DTIC ADA519806: U.S. Coast Guard Health Services Responders in Maritime Homeland Security

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U.S. COAST GUARD HEALTH SERVICES RESPONDERS
IN MARITIME HOMELAND SECURITY
Captain Arthur J.French,MD,USPHS,Joe DiRenzo III,and Chris Doane
Superioroperationalserviceisourcorepurpose,andwehavelongbeen
recognizedastheworld’sbestCoastGuard.Americaexpectsthatwe
willbringthesamelevelofprofessionalismandmaritimeleadershipto
thewaronterrorismthatwehavetraditionallybroughttoallourother
missions.
ADMIRALTHOMASH.COLLINS,USCG
U
nlikemostotherfederalagencies,theCoastGuardisatruefirst-response
organization, with statutory authority and responsibilities that allow re-
sponses following a disaster without waiting for a
CaptainFrenchisa1973graduateoftheU.S.Coast
GuardAcademyanda1984graduateoftheUniformed StaffordActdeclarationofstaterequestforassistance.
Services University of the Health Sciences School of This ability and expectation have been lauded in the
Medicine.AftersevenyearsasaCoastGuardlineofficer
publicpresscritiquesofthegovernment’sresponseto
hetransferredtotheU.S.PublicHealthService.Heis
boardcertifiedinemergencymedicineandhasservedin HurricaneKatrina.AsanagencywithintheDepartment
avarietyofoperationalassignmentsasaflightsurgeon. of HomelandSecurity,theleadfederaldepartmentfor
He is presently assigned to Coast Guard Headquarters.
responsestoterrorismandnaturaldisasters,theCoast
Mr.DiRenzoisagraduateoftheU.S.NavalAcademy
Guardmustmaintaincapabilitiestorespondtoterror-
(1982),theNavalWarCollege,andtheMarineCorps
CommandandStaffCollege;holdsanMAinbusiness ism and all-hazard incidents in the maritime and
administrationfromCaliforniaCoastUniversity;and
coastal regions. Katrina demonstrated that medical
isadoctoralcandidateinbusinessadministration,with
aspecializationinhomelandsecurity,atNorthcentral first responders are integral players during cata-
University,Prescott,Arizona.Afternineyearsinthe strophic incidents in addition to search and rescue
Navy,hetransitionedtotheU.S.CoastGuard,retiring
(SAR)responders.Intermsofresponseplanningand
in2003.HeiscurrentlytheAnti-TerrorismCoordina-
tor of the Coast Guard Atlantic Area staff. execution, Coast Guard health service personnel are
Mr. Doane is a 1980 graduate of the University of anuntappedresource.
Maine–Machias,andholdsanMSdegreeinoceanen-
The Department of Homeland Security (DHS)
gineeringfromtheUniversityofNewHampshire.He
hasbeenleadinganeffortincorporatingalllevelsof
retiredfromtheCoastGuardinSeptember2003.Heis
nowtheCoastGuardAtlanticAreaChiefofResponse government and the private sector to build a com-
and Port Security.
prehensive and coordinated campaign to minimize
theriskofterrorismtotheUnitedStates.Muchofthe
Naval War College Review, Summer 2006, Vol. 59, No. 3
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1. REPORT DATE 3. DATES COVERED
2006 2. REPORT TYPE 00-00-2006 to 00-00-2006
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
U.S. Coast Guard Health Services Responders in Maritime Homeland
5b. GRANT NUMBER
Security
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
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74 NAVALWARCOLLEGEREVIEW
department’sandCoastGuard’seffortshavefocusedonthreatandvulnerability—
thatis,preventingterroristattacks.Wemustalsoensurethatanappropriatein-
vestmentinmasscasualtyresponsecapabilitiesismadetominimizetheconse-
quences of a terrorist attack, transportation security incident, or natural
disaster. This article will examine maritime consequence management and a
proposalforusingtheCoastGuard’shealthservicespersonnelasanintegralre-
sourceforitsresponsibilitiesundertheNationalResponsePlan.
