed in an emergency management agency. And basically, this is, again, a variation of the incident command system. Next slide. We'll go on now to talk about multi-agency coordination systems. So a classic example of that is an emergency management agency, like Maryland Emergency Management Agency, or another state, most states have some variation of an emergency management agency, and also emergency operations centers, as I mentioned earlier. An emergency operations center is like a nerve center, just like mission control in Houston is kind of the analogy I like to give. Because it's important, the term that we use in the field of preparedness is situational awareness. All representatives involved in a response, whether it's, for example, the Key Bridge disaster, you may recall, this March of this year in Baltimore, it requires response from varying agencies and jurisdictions. And so along with that, we need to know, those responders and stakeholders need to know what's going on at any given point in time. So typically, these emergency operations centers have television monitors, flat screens in front to allow the various agency representatives to be apprised of what's going on in real time. So that's the second piece underneath the NIMS umbrella. The first piece was incident command system, and we just talked in advance about some of the variations. Unified command, which is like a, where you have adjacent jurisdictions dealing with a circumscribed event, such as a hazardous contaminant spill in a local reservoir. Another variation, again, is area command, which is particularly useful for large-scale infectious disease events. And then the second piece that we just mentioned under the NIMS umbrella is multi-agency coordination systems. Again, a useful way to think of it as an emergency operations center, like mission control, essentially for disasters. Next slide. Okay. And by the way, when you see press conferences being held during a disaster, those are usually held in a particular room co-located, or often within a particular room co-located within the emergency operations center. Next slide. Okay. This slide is, again, more for detail. We're not gonna focus on it as heavily, but you'll notice that there's like an org chart. One of the themes throughout tonight is you'll see org charts. And one of the important things we'll talk about is that the incident command system and its variations, whether it's the area command or unified command, all rely on what's called a manageable span of control. Now, I'm not gonna ask you whether, because it might be disheartening to hear the answer, the number of people that one person can manage simultaneously effectively. If you're managing more than seven people at a time, that's more than what we call the manageable span of control. So the ideal range of boxes underneath a given box above it is between no fewer than three boxes and no more than seven. And we keep it lean and mean. That's not a very scientific term, but we only use the resources we need to. We don't waste resources. We don't have them to waste, obviously. But that's called the manageable span of control. So you can see here in this example, there's an EOC manager, and look how many boxes underneath the EOC manager. There's a coordination box, communications, resource management, and information management. So we are within that three to seven range of manageable span of control. Next slide. So one of the things I wanted to talk about tonight, which is important, are regulatory aspects and legal aspects of the Incident Command System and the National Incident Management System, which is the umbrella over it, as we talked about. There are two different types of agreements. There are legal agreements that allow for different jurisdictions to cooperate with each other effectively in a disaster. One is called mutual aid. This is typically between counties. Or, yes, this is typically between counties. For example, in Maryland, and I'm just giving Maryland as an example because I know the counties here pretty well. So we have, for example, Baltimore County, Maryland, and Anne Arundel County, Maryland, which are essentially adjacent to each other. So there might be a mutual aid agreement between the county executive of Baltimore County and the county executive of Anne Arundel County, Maryland, in advance of an event, saying that if Baltimore County is under great duress, short of resources, that Anne Arundel County will provide that kind of aid, mutual aid to Baltimore County, and vice versa. That's mutual aid. Again, we try to avoid acronyms, but you will see them, so I'm using them here. It's called emergency management assistance compacts. And what that is is between states. So, for example, you could have an emergency management assistance compact between Georgia and Arizona. I'm making that up. Where if Arizona were affected by a disaster, there could be a preexisting legal arrangement with the state of Georgia, where Georgia resources would come to the aid of those personnel in Arizona, and vice versa. So those are some legal aspects, and it's really incumbent on elected officials to create these kinds of legal arrangements in advance, ideally, of a disaster. Next slide. So the beauty of the National Incident Management System, as I mentioned earlier, and I'm just gonna re-highlight here, is that it's systematic. It allows for a systematic approach. The National Incident Management System, or NIMS, allows for a systematic approach to organize the process of planning, to do what's called hazard vulnerability assessments, meaning assessing what are the likely risks. If you live in Duluth, Minnesota, you're not worried about hurricanes. If you're in Miami, Florida, chances are you are, or should be, given that we're seeing, unfortunately, increased frequency and severity of hurricanes as early as June this year, because of, no doubt, due to climate change-related patterns. It allows, the National Incident Management System allows for