Health Officer Roles in Emergency Preparedness

Transcription

1 Health Officer Roles in Emergency Preparedness Richard O. Johnson, M.D., MPH, FAAP Health Officer, MHOAC, Alpine County CCLHO Semi-Annual Meeting, October 4, 2018

2 Outline Context California Public Health and Medical Emergency Operations Manual (EOM) MHOAC Program Manual (Guide) The Required Additional Pieces Healthcare Coalition Med/Health Multi-Agency Coordination (MAC) Group TRAIN M/H Incident Management Team Functioning at the Edge of Chaos 2

3 White House shines high-level spotlight on biodefense, CIPRAP News, 9/18/18 To be led by Dr. Robert Kadlec, DHHS, ASPR 3

4 Department of Homeland Security Target Capabilities/Universal Task List Epidemiological Surveillance and Investigation Public Health Laboratory Testing Responder Safety and Health Environmental Health WMD and Haz Mat Response and Decon Isolation and Quarantine Emergency Public Information and Warning 4

5 Department of Homeland Security Target Capabilities/Universal Task List Emergency Triage and Pre-Hospital Treatment Medical Surge Medical Supplies Management and Distribution Mass Prophylaxis Mass Care Fatality Management 5

6 This week, the House passed H.R. 6378, the Pandemic and All-Hazards Preparedness and Advancing Innovation Act, under suspension of the rules. The amended bill reauthorizes public health security programs for five years. The Senate has not yet considered its own version of the bill. Current authorities expire on September 30th. 6

7 Definition of Disaster A disaster is a serious and possibly sudden event on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help

8 Disasters are a threat to the public s health: abrupt or prolonged increases in illness, injury, or death disruption or destruction of the healthcare infrastructure (including space, stuff, and staff) population displacement either in or out psychological distress changes in the environment often longstanding if not permanent

9 Definition of Resilience Resilience is the capacity to withstand stress and catastrophe - The ability to return to original form - The ability to bounce back - Note: not avoidance, but working through flexibility, endurance, persistence, fortitude, etc.

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11 California Public Health and Medical Emergency Operations Manual (EOM) For Official Use Only (FOUO)

12 Purpose of the EOM Primary focus is the standardization of operational processes between: Operational Areas (OAs) and the MHOACs Mutual Aid Regions and the RDMHC Programs State (e.g., CDPH and EMSA)..during unusual events and emergency system activations, for..situation Reporting and Resource Requesting.. in coordination with Emergency Management at each SEMS level 12

13 Purpose of the EOM The EOM does not prescribe the manner in which local governments or Operational Areas conduct their internal business, but does establish baseline expectations. In fact, the term in accordance with local policies and procedures is the most common phrase used in the EOM. 13

14 EOM Organization Section I: Public Health and Medical Response Functions Common operational processes that support coordinated statewide response when incidents involve the Public Health and Medical System Incident Considerations Communication & Information Management Resource Management Multi-Agency Coordination Disaster Finance 14

15 EOM Organization Section II: Function Specific Topics Provides greater detail on the response to specific types of emergencies Describes the roles of key participants in the Public Health and Medical System There are currently 12 Function Specific Topics New/revised topics under development: Emergency Legal Powers Drinking Water BioWatch Disaster Behavioral Health including Resource Typing by Mission Type Patient Movement Risk Communication 15

16 Function Specific Topics 1. Communicable Disease 2. Drinking Water 3. Food Emergencies 4. Hazardous Materials (HazMat) 5. Health Care Facilities 6. Health Care Surge in the Continuum of Care 7. Patient Movement 8. Mass Fatality 9. Nuclear Power Plant Emergencies 10. Nuclear Weapon Detonation 11. Public Health Labs 12. Risk Communication 16

17 SEMS Level Emergency Function/Recovery Function State ESF-10 Hazardous Materials and Oil Handles Request ESF-8 Public Health and Medical Handles Request ESF-6 Mass Care Regional REOC Assists with Resource Requests RDMHS Assists with Resource Requests Op Area OA OES processes Resource Requests MHOAC processes Resource Requests Local DISASTER RELATED ENVIRONMENTAL HEALTH PROGRAMS

18 SEMS and the Public Health & Medical System State Level Duty Officer, MHCC, SOC Region Level RDMHC Program, REOC Operational Area Level MHOAC Program, OA EOC Local Government Level LHD, LEMSA, DOC Field Level EMS Providers, Healthcare Facilities 18