The Coast Guard has also focused on prevention in its efforts to secure the
U.S.maritime domain.For over fifty years the Coast Guard has been charged
with overarching responsibility for the safety and security of American ports
andwaterways.TheMaritimeTransportationSecurityActof 2002underlined
theservice’sroleastheleadfederalagencyformaritimesecurity.Since9/11it
hasproducedoutstandingresults.Thenation’smaritimetransportationsystem
is far more secure than it was on 11 September 2001, and the improvement
continues.
Forovertwocenturies,theCoastGuardhasbeenchargedwithleadresponsi-
bilitiesformaritimeconsequencemanagement;infact,mostpeoplethinkofthe
Coast Guard in connection with maritime searches and daring,dramatic res-
cues.TodaythisroleinmaritimeSARhasbeencodifiedinaNationalSearchand
Rescue Plan.Similarly,the Coast Guard has long been responsible for marine
environmental protection and response; that role too has been formalized,in
theNationalContingencyPlandevelopedinaccordancewiththeOilPollution
Act of 1990. This plan makes the Coast Guard the lead federal agency for re-
sponding to oil spills and hazardous material releases, including intentional
chemicalorbiologicalreleases,inthecoastalzone—thatis,alltidallyinfluenced
watersandadjacentwaterfronts.
Theservice’sresponsibilitiesasaleadagencyinvolvenotjustfederalagencies
butstateandlocalgovernmentsaswell.ThisfacthasgiventheCoastGuardacol-
lective“persona”uniqueamongfederalagencies—thatof atruefirst-response
organization,whoseassetsarriveonscenealongside,ifnotaheadof,thoseoflo-
calagenciesandoperateinfullpartnershipwiththelocalresponsecommunity.
Formanystatesandmunicipalities,theCoastGuardistheprimaryresourcefor
security,search,andrescueresponseonthewater.TheKatrinaresponsedemon-
stratedthattheCoastGuardmayalsobetheprimaryor,insomecases,theonly
firstresponderincoastalcommunitiesdevastatedbyadisaster.
WhiletheCoastGuardistheleadfederalagencyforcoordinatingresponses
in the maritime domain,the service lacks the capacity to meet all of these de-
mands; further, its jurisdiction and responsibilities in various aspects of the
maritimedomainaresharedwithothergovernmentagencies.Therefore,ithas
built cooperative partnerships,at all levels and in both the public and private
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FRENCH,DIRENZO,&DOANE 75
sectors,designedtopoolresources.Thekeystosuccessinthisrespecthavebeen
theIncidentCommandSystem(ICS)andtheconceptof“unifiedcommand.”The
latterisquicklydescribed—underitsrubric,entitieshavingsignificantjurisdic-
tionsover,orstakesin,anincidentoroperationproviderepresentativeswithau-
thoritytoactinadecision-makingcouncilthat,inturn,ensuresunityof effort.
Thisprocesshasproveneffectiveoverthelastdecadeandhasbeenmandatedfor
allfederalagenciesbyHomelandSecurityPresidentialDirective5,assetforthin
the National Response Plan and the National Incident Management System.
FortheCoastGuard,theIncidentCommandSystemgoesbacktothe1989
ExxonValdezoilspillandtheOilPollutionActof1990,asaresultofwhichthe
CoastGuardadoptedtheICSfromtheNationalFireServiceasafairlyrobustin-
frastructureforrespondingtomaritimespillsandreleases.Untilthe11Septem-
ber 2001 attacks, the system was primarily limited to environmental hazards.
Becausefewcasualtieswereinvolved,therewasnooperationalrequirementfor
medicalfirstresponders;concernwasfocusedonenvironmentalissuesandre-
spondersafety.Asoil-spill-preventionprogramstookeffectthenumberofspills
decreased,andtheCoastGuard,asagoodstewardof thetaxpayer’sdollar,al-
lowedtheresponseinfrastructuretoshrink—reducingfundingforequipment,
reassigningpersonnel,etc.