a systematic approach to develop a mitigation strategy to mitigate the impacts of an event, and an approach to adopt and implement the plan accordingly. Next slide. There are different types of plans. I'm not gonna go into great detail here, but I do wanna highlight that two kinds of plans that are really, really important for you to kind of know is what are called emergency operations plans, or EOPs. These are how your jurisdiction will respond to an emergency. So these are often, they shouldn't be in a dusty binder. They should be readily accessible by response leadership and personnel, and should be updated to reflect the latest response approaches. Another one that I wanna highlight is what's called, and it's actually bolded in bold white font, called corrective action plan. So one of the things that we need to do, frankly, better at, not just in the US, but around the world, is identify lessons learned from disasters, and apply those lessons learned to improve responses to future disasters. How do we do that? Well, we develop corrective action plans, meaning after a disaster, or even after a drill to simulate a disaster. What did we learn that went well? And what did we learn about things that could have been done better? And how do we take things that, how do we optimize and leverage the things that were done well, and address areas for improvement? Otherwise, there is no continuous quality improvement process possible within the field of emergency preparedness. So this is really critical. There is something called a Homeland Security Exercise Evaluation Plan, or HSEEP, that actually provides guidance about how to write reports, what are called after action reports, following either an exercise or a real disaster. There's a time window, typically of 60 days, when they're supposed to be generated. And one of the challenges is, is that we need to take a more unflinching look at what did not go well, as well as identifying what did go well. So those are the two key types of plans I wanna highlight here on this slide. Next slide. So I just wanna highlight five steps, a five-step approach to creating a mitigation plan. So if you're running a health department, if you're the head of occupational medicine for a large or small corporation, and you're tasked to identify a plan to mitigate the effects of an event, or mitigate the risk of an event, there are five steps to what we call risk mitigation. The first is to identify what are the potential risks, and those can be very jurisdictionally specific. So that's on the top left of this slide, and then going from left to right, performing a risk assessment. There's actually a tool from Kaiser Permanente that's openly accessible, where you can have a populatable Excel spreadsheet to rank, order the list of most likely threats. It's called a hazard vulnerability assessment. Then you, and that allows you to prioritize accordingly. So you wanna, you know, in public health, we have to do more with less all the time. So the idea is you wanna prioritize how you're gonna allocate your scarce resources toward those events that are most likely to happen in your jurisdiction. Again, going back to the example of Duluth, Minnesota, hurricane, not a concern. Miami, Florida, yes. So that's how we need to think about that. Track the risks. Are risks changing over time? So these are not static documents, and it may be that we can have evolving risks as we learn more. Think about MPOTS, for example. Think about Zika, which had been a footnote in medical textbooks, right? But these are things that we are seeing reemergence of. So these are the kinds of things that are involved in a risk mitigation plan. And last but not least, implement and monitor the progress. So one of the great features of this training series that Dr. Alexander and colleagues have developed is there's a sort of the surveillance of how things are going, and this is kind of a form of surveillance. How are we doing? How are we monitoring the progress of the plans that we've implemented? So this is all systematic. Next slide. Exercises and drills. There are different types of emergency preparedness exercises under the National Incident Management System and Incident Command System, and this is really, really important. The most basic type of exercise, the cheapest to implement, but a critical one is called the tabletop exercise. It's a discussion-based exercise. Then you can build up from that into what's called a functional exercise or like a walkthrough clinic without heavy equipment. And then the next level up is what we call full-scale exercises. And that's where you'll see, for example, the French word moulage. You'll see people with ketchup to simulate blood and the like. You'll have tagging to indicate triage decision-making and the like. So the point here is that whether you're doing, as I mentioned earlier, an exercise and doing an after-action report based on that or an after-action report based on a real-world event, every after-action report should be accompanied by a corrective action plan. How can we do better based on what we learned of what didn't go well as well as could have? Next slide. The last item underneath the NIMS umbrella. So again, first item is Incident Command System and the related flavors of Unified Command and Area Command. Second item we talked about is the Emergency Operations Center, so sort of multi-agency coordination. And the third piece is public information. Beyond the scope of our discussion today, but there's something called the Joint Information System. There's actually a rule book for underneath the National Incident Management System for how to literally present messages, fonts, level of reading, reading level and the like to allow for standardized coordinated messaging. And that's very important to optimize risk communication. Next slide. So let me just briefly now transition and to Incident Command. Basically, we've already covered most of the main things for tonight, but I wanna highlight