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20 MHOAC Program Medical Health Operational Area Coordination Program functions Health and Safety Code the MHOAC in cooperation with the county office of emergency services, local public health department, the local office of environmental health, the local department of mental health, the local EMS agency, the local fire department, the regional disaster and medical health coordinator (RDMHC), and the regional office of the Office of Emergency Services (OES), shall be responsible for ensuring the development of a medical and health disaster plan for the operational area 20

21 The medical and health disaster plan, policies, and procedures shall consist of the following (17) functions at a minimum: 1. Assessment of immediate medical needs. EMS/LHD 2. Coordination of disaster medical and health resources. EMS/LHD 3. Coordination of patient distribution and medical evacuations. EMS 4. Coordination with inpatient and emergency care providers. EMS

22 MHOAC Functions 5. Coordination of out-of-hospital medical care providers. EMS 6. Coordination and integration with fire agencies personnel, resources, and emergency fire prehospital medical services. EMS 7. Coordination of providers of non-fire based prehospital emergency medical services. EMS 8. Coordination of the establishment of temporary field treatment sites. EMS

23 MHOAC Functions 9. Health surveillance and epidemiological analyses of community health status. LHD 10. Assurance of food safety. LHD 11. Management of exposure to hazardous agents. LHD 12. Provision or coordination of mental health services. LHD 13. Provision of medical and health public information and protective action recommendations. LHD

24 MHOAC Functions 14. Provision or coordination of vector control services. LHD 15. Assurance of drinking water safety. LHD 16. Assurance of the safe management of liquid, solid, and hazardous wastes. LHD 17. Investigation and control of communicable disease. LHD

25 Earthquake Scenario On Thursday, October 4, at 10:05 AM local time, a damaging earthquake strikes your county without warning. The epicenter is determined to be about 100 miles from your current location. Seismologists measure the earthquake a magnitude 6.5, making it the largest earthquake to hit the region in more than 100 years. Ground shaking from the main shock lasts for approximately 45 seconds in some areas. Aftershocks of varying intensity are felt throughout the region for several days after the main shock and cause further damage to structures already weakened by previous shaking. Tremors are felt as far away as the 500 miles away from the epicenter and damage is seen throughout the entire region. As a result of this earthquake, shaking and soil liquefaction of land caused the following: Hospitals are inundated with large numbers of individuals seeking medical attention Damaged critical infrastructure, such as bridges and roadways Compromised or damaged oil and natural gas pipelines Structural damage to drinking water treatment and distribution and wastewater collection and treatment facilities Power outages as a result of transmission line damage Communication failure because of cell phone tower and phone line damage 25

26 Pandemic Scenario On Thursday, Oct 4, at 0615 you receive a phone call from the airport located in your jurisdiction stating that a few passengers on Flight 451 have fallen ill and are experiencing influenza like illness (ILI). Flight 451 is an Airbus A319 plane with a seat capacity of 160 people and is a connecting flight from San Francisco International Airport. Flight 451 is scheduled to land at Human-to-human transmission of a novel strain of influenza virus H7N9 has been identified in a few Southeast countries in Asia and one of the ill passengers confirmed he traveled into that region with his pregnant wife. He, however, does not know the other three ill passengers on board. Currently, no cases of this virus have been identified in the U.S., however, your jurisdiction has been experiencing an above-average flu season and most of your healthcare facilities are inundated with ILI cases. 26

27 MHOAC Program In order to accomplish the 17 functions, a MHOAC program will: Serve as the OA Public Health and Medical Mutual Aid Coordinator Support the Medical and Health Branch of the OA EOC Ensure the 17 functions are adequately addressed in the Operational Area Medical and Health Disaster Plan 27

28 MHOAC Program In order to accomplish the 17 functions, a MHOAC program will: Maintain a 24/7 point of contact Maintain a directory of health and medical resources in the Operational Area Serve as the single point-of-contact within the OA for information related to the public health and medical system Initiate the creation of field-to-oa Situation Reports Create and share OA Medical and Health Situation Reports Coordinate medical and health resources and requests within and beyond the OA 28

29 RDMHC Program Regional Disaster Medical and Health Coordination Program functions Health and Safety Code deliver medical or health mutual aid to the area affected by the disaster, at the request of the authority, the State Department of Health Services, or the Office of Emergency Services, a regional disaster medical and health coordinator in a region unaffected by the disaster may coordinate the acquisition of requested mutual aid resources from the jurisdictions in the region. develop plans for the provision of medical or public health mutual aid among the counties in the region. 29