Withtheterroristattacksof9/11,theCoastGuard’sseniorleadership,start-
ingwiththeCommandant,thenAdmiralJamesM.Loy,understoodthetrans-
formationneededandestablishedmaritimehomelandsecurityastheservice’s
number-onemissionpriorityalongsideSARandrebalancedmissionemphases
in terms of this national mandate. Since then all Coast Guard programs have
beenrequiredtoimprovecurrentandfuturereadinessforthe“newnormalcy,”
asdescribedintheCoastGuardMaritimeStrategyforHomelandSecurity.1
TheMaritimeStrategy,whichprescribesprinciples,strategies,andprogram
elements,establishesprevention,detection,anddeterrenceastheprimaryfoci
of the Coast Guard’s security efforts.Such critical issues as maritime domain
awarenessandimplementationoftheomnibusMaritimeTransportationSafety
Act have dominated the allocation of the service’s financial and human re-
sources.Withrespecttothelatter,theservicehascalleduponitspersonnelto
perform at levels well above normal in preventing maritime terrorist attacks,
and indeed they do, but as a result they have little time left for consequence-
managementpreparedness.Whileeveryoneacceptstheoldadagethat“anounce
ofpreventionisworthapoundofcure,”preventionagainstterrorismcannotbe
100percenteffective,theMaritimeStrategyacknowledges:“Themaritimeterror-
ist threat presents a daunting challenge,and adequate measures against it can
neverbecompletelyguaranteed.”AsHurricaneKatrinademonstrated,wewill
alsoalwaysbefacedwithresponsestomajornaturaldisasters.
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76 NAVALWARCOLLEGEREVIEW
The service’s lack of emphasis on consequence management does not align
withtheMaritimeStrategy,whichstates,“TheCoastGuardequallyvaluesemer-
gencypreparednessandtheresponseneededtominimizedamageandrecover
fromanyfutureterroristattacksthatmayoccur,despiteitsbesteffortsatpre-
ventionanddeterrence....Tomeetthisnewthreatincreasedlevelsofprepared-
ness and response capabilities are required, including additional personnel
speciallytrainedandequippedtomitigatetheimpactsof aterroristincident.”
Nonetheless,anddespitetheincreasedriskofaterroristchemical,biological,radio-
logical,nuclear,orhigh-yield-explosive(CBRNE)attack,otherthanstrengthen-
ingtheCBRresponsecapabilitiesofitsNationalStrikeForce,theCoastGuard
hasdonelittletorebuilditsformeroilandhazardous-materialresponseinfra-
structure.Nor has it adequately addressed the unique first-responder require-
ments of mass casualties in an intentional or unintentional incident,
particularlyasmightresultfromanattackonacruiseship,high-capacitypas-
sengervessel,orcrowdedwaterfrontvenue.
ThisshortfallisfurtherexacerbatedbythedeclarationintheMaritimeStrat-
egythat“theCoastGuardwillparticularlyensurethereadinessof itsforcesto
worksafelyinareaswhereCBRNEweaponshavebeenused,aswellasitsability
to communicate with first responders from other military, civil, and law-
enforcementagenciesinapplyingcommondisaster-reliefandterroristincident
protocols.”Inaddition,thepresidenthasdirectedthatwewillbuild“anemer-
gencymanagementsystemthatisbetterabletomanagenotjustterrorismbutall
hazards;amedicalsystemthatisnotjustbetterabletocopewithbioterrorism
butwithalldiseasesandallmannerofmass-casualtyincidents.”2Anattackona
chemicaltankshiporaterroristcraftloadedwithachemical,biological,radio-
logical,orhigh-explosiveweapontobeexplodedinapopulatedseaportwould
severelytestourmaritimeresponsecapabilities.
ThechallengerequiresthattheCoastGuardadaptitsinternalresponseinfra-
structureanditsmedicalexpertisetotheprospectofmaritimemasscasualties.