Incident Command. Incident Command, as I mentioned, has been around since the 1970s. And Incident Command and all of its variations, Unified Command and Area Command, kind of look very much like the military, a military-like structure of hierarchy. And the reason for that is in a disaster, we don't refer to each other, if you're responding with someone else, by their names. I may not know the name of the person I'm working with. And frankly, I don't need to know the name of the person I'm working beside. I need to know their title. Are they the Incident Commander? Are they the Safety Officer and so on? So next slide. And this is important because in public health, we don't do Incident Command every day. Our counterparts in law enforcement and fire services do, but not in public health. So this makes it more challenging. The expression, if you don't use it, you lose it. This is really one of those things that is why I'm so appreciative of this training series because I can't overemphasize the importance of embedding Incident Command skills and terminology to make it like a muscle memory thing as much as possible, rather than something we look at every blue moon and hope to remember it. So it enhances public health response. It provides collaborative framework, and it's very systematic and provides a structure for emergency preparedness activities. Next slide. So one of the great things about the Incident Command system is we don't have to use it just during a disaster. There are a lot of, quote, routine non-disaster activities that we can use Incident Command to optimize in public health. Things like a health fair. A health fair is a very complex event. A lot of things can go wrong in a health fair. And so we can actually use Incident Command to organize the implementation of a health fair or a seasonal flu clinic or a variety of other non-emergent scenarios. And that allows us to get good at it and get familiar with it. Next slide. So how is ICS structured? So I'm a big fan of mnemonics. Not everybody is, but I think it's useful in this case. So let's talk about the structure of the Incident Command system. Next slide. So we've already talked about the Incident Command system's origins, 50 years old. It's based on organizational best practices. And its structure is also based on organizational best practices. The key word here, just briefly, in the Incident Command system is the word command. Very much like the military, the Incident Commander and every disaster response under NIMS and every disaster response, large or small, should utilize Incident Command or one of its variations, okay? And every disaster response should have an Incident Commander. Even if you're looking at a one car accident, single car accident, and you see a law enforcement personnel with flares, that person, by definition, is the Incident Commander. So things that we routinely see are actually applications of the Incident Command. So I don't want this to come across as an exotic kind of framework. We use this all the time in the US. So next slide. The Incident Commander, by definition, there must be an Incident Commander for every event. And whether it's a large-scale disaster or a smaller-scale emergency, the Incident Commander is the first person to arrive on the scene, by definition. But it may not be the right person who was the first. And by first person, I mean first governmental official to arrive on the scene. But maybe it's not the right, quote-unquote, right governmental official, because the event is not conducive to that person's agency. So if, for example, there's an explosion, and the first person to arrive on scene is the public health epidemiologist, well, that may not be the right person based on that event. That's not a slight epidemiologist, it's just not the right matchup. So we'd wanna switch the Incident Commander to someone from the, quote, right agency, in this case, from the, to the fire chief, for example, who is familiar with explosions and readiness aspects for those kinds of events. So the Incident Commander is the default leader, and every event must have an Incident Commander. And if there's a change of Incident Commander from the, let's say, the wrong person, quote-unquote, or is the first to arrive on scene, the switch to a new Incident Commander who's the right person is called Transfer of Command. What I want you to notice in this picture is that they're wearing vests. And you will see this, or should see this, in Incident Commander responses. And if you look closely, you'll see Operation Section Chief, okay? It doesn't say John Jones, it says Operation Section Chief. I may not know this person from a hole in the wall, and it doesn't matter whether I do. It matters that I know what their title is under Incident Command. Next slide, please. Okay, so let's talk about the, what we call the Command Staff. So the mnemonic that I'm gonna build, I want you to think of a sailboat that's flopping over, okay? So the mnemonic for remembering the Incident Command structure, and even its variations that we talked about earlier, is I sail flop. Okay, you're gonna say, that's ridiculous. That's not even a sentence. And it pains me, because I'm a former English major, so I shouldn't even be giving bad mnemonics like this. but it works. So ISAIL FLOP means you have an incident commander, okay, you have, and that, remember that person is the default leader of the response. Underneath the incident commander, you would have a safety, or could have a safety officer. For example, in a flu, or COVID clinic, vaccination clinic, the safety officer would be responsible for making sure that people are not recapping needles unsafely, things like that. Agency representatives, technically, it's, I lied to you here, not in a malicious way, but they're not technically part of the command staff. They are housed at the emergency operations center, but ISAIL FLOP is not easy to remember. So just, I'm just using that as an addendum to just keep them in mind. So