30 RDMHC Program A regional-level program which includes: RDMHC (Coordinator) is an appointed position within each of the six Mutual Aid Regions RDMHS (Specialist) supports the RDMHC in the implementation of the RDMHC program functions Supports the Medical Health Branch at the REOCs in coordination with CDPH and EMSA 30

31 RDMHC Program Maintains a 24/7 point of contact Coordinates with the MHOAC Programs within the Mutual Aid Region Ensures the availability of public health and medical emergency resource directories within each Operational Area in coordination with the MHOAC Programs Coordinates information sharing, situational reporting, and medical and health resource management 31

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34 State Level Public Health and Medical Coordination CDPH is the lead state agency for public health and environmental health EMSA is the lead state agency for medical, including emergency medical services Cal OES, CHHS, and other state agencies, in coordination with CDPH and/or EMSA, provide support as needed 34

35 State Level Public Health and Medical Coordination Operates 24/7 Duty Officer Programs Receives notifications from internal and external contacts Provides notifications to internal and external partners CDPH, EMSA, and Department of Health Care Services and other state agencies with a public health and medical mission support California EF 8 Coordinates and supports state level public health and medical activities though the Duty Officer Programs and the MHCC Supports activation of the Medical and Health Branch at the SOC and REOCs 35

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37 Day-to-Day Activities Activities related to an agency s statutory and regulatory authorities and responsibilities Drinking Water Disease Control Mental Health Services Healthcare Facilities 911 Day-to- Day Activities Permits, Certifications, & Records 37

38 EOM Section 1, Page 31 38

39 Condition Unusual events may occur that do not rise to the level of an emergency but warrant enhanced situational awareness and notification of partners Day-to-Day Activities Unusual Events Emergency System Activation 39

40 Unusual Events An incident that significantly impacts or threatens public health, environmental health, EMS or other components of the medical system May be self-limiting or a precursor to emergency system activation The EOM definition of an unusual event is applied based the circumstances of the incident This condition differs from the specialized use of this term in reference to nuclear reactors 40

41 Unusual Events The determination of significant impact or threat is applied within the context of a reference baseline for the affected jurisdiction: An incident may significantly disrupt essential services in one county A similar occurrence in another county may have minimal impact *Local plans, policies, and conditions will help in making this determination 41

42 Unusual Events Criteria for determining an Unusual Event: Significantly impacts public health or safety Disrupts or is anticipated to disrupt the Public Health and Medical System May require resources beyond the capabilities of the OA Produces media attention or is politically sensitive Leads to a Regional or State request for information Whenever increased information flow will assist in the mitigation of the incident s impact 42

43 Information Sharing: Unusual Events Increased response activities necessitates enhanced information sharing Timely communication of incident information is essential to developing a common operating picture Sharing information with response partners supports situational awareness and decisionmaking Increased information sharing facilitates effective support and coordination and supports resource management 43

44 EOM Section 1, Page 32 Information Flow during Unusual Events 44

45 Situation Reporting (SitRep) MHOAC Program - Principal point-of-contact within the OA for information related to the public health and medical system - Gathers pertinent information from response partners - Prepares the Medical and Health Situation Report for the OA within 2 hours of event - Shares the SitRep with relevant partners Local, regional and State emergency management agencies at all SEMS level RDMHC Program CDPH/EMSA Duty Officers 45

46 SitRep: Information Gathering Obtain information from system partners and gather data based on the elements within the Medical and Health SitRep Gather Data/Information Public Health and Medical Emergency Management First Responders Lab, Epi, EMS, Healthcare Facilities, Environmental Health, Mental Health, Other Public Health and Medical Partners OA Status Information, Coroner, Other OA Partners Law, Fire and other First Responders 46

47 SitRep Updates Provide updated SitReps when: - There are significant changes in status, prognosis or actions taken - Once within every Operational Period - As requested by Region/State 47

48 MHOAC The Situational Reporting & Sharing REQUESTS & REPORTS OP AREA RDMHS/C SITUATIONAL AWARENESS PULL/PUSH MHOAC PULL/PUSH SITUATIONAL AWARENESS REQUESTS & REPORTS 48

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53 Condition Day-to-Day Activities Unusual Events Emergency System Activation 53

54 Emergency System Activation Occurs when an incident leads to activation of DOCs and/or EOCs, or when an Operational Area activates any aspect of its Medical Health Disaster Plan 54