Medicalbackgroundswillbeneededifresponseteamsaretobringcomprehen-
siveperspectivestoplanning,coordinatingwithotherentities,andofferingnec-
essarystaffexpertise.Theservicehastakenthepositivestepofestablishingtwo
IncidentManagementAssistTeams,deployablegroupsofspeciallytrainedand
highlyexperiencedpersonnelintheIncidentCommandSystemandmajorinci-
dent management. They have assisted Coast Guard incident commanders on
multipleoccasions,includingtheresponsetoKatrina,providinganucleusofin-
cidentmanagementexpertisewithoutstandingsuccess.Unfortunately,theduty
isacollateralone;theteams’membersarepermanentlyassignedtoavarietyof
CoastGuardcommands.Theseunitsarealreadyhardpressedtomeettheirday-
to-day mission load, and their commanders are increasingly reluctant to allow
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FRENCH,DIRENZO,&DOANE 77
theirqualifiedpersonneltojointheteams.Attemptstocreatepermanentbillets
tostafftheassistteamshavefallenshortinbudgetarycompetition.Whileeffec-
tiveinincidentmanagement,theseteamsdonothavehealthservicespersonnel
assignedtoprovideabridgetothemedicalcommunityandamedicalperspec-
tivetotheincidentmanagementplanning.
MARITIME POPULATIONS AT RISK
History shows that some terrorist groups seek to achieve their goals by maxi-
mizinghumancasualtiessoastogainthemostpublicitypossible.Thegrowthin
thepassengercapacityandnumbersof cruiseshipsandferriesoperatinginor
adjacent to U.S.waters has thus increased the probability of an intentional or
unintentionalmaritimemass-casualtyincident.Cruiseshipsalonecarrymorethan
6.5millionAmericancitizensannually.Cruiseshipsandferriesare“soft”targets
forterroristattacks;clearlypassengersofthesevesselsareapopulationatrisk.3
Anattackonsuchashipcouldgeneratehundredsofcriticalcasualtiesrequir-
ing airway, oxygenation, ventilation, and intravenous support. Previous inci-
dents show that the sinking of a vessel would result in a large number of
hypothermiccasualties.4Inthecaseof achemicalorbiologicalattack,psycho-
logicalcasualties—symptomaticbutstable—wouldoutnumberactualphysical
casualtiesbytenorfifteentoone.5Theresponsewouldbelittlelessforanattack
thatdidnotproducelargenumbersofinjured;allofthehundredsofpassengers
(some cruise ships and ferries carry in well excess of a thousand passengers)
wouldhavetobescreenedandprioritizedforevacuation.
The likely consequences of a maritime mass-casualty incident,then,will re-
quire a deliberate multidiscipline, multistakeholder, multiresponder approach
from emergency-response planners in the homeland security and search-
and-rescue communities. This includes planning an adequate health services
support (HSS) architecture. The core priorities include saving lives, reducing
suffering,andmitigatingtheimpactonanaffectedpopulation;inallofthesethe
medicalcommunitywillbearaheavyburden.Howwellweprepareformaritime
mass-casualtyincidentswilldeterminewhetheritcancarrythem.6
WhiletheresponsetoHurricaneKatrinawasnotatruemaritimeincident,
andotheragencieshadleadresponsibilityforcasualtycare,thelackofinvolve-
mentbyCoastGuardhealthservicespersonnelinplanningforandexecutinga
hurricane response was reflected in initial weak coordination between Coast
Guardrescuersandmedicalresponsepersonnel.TheCoastGuard’ssearchand
rescue personnel did an incredible job responding to pluck Katrina’s victims
fromperilandtransportthemtosaferlocations.Thisresponserepresentedper-
haps the largest mass rescue operation in the service’s history.However,while
victimsweretransportedtolocationsof relativesafety,thesemovementswere
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78 NAVALWARCOLLEGEREVIEW
noteffectivelycoordinatedduringtheearlydaysoftheresponsewithemergency
medicalsupportpersonneltooptimizepostrescuecare.Thislessthanoptimum
coordinationreflectsthelackofamedicalperspectiveintheservice’scommand
responseplanning.