safety officer, agency representatives, information officer, we use the term information officer, not public information officer. So these are very specific terms that are standardized, whether we're in Baltimore, or Boston, or anywhere else. And then liaison officer is the go-between. And that, what that means is the liaison officer is the person who is relaying all the questions up to the incident commander, or trying to filter them out themselves before it reaches the incident commander. You could imagine if the incident commander were just fielding questions all the time, how overwhelming it would be for the incident commander. Next slide. So the command staff is SAIL, or actually SIL, so remember SAIL. The general staff are called chief. This is just terminology. It's not, you know, it's the kind of thing you just have to know, but the mnemonic helps. So the mnemonic here, the flop part of the mnemonic is for the general staff. So you can see finance, F for finance and administrative section chief, they manage the budget. Logistics manages the stuff, supplies. Operation determines, okay, when we're going to open this vaccination clinic site, and how long it's going to run, and the like. And the planning section chief does what's called that incident action plan over operational periods, which is often 12 hours at a time, but for a pandemic could be 24 hours at a time. So FLOP for flop. Next slide. So I, SAIL, flop, incident commander, safety is I, safety officer is S, A, agency representatives, I, information officer, L, liaison officer, and then flop, F, finance and administrative section chief, L, logistics section chief, O, operations section chief, P, planning section chief. If you can remember that, you have remembered the incident command system. And by the way, if you want to add more boxes, you add them under the F, the L, the O, or the P, with that manageable span of control that we talked about from three to seven. You should never have fewer than three boxes hanging from the box above it, and never more than seven boxes hanging from the box above it. Elected and appointed officials should not be the incident commander. That's the take home slide, or take home item from this slide. The reason for that is not because they could not do the job, but there's a sort of perceived political conflict there, and so the mayor should not be the incident commander, for example, in a response. It should be the health officer or the fire chief in that community. Next slide. So let's quickly move into features and concepts, and I want to save time for questions and answers. Next slide. We manage by objectives. The rule in disasters is saving lives first, first priority. Second priority is keeping the incident from expanding, and third priority is property preservation. So Susie Orman, who used to be on TV, used to say people, then money, then things. This is the disaster version of that. Saving lives first is the first priority. Keeping the incident from expanding is the second priority. Third is property preservation. So those inform our objectives, and that's what we talk about here where it's highlighted management by objectives. We will talk about these other items very briefly. Next slide. Okay, so we manage by objective. Next slide, please. Next slide. So that's listed here. This is the rank order of what determines what our objectives are for an incident response, and of course how we save lives varies depending on the incident, right? For an infectious disease event, we're using antivirals and vaccines. For a hurricane event, we may have water rescue and the like, but the prioritization, the sort of buckets of prioritization are constant regardless of the type of event. Next slide. Common terminology, as I mentioned earlier, the word chief, right? Logistics section chief, and those kinds of things. Safety officer. So the ISAIL flop is common terminology. It doesn't matter what city you're in, what county you're in, whether you're talking about federal, state, or local. It's the same terminology, and that's the beautiful thing. We're all using the same sheet of music. Next slide. And we'll go to the next slide. Manageable span of control. You should all have that memorized by now. It's that three to seven range we talked about. You don't have to have it memorized, but it's just three to seven. Next slide. So this follows the manageable span of control, for example, because you have three resources hanging down from the box above it, which is the supervisor box. Next slide. And next slide. So resource management, we have to be lean and mean. We may not even need a safety officer. Typically we do, but if it's a small enough event, maybe the incident commander can do those functions. Usually, though, if it's any kind of large scale event, there's delegation that happens very quickly. The incident commander, by the way, unless they delegate a safety officer, information officer, and liaison officer, and unless they delegate a finance, logistics, operation, or planning section chief, they have to do that all themselves. So you can imagine for a complex event, you're doing rapid delegation to those various functions. Next slide. So resource management, one of the important points is that we don't just wait for the event to end and then figure out where do we return our helicopters and our ambulances. We actually begin planning about demobilization from the inception of the event, which may seem counterintuitive, but you don't want to wait until the end of the event and begin thinking about, okay, well, where are we going to return our equipment to? So that's important for resource management. It's important to track resources, and there are human resources and material resources, but both are relevant in disasters using incident command. Next slide. So if you're on an incident command response, you're in one of three categories. You're either currently working on an assignment and unavailable to do something else. The next is you're