55 EOM Section 1, Page 33 Information Flow during Emergency System Activation 55

56 Public Health and Medical System Condition Color Current Condition of the Public Health and Medical System Condition GREEN Normal Operations: Situation Resolved YELLOW Under Control: NO Assistance Required ORANGE Modified Services: Assistance from within OA RED SOME Assistance required from outside the OA BLACK Impaired Services: MAJOR Assistance Required GREY - Unknown The Public Health and Medical System is in usual day-to-day status. Situation resolved; no assistance required. The Public Health and Medical System is managing the incident using local resources or existing agreements. No Assistance is required. The Public Health and Medical System requires assistance from within the local jurisdiction/operational Area. The Public Health and Medical System requires assistance from outside the local jurisdiction/operational Area The Public Health and Medical System requires significant assistance from outside the local jurisdiction/operational Area. Condition is Unknown 56

57 Resource Coordination Coordinating Entities Field Entity (all HCC Partners) Local Government (City, County) Medical vs. Non-Medical Operational Area MHOAC Program Mutual Aid Region RDMHC Program State EMSA, CDPH, DHCS (MHCC) 57

58 Resource Coordination Emergency Assistance Agreements Facility-to-Facility agreements Automatic Aid Agreements Pre-Disaster Contracts Assistance by Hire Agreement Mutual Aid Government-to-government support Limited capacity in the Public Health and Medical System Catastrophic planning 58

59 Resource Requesting Address the Need Define Mission / Task / Activity Identify the intended outcome Box 4 on Request Form Ensure alternatives are considered Wrap Around Services (Logistical Support) Work with MHOAC/RDMHC Program to refine request 59

60 MHOAC Questions for Resource Requesting Is the resource need immediate and significant (or anticipated to be so)? Has the supply of the requested resource been exhausted (or is exhaustion imminent)? Is the resource available from the internal, corporate supply chain? Is the resource or an acceptable alternative available from other vendors? Is the resource available through pre-existing agreements? Have payment/reimbursement issues been addressed?

61 Resource Requesting MINIMUM DATA ELEMENTS RESOURCES REQUEST: MEDICAL AND HEALTH Describe current situation. Submit Medical and Health Situation Report as soon as possible. Describe the requested mission (e.g., ability to transport 20 critically injured pediatric patients). Describe needed equipment, supplies, personnel, etc. and acceptable alternatives. Provide contact information and specific delivery location with a common map reference. Indicate if logistical support is required (e.g., food and shelter for personnel, fuel for equipment). Indicate urgency of need. 61

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64 Flow of Resource Requests and Assistance During Emergencies EOM Section 1, Page 50 64

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66 MHOAC PROGRAM MANUAL (template) Rick Johnson, MD, MPH Health Officer Nancy Lapolla EMS director Stephanie Murti MHOAC Project Coordinator 2016 Ada Chan MHOAC Project Coordinator 2017 Nancy LaPolla,

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71 Notification of the MHOAC

72 Situational Awareness

73 Situational Awareness

74 Bed Polling

75 Flash Report MHOAC to RDMHS

76 Field to OA Sit Rep/Resource Request - 1

77 Field to OA Sit Rep/Resource Request - 2

78 Field to OA Sit Rep/Resource Request - 3

79 Field to OA Sit Rep/Resource Request - 4

80 Field to OA Sit Rep/Resource Request - 5

81 MHOAC inserted into MAC System

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88 Incident Response Guide

89 MHOAC Function 1 and IRG

90 MHOAC Function 2a and IRG

91 MHOAC Function 2b and IRG

92 MHOAC Function 3 and IRG

93 MHOAC Function 4 and IRG

94 MHOAC Function 5 and IRG

95 MHOAC Function 6 and 7 and IRG

96 MHOAC Function 8 and IRG

97 MHOAC Functions 9, 10, and 11 and IRG

98 MHOAC Function 12 and IRG

99 MHOAC Functions 13, 14, and 15 and IRG

100 MHOAC Functions 16 and 17 and IRG

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103 Healthcare Coalition members hospitals EMS Emergency Management (OES) Local public health Local environmental health Local Behavioral health Local social services Community clinics, dialysis, urgent care, provider offices Long-term care facilities Home health, hospice Other organizations (FBO, CBO ARC, Salvation Army) Fire Law others

104 Health Care Coalition Objectives Facilitate information sharing among participating healthcare organizations (Tier 1) and with jurisdictional authorities (Tier 3) to promote common situational awareness. [1] Facilitate resource support by expediting the mutual aid process or other resource sharing arrangements among Coalition members, and supporting the request and receipt of assistance from local, State, and Federal authorities. Facilitate the coordination of incident response actions for the participating healthcare organizations so incident objectives, strategy, and tactics are consistent for the healthcare response. Facilitate the interface between the Healthcare Coalition and relevant jurisdictional authorities (Tier 3) to establish effective support for healthcare system resiliency and medical surge. hcarecoalition/chapter2/pages/overview.aspx