MARITIME FIRST RESPONDERS
The term “first responder” has several definitions, depending upon context.
Federal Emergency Management Agency (FEMA) first-responder grants go to
law enforcement, fire/rescue, and emergency medical services agencies. The
medicalandpublichealthgrantprogramsoftheU.S.DepartmentofHealthand
HumanServicesconsideremergencymedicalagenciesandhospitalsasfirstre-
spondersaswell,totheextentthattheyare“firstreceivers”ofvictims.Therele-
vant joint capstone document discussing the five phases of casualty care
managementdefinestheroleoffirstresponders:
The first response may include self-aid and buddy aid, combat lifesavers, medics,
hospital corpsmen, physician assistants (PAs), physicians, or other medical person-
nel. The first responder should have a working knowledge of the next level of care
available and the patient movement system. Within this phase, the focus of health
care providers is to save life and limb and stabilize the patient sufficiently to evacuate
to the next level of care. A stabilized patient is one whose airway is secured, hemor-
rhage is controlled, shock is treated and fractures are immobilized.7
The2005federalbudgetincluded$3.6billiontofundfirstresponders—a780
percent increase since 9/11. The Bush administration has proposed doubling
first-responder-preparedness grants to high-threat urban areas.In fiscal 2004,
DHSawardedmorethanforty-sixmilliondollarstometropolitanmedicalre-
sponseteams,establishedfordomesticWMDincidents.However,federalgrants
forcivilianfirstrespondersdonotnecessarilytranslateintoimprovedmaritime
first-response capabilities unless gaps in maritime capabilities are deliberately
identified and dollars are spent to address these gaps specifically.Though the
CoastGuardremains,inthemaritimerealm,theprimaryfirstresponderamong
federal, state, and local agencies, it does not receive federal first-responder
grantsandhasrealizedminimalgrowthinitsbudgetinthisarea.Untilperson-
nelareassignedtocarefulplanningformaritimecontingencies,gapsandshort-
fallswillremainundocumentedandthereforecontinuetobeignored.
InaccordancewiththeNationalSARPlan,NationalContingencyPlan,and
National Response Plan, which apply respectively to various circumstances,
CoastGuardgeographicalcommanders(thatis,commandersofsectorsanddis-
tricts)willbethefederalincidentcommandersformass-casualtyresponsesoff-
shore,neartheshore,oronthewaterfront.Forincidentsoccurringbeyondthree
nauticalmiles(i.e.,beyondstatewaters),theCoastGuardhassolejurisdiction
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FRENCH,DIRENZO,&DOANE 79
and responsibility for consequence management. But command staffs, while
skilledandexperiencedincoordinatinglarge-scale,unifiedincidentresponses,
donothavethehealthandmedicalexpertiserequiredtorecognize,planfor,or
comprehensivelyaddressthemedicalissuesthatwouldresultfromamaritime
mass-casualty incident. The U.S. maritime search-and-rescue system is de-
signedprimarilyforincidentsoflimitedsizewithrelativelyfewvictims,which
constitute the vast majority of cases. For them the Coast Guard relies upon
small-boatandairstationsstrategicallylocatedalongthecoastandinestuar-
ies. Generally, each Coast Guard boat or air station has one ready crew on
board; these crews, supported by personnel in dispersed district and sector
command centers,are expert in locating and rescuing victims in small num-
bers.Mostcrewmembershavebasicfirstaidtraining;somehavequalifications
as emergency medical technicians. These Coast Guard capabilities are aug-
mentedbylocalcommunitysquadsandstate-ownedassets.Thesestateandlocal
respondershavetrainingandqualificationslikethoseofCoastGuardrespond-
ers;theseunitsarefewinnumberandcapacity,andtheyarelimitedtoinshore/
near-shoreoperations.