ready and raring to go, but you haven't been given your assignment. You're rested, but you just are awaiting your assignment. Or third, you've just completed a shift of response work, and you need to rest, and so you're not available. So we call those tactical resources, and that refers to people. Next slide. Organizational facilities. So there's standardization of organizational facilities very briefly, and I'll just highlight that quickly here. Next slide. Oh, I'm sorry. So organizational facilities, just to highlight, the key thing here is that the organizational facility that every incident command response should have is an incident command post. It doesn't have to look like any particular type of building, but it has to be labeled either as incident command post or often it looks like a flag with a blue triangle and a white triangle bisecting it. The other facilities that could be what are called camps and bases and things like that are beyond the scope of our discussion today, but they have particular names, and that's the key thing. They're standardized. Next slide. So the incident action plan, and we'll just go through this here. The incident action plan is that real-time plan that we talked about. It's often 12 hours at a time. If it's a long event, it could be up to 24 hours at a time, and the planning section chief develops this real-time incident action plan, and that's done based on the evolving scenario. Now FEMA says the incident action plan can be oral or written. My rule of thumb is that when in doubt, write it down. If you've ever heard of the game telephone, where a person says something and then by the time it reaches the seventh person, the message is garbled or a different message. So when in doubt, write it down. That avoids that potential pitfall. Next slide. Every incident action plan, if I were doing an incident action plan for the next 12 hours from now, has to have four elements. What do we want to do during that 12-hour period, which is called operational period? Who's responsible for doing it? How do we communicate with each other in doing so, and what happens if someone, a responder, gets hurt in the process of doing so? So there's a safety element built into every operational period under the action plan. Next slide. Integrated communications, this goes back to the term of interoperability. Typically, 800 megahertz is a standardized radio frequency that we use for two-way radios, but it's essential that that be drilled and exercised upon and determined in advance of a response to avoid, unfortunately, the tragic disconnects of communication that occurred during Hurricane Katrina, as we talked about earlier. Next slide. And accountability means that, for example, we track resources. We track, if an ambulance was used, we need to know where it is, where it's being deployed to. If an epidemiologist is being deployed, we need to know where they're being deployed to. So there's an accountability mechanism, and so that allows for a robust response using the incident command system. Next slide. So in summary, and I know we covered a lot, but we'll highlight just quickly the take-homes. Next slide, please. The summary is that all of this is available on FEMA, but in a much more expansive way. Let's just say it that way. And it's very well done on FEMA, but I think what I've tried to do here is distill a multi-hour training into something that provides the essentials of what you would need on board exams and in your practice-based work. There's also the National Association of County and City Health Officials, which has excellent references there, too. Next slide. I also want to acknowledge my colleague, Andrew Rosenblum, who's an EMS responder and has given excellent insight to inform this presentation. Next slide. So I realize we have a few minutes. I know we covered a lot, but happy to answer any questions that you may have. I'll turn it over to Anita. Oh, Anita, I'm not sure I can hear. We don't have any questions as of yet, but President and other attendees are welcome to submit questions. Or Dr. Alexander, I'll turn it over to you if you want to kick it off. Dan, how do people learn what to do in their roles? Excellent question, Miriam. So this needs to be part of in-service trainings in health departments and hospitals. Drills and exercises are great ways to practice and learn what one's roles are and how it applies to them. And so that should be part of the preparedness training. And preparedness training is one of the expectations that agencies involved in disaster response are supposed to undertake. But that is exactly the what is my role kind of question needs to be front and center. Great question. So Dan, someone just asked a question, and it's the question that I was sort of bitching and moaning to you about when we started today, which was what about in occupational health? And it's interesting because I work in a multi-hospital system and was just bemoaning the fact that we don't do simulated exercises of any sort here. And we assume that the only kinds of events that would happen would come in through the emergency department and would be nicely packaged in such a way that all they needed was clinical care and could be easily treated and shipped upstairs in nice, tidy boxes. I don't know what your experience has been within health care organizations, Dan. Yeah, no, it's a big challenge, Miriam. And one of the things that we want to emphasize is that we have a lot of people who are in the hospital, and we have a lot of we want to emphasize by we I mean in academia, those in academia, those in practice space, is that everyone needs to get this training if you're part of any aspect of disaster response, whether you're hospital-based or health department-based or other agency. And the nice thing about it, as we talked about today, is that it's all standardized. The terminology is standardized. Now, in terms of who performs what role within the organization, that needs to be specified within in-house training. But as part of just standard training, that really needs to be a bedrock, I think. And are there federal guidelines on how public health agencies are supposed to work with their health care organizations within their jurisdiction? Yes, another great question. So there's something called health care coalitions, which are basically hybrid models of health departments and hospitals within a jurisdiction that collaborate and cooperate. And so not every jurisdiction has those coalitions, but they're usually in larger cities or relatively large cities. And the take-home is that everything is under the NIMS umbrella. So all exercises and drills really should incorporate some aspect of the National Incident Management System and incident command specifically, or variations of incident command, so that if you're having a drill involving or a tabletop or a full scale involving a hospital or health department, they're all being expected to know and show their competency with the applying incident command concepts. So, Dr. Barnett, we have three more questions, if it's okay for you to just stay on and answer them. We had a question in the chat from Program Director Polly Thomas. Can we develop a national tabletop? Are there some guidelines just to help develop a national tabletop? Yes, really, really important question. So there have been national level full-scale exercises. And actually, the Johns Hopkins – this is not a Johns Hopkins plug. I want to be very clear. The Johns Hopkins Center for Health Security has done a lot of national tabletop exercises, including ones that involve pandemic threats and the like. So I think we need more of those, frankly, because that allows us to get key stakeholders and key leaders around the table to think about these really hard questions that would arise, especially based on lessons learned from COVID moving forward as we deal with new and re-emergent threats. So there's not a standard model for how to do it, but the idea of having tabletop exercises at senior levels of government is, I think, absolutely critical. Are those things that could be modified and done virtually across, say, preventive medicine programs? Yeah, some of them are publicly available online and can be adapted accordingly, for sure. Some of these were video recorded, not all of them. But the good thing is that if you Google preparedness exercises and tabletop exercises, there's a lot of publicly available scripts and scenarios that can be readily adapted by hospitals, health departments, and other allied organizations. And to Polly, that's certainly something we could look into as part of this ACPM thing we're doing for the residents. So, Polly, I'll take that on. Go ahead, Anit, with the next question. Last two questions. How is an incident commander determined where there is not a geographic location to be first on site? Right. Great question. These are all great questions. I don't mean to sound like a broken record, but these are all important questions. The determination needs to be done, ideally, before an event, who the incident commander would be at the jurisdictional level based on the type of event. So for example, as I alluded to earlier, an explosion, whether it's a bomb, conventional bomb, or what we call a dirty bomb, which is a radiologic dispersal device. Typically, the agency that would be responsible, and hence the incident commander, would be the fire chief, for example, supplemented by state and federal resources, of course. But again, the lead agency should typically be the local agency. So there's not really a rule of who should be the lead. It's really determined at the jurisdictional level, but it should be part of jurisdictional preparedness planning and pre-event decision making. This is another question. What are some strategies to demobilization responsibly? Yes. So we want to make sure that we have an inventory of all the equipment and a list of all the responders. In fires, for example, fire departments monitor extraordinarily closely, and rightly so. If six firefighters go into a building, six firefighters had better come out. We have a similar mechanism that's essential in disaster response because we need to account for personnel, their whereabouts, and so there should be sort of a sign-in. There is a sign-in mechanism, which is beyond the scope of our discussion today, but really important, and a way to, once people have arrived home safely, they should notify their agency. So that way we know that the responders themselves are safe. And final question is, some residents want to know if they are interested in participating in national or regional tabletop exercises, how can they go about finding one in their region? Yes. So my first recommendation would be to go to the Federal Emergency Management Agency, FEMA, which has resources and can provide guidance of ways to get involved. Also, there is something called Community Emergency Response Teams, which have been around for a long time, which are a great way for, at just the community level, for citizens to become engaged in jurisdictional preparedness activities. But FEMA is really a great resource, and FEMA has what's called an Emergency Management Institute in Emmitsburg, Maryland, as it turns out, and they're another resource that can provide guidance on trainings and ways of engagement. Thank you so much, Dr. Burnett and Dr. Alexander, for staying a few minutes over. We will hear more from Dr. Burnett, who is also going to be our lecturer for the second topic on September 26th. I know some of you did not receive the registration for this one, so we'll make sure that we properly promote the other webinars to both the program directors and all of the residents from across three specialties. Thank you, everybody. Have a wonderful evening. Thank you all very much for coming. Good night.

preventive medicine

ACPM

webinar

Dr. Miriam Alexander

Dr. Dan Barnett

NIMS

ICS

emergency preparedness

public health emergencies

training and drills