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107 The primary function of a MAC System is to coordinate activities and prioritize incident demands for critical resources MAC Systems provide support, coordination and assistance with policy-level decisions EOCs and MAC Groups are two examples of MAC System elements MAC System 107

108 How the System Works 108

109 Multi-Agency Coordination Groups Incident management may also involve Multiagency Coordination Groups (MAC Groups). A MAC Group is composed of senior officials, such as agency administrators, executives, or their designees, who are authorized to represent or commit agency resources and funds in support of incident activities. A MAC Group acts as an executive or policy-level body during incidents, supporting resource prioritization and allocation, and enabling decision making among elected and appointed officials and those responsible for managing the incident. In some communities and jurisdictions, MAC Groups are located at or near EOCs in order to authorize additional resources, approve emergency authorities, and provide guidance on emerging issues. 109

110 MAC Group Multi Agency Coordination (MAC) Groups are part of the off-site incident management structure of NIMS. MAC Group members are typically agency administrators or executives from stakeholder agencies impacted by and with resources committed to the incident. The MAC Group may also include representatives from nongovernmental organizations. During incidents MAC Groups Act as a policy-level body Support resource prioritization and allocation Make cooperative multi-agency decisions Enable decision making among elected and appointed officials with those managing the incident (IC/UC) MAC Groups do not perform incident command functions. MAC Groups do not replace the primary functions of operations, coordination, or dispatch organizations.

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112 Pandemic Influenza, 2009-?10 112

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114 Train color code TRAIN Color Code Patient Transport Risk Transportation Requirement Blue No Risk Car (Non-ambulance)/Car seat Green Low Risk BLS Ambulance Yellow Medium Risk ALS Ambulance Orange Moderate Risk Critical Care Transport (CCT) Red High Risk Specialized Transport

115 Transport Car (Nonambulance) ADULT TRAIN TOOL BLS (2 EMT Team) ALS (1 EMT, 1 Paramedic) (EMT/Paramedics & CCT RN) Specialized (Staffed depending on need) Life Support Stable Minimal Minimal/Moderate Moderate Maximal Mobility Car/Wheelchair Stretcher/ Wheelchair/Stretcher Wheelchair/Stretcher Stretcher/Immobile Immobile/Bariatric Monitoring Level/ Stability Routine Vitals Routine Vitals + O2 sat; Moderately stable Specialized OR Frequent Vitals + Cardiac Continuous; changing requirements; Monitoring; Interventions status; Interventions Equipment or Scarce possible probable resources; Complexity Pharmacy PO Meds IV Drip 2, type and Isolation Status Life Support Minimal = Moderate = Maximal = IV Lock IV Fluids IV Drip without titration BASED ON MEDICAL NEED TitratedIV Drip; TPN Dependent O2; peripheral IV; Trach (non-vent and does not require deep suction during transport) monitoring requirement Highly Infectious Patient CPAP/BiPAP/Hi-Flow; Chest tubes; Continuous Nebulizer; Stable home/long-term vent (requires transport with RN or RT to maintain ventilator support) Ventilator; ECMO; External Pacemaker; Highly specializedequipment Pharmacy IV Drip = Pharmacologic agents that cannot be discontinued for transport, agents that require active monitoring. IV drips that can be maintained safely at current rate vs. those that need close monitoring and possible titration en route to destination (i.e. vasopressors, insulin, etc.) Mobility Car (vehicle) = Able to get in and out of non-ambulance car, van, or bus; sit up; follow commands Wheelchair = Stretcher = Immobile= Bariatric = Some impairment related to mobility; unable to ambulate for long distances Unable to ambulate or contraindicatedto current medical status/condition Unsafe to move without specialized equipment; non-ambulatory; unstable cervical fracture Patient whose weight exceeds 350 pounds and who requires special equipment for transport