Mass-rescue/casualty situations, which are not routinely practiced, could
quickly overwhelm such resources. Exercises are being scheduled, but mean-
while,planningforcomprehensive,multiagencyresponseslags.Thisshortfallis
dueinparttoalackofplanningcapacitywithintheCoastGuard;therearesim-
plynotenoughpeopletoconductdailyoperationsandplanforfuturecontin-
gencies as well. In addition, the perspectives of personnel and commands
developingplansarelimitedbytheirindividualexperience.Forexample,“boat
drivers”andotheroperatorstendtofocusonlocating,rescuing,andtransport-
ingvictims,tendingtooverlookthemedicaldetailsinvolvedwithtreatingthe
victims. Planning teams must incorporate personnel from a wide variety of
backgrounds, including medical, to ensure the synergy required to develop a
comprehensive plan that addresses all aspects of a mass-rescue/casualty re-
sponseandleveragesallnecessarygovernment/private-sectorcapabilities.
Studies of conventional mass-casualty incidents have shown that 10 to 15
percent of casualties will die should theynotreceivetimelyprehospitalinter-
vention.Manymaritimeincidentswillinvolveprolongedevacuationandtrans-
porttimes,meaningthatadvancedlifesupportwillhavetobedeployedtothe
scene.Secondarytriagebyadvanced-levelmedicalrespondersatoffshorecasualty-
collectionpointswillbecritical;theserespondersrequireahigherlevelofclini-
calexpertisethanthatofemergencymedicaltechnicians.TheCoastGuardcutters,
Navy ships,and merchant vessels that would act as offshore casualty-collection
pointslacksuchmedicalteams.Perhapsmunicipalmedicalrespondersorfed-
eralandDefenseDepartmentdisasteraugmentationteamscouldrapidlydeploy
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80 NAVALWARCOLLEGEREVIEW
toandoperateonthesceneatamaritimeincident;theiravailabilityandcapabil-
itytodosohavenotbeenadequatelyexplored.
Allthisdoesnotalignwellwiththeexpectationsoflocalorstategovernment,
orofthepublic.ThegeneralpresumptionisthattheCoastGuardisasprepared
torespondtoamaritimemass-casualtyincidentasthelocalcommunityistore-
spondonland.Communitieswithinfiftymilesofthecountry’slargest120cities
arecoveredbyfederallyfundedMetropolitanMedicalResponseTeamscapable
of treatingathousandcasualties;nosuchsupportiscurrentlyinplaceforthe
maritime region. Coast Guard area commanders have identified this gap as a
prioritystrategicissue.8
TheCoastGuard’sinternalhealthservicessupportpersonnelneedtobeac-
tivelyinvolvedintheprocessofunderstandingandaddressingthesesubstantial
gaps in preparedness. The Katrina response demonstrated the lack of active
healthservicesresponders’engagementwithoperationalresponders.Withthe
exceptionofSafetyandEnvironmentalHealthOfficersandforensicdentists,the
medical response was limited to augmenting aviation medicine support to
CoastGuardaircrewsatfixedoperatingbases.Nophysiciansweredeployedto
augmentrescueandoperationalunitsandassistwithcoordinationwithmedical
responseorganizationsorthenumerousmedicaltriageandtransportationis-
sues.NorwereCoastGuardhealthservicespersonneldeployedtoassistDoDor
DHS medical teams in caring for the displaced evacuees. While the Air Force
provided its own medical evacuation crews during the evacuation of patients
stagedattheNewOrleansAirport,CoastGuardC-130srequiredaugmentation
fromotherservicesforMEDEVACcrews.TheDefenseDepartmenthaslearned
throughpainfulexperiencetoincludehealthservicesinmissionplanning,but
nosuchculturechangehasoccurredintheCoastGuard.Inaddition,Coast
Guard staffs have hesitated to “lean forward” and ensure that operational
commanders fully appreciatethemedicalandhealthdemandstheywillface
in a mass-casualty incident and to promote their service’s health support
capabilities.
TheHSSprogramhastraditionallynothadanoperationalresponserole,in-
stead supporting health protection and health fitness for Coast Guard forces.
TheDirectorof HealthandSafetymanagestheservice’sprogramatthehead-
quarterslevel.ThechainofcommandforlocalCoastGuardclinicsandsickbays
runsthroughIntegratedSupportcommandsviaregionalMaintenanceandLo-
gistics commands. The result is an administrative and operational separation
betweenCoastGuardoperationalcommandersandhealthservicessupportac-
tivitiesthatimpedescoordinationofmedicaloperational-responseplanning.
WhileCoastGuardhealthservicessafetyandenvironmentalhealthofficers
havebridgedthisoperational-supportgapandarewellintegratedintomarine
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FRENCH,DIRENZO,&DOANE 81
safetyandoperationsresponseplans,theinclusionoflocalhealthservicesindi-
rectplanningforandsupporttomass-casualtyresponseshasbeeninconsistent
and ill defined. With the exception of a 1990s medical response “away team”
conceptintheCoastGuard’sSeventeenthDistrictinAlaskaandapartneringat-
temptintheThirteenthDistrict(inMarineSafetyOfficePugetSound,between
Coast Guard health services representatives, the Defense Department, and the
DepartmentofHomelandSecurity’sRegionalNationalDisasterMedicalSystem
Coordinator),thediscrepancybetweenCoastGuardhealthandmedicalmaritime
homeland-security requirements and operational readiness has not been ad-
dressed.This“delta”mustbeclosednow,beforeanattackoraccidentforcesmedi-
cal and health shortcomings to be solved in the midst ofa mass-casualty crisis.
The Coast Guard must proactively engage its HSS component in maritime
homeland security mission planning, preparedness, and operations. Opera-
tionalcommandersneedto“mine”theirhealthservicessupportpersonnelfor
informationonthemedicalthreatstothepopulationsatrisk,theresponsecapa-
bilities required to mitigate these threats, and the availability of medical re-
sourcestomeettheseneeds.Theyalsoneedtocausetheirpersonneltointeract
anddevelopcooperativerelationshipswiththeirhealthservicespeersatother
medicalfacilities.TheCoastGuardMedicalManualalreadyassignsseniormedi-
calofficersresponsibilitiesfordisasterplanningandcoordinationwithlocalau-
thorities,butitneedstobedefinedfurtherbydoctrineandsupplementedwith
policy guidance, particularly with respect to maritime disasters.9 Planning
should adapt a “network-centric”concept,one that relies on regional medical
capabilities and mutual aid to support maritime incident management.10 Re-
gionalmedicalmutual-assistancemaritime-responseplansthatassociateCoast
Guardhealthserviceswithspecificgeographicalareashavenotbeenestablished
inmostplaces.Creatingthesenetworkswillrequireclosecoordinationandded-
icatedcommunication.
CoastGuardresponsibilitiesfordirectsupportofmaritimehomelandsecu-
ritypreparednessandresponseneedtogobeyondplanningandcoordination
support to include operational support. While medical personnel from other
agencies may become available for rapid deployment to a maritime incident,
Coast Guard health services support personnel represent a valuable resource.
CoastGuardAuxiliaryhealthcareprovidersalsoserveas“forcemultipliers”and
backfillfordeployedactive-dutyhealthcareprovidersduringsurgeoperations.
Doctrineneedstocreate,andaligntheservice’sfirstresponderswith,thehealth
andmedicalrolesforterrorismandmass-casualtyoperationsprescribedbythe
Department of Homeland Security.11 The Coast Guard Incident Management
Handbook defines numerous medical,health,and safety roles for responses to
maritimemass-casualtyscenarios(hazardous-materialsaccidents,collisionsof
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