116 Snf train tool Transport Car (Nonambulance) BLS (2 EMT Team) ALS (1 EMT, 1 Paramedic) CCT (EMT/Paramedics & RN) Specialized (Staffed depending on need) Mobility Car/Wheelchair Wheelchair/Stretcher Wheelchair/Stretcher Stretcher/Immobile Stretcher/ Immobile/Bariatric Monitoring Level/ Stability Routine Vitals Routine Vitals + O2 sat; Moderately stable Pharmacy PO Meds IV Lock Isolation Status Life Support Pharmacy Mobility Minimal = Moderate = Maximal = IV Drip = Car (vehicle) = Wheelchair = Stretcher = Immobile= Bariatric = Frequent Vitals + Cardiac Monitoring; Interventions possible IV Fluids IV Drip without titration BASED ON MEDICAL NEED Continuous; changing status; Interventions probable Titrated IV Drip; TPN Dependent Specialized OR requirements; Equipment or Scarce resources; Complexity IV Drip 2, type and monitoring requirement Highly Infectious Patient O2; peripheral IV; Trach (non-vent and does not require deep suction during transport) CPAP/BiPAP/Hi-Flow; Continuous Nebulizer; Stable home/long-term vent (requires transport with RN or RT to maintain ventilator support) New Ventilator; External Pacemaker; Highly specialized equipment Pharmacologic agents that cannot be discontinued for transport, that require active monitoring. IV drips that can be maintained safely at current rate vs. those that need close monitoring and possible titration en route to destination (i.e. vasopressors, insulin, etc.) Able to get in and out of non-ambulance car, van, or bus; sit up; follow commands Some impairment related to mobility; unable to ambulate for long distances Unable to ambulate or contraindicated due to current medical status/condition Unsafe to move without specialized equipment; non-ambulatory; Patient whose weight exceeds 350 pounds and who requires special equipment for transport

117 Pediatric patient movement with emergency system activation ICS, SEMS, NIMS 117

118 Pediatric patient movement with emergency system activation A request for assistance (available bed and/or EMS resource) goes from the sending facility/agency to the OA EOC and MHOAC. The role of the personnel in the activated government response center is one of support and coordination of resources and resource requests from facilities and EMS providers. However, In order to maximize the efficient utilization of all available and appropriate resources, requests for patient movement will be regulated by the DOC/EOC/MOC and the MHOAC. Normal patient referral networks and transport team protocols will be suspended. Control of EMS assets will under the control of the DOC/EOC/MOC and the MHOAC, including the allocation of scarce resources when the demand/need exceeds the available resources. If the DOC/EOC/MOC and MHOAC in the affected OA is unable to function, then the REOC and RDMHS will carry out these functions. 118

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121 The Evolution of an Incident 121

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126 WHO concerned as Congo faces perfect storm for Ebola to spread Ebola response faces grave obstacles as count hits

127 Event Incident Chronological Timeline Representation Assumes: - IC to manage the ad hoc responding organizations - Operations Section Chief to carry out the mission - Planned by the Planning Section Chief - Supported by the Logistics Section Chief - Paid for through the Finance Section Chief All in a state-of-the-art EOC with flat screen TVs, radios, computers, with ICS forms on the computers, ready to be filled out for federal compliance and possible later reimbursement. 127

128 The Reality Initial Chaos Screaming injured people, bodies Crowds, media, elected officials Law, fire, EMS, healthcare workers overwhelmed, may not hurt or not able to function Fires, mud, water, wind, cold/hot, snow/rain Environmental destruction Conflicting information, rumors Lack of communication and transportation 128

129 The Questions Situation Awareness What has happened? What have I never seen before is foreign to me? What have I seen before is familiar to me? What do I know? What do I need to know? What do I want to do? What do I have to do? What can I do? What am I trying to accomplish here? 129

130 Tenets of Working in Chaos - 1 The party already started you are late you need to catch up Find the right MHOAC ahead of time effective in chaos, experienced, trained, educated Not every incident has a playbook sometimes you just need to think sensemaking in chaos 130

131 Tenets of Working in Chaos - 2 Manipulation and improvisation are not dirty words leadership is defined as giving purpose, direction and motivation to people when there is eminent physical dangers and where followers believe that leader behavior will influence their well-being or survival. Be calm, focused, positive, relentless, apply experience, set aside ego, overcome obstacles, anticipate/manage change, determine objectives, define expectations, establish priorities, trust subordinates, constantly evaluate and adjust. BE DECISIVE 131

132 Tenets of Working in Chaos - 3 The starting point for insightful problem solving is leverage points specific things, events, PEOPLE pre-existing relationships, social capital. Social Capital is the stock of active connections among people; the trust, mutual understanding, and shared values and behaviors that bind the members of human networks and communities and make cooperative action possible. 132

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134 If we don t hang together we will all hang separately - Ben Franklin

135 Richard O. Johnson, M.D., MPH, FAAP Contact info: cell: