Paul K' Carlton, Jr', MD, FACS

1
Rural Hospital Design Network 14 June
Rural Healthcare Viable Solutions
Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF,
Ret Professor of Surgery, HSC Director of
Homeland Security HSC 14 June 2005
2
Rural Hospital Design Network 14 June
Surge Hospital Criteria includes Affordability
Dual Use
3
Rural Hospital Design Network 14 June
You may obtain a copy of this presentation at
www.tamhsc.edu/homeland/
4
Rural Hospital Design Network 14 June
America is in Danger!
5
Danger Always Present, Just
Beneath the Surface
6
Facing Reality is Difficult
None of us Want to Face What Lies Ahead of
Us We Must!
7
Change Is Hard
Every revolutionary idea evokes three stages of
reaction

• Youre nuts!
• It would work, but no reason to change!
• You like it? It was MY idea!

8
Traits of a Terrorist

• Terrorism IS
• Politically motivated violence deliberately
  targeted at civilians
• Instruments of social and political change
• Terrorism seeks to break peoples will so they
  surrender principle to save themselves
• Terrorism is NOT
• Senseless or random
• One mans terrorist is NOT anothers Freedom
  fighter
• A viable negotiating technique
• One to seek compromise

Source Dr. Llana Kass, Apr 04
9
GOAL
Destroy will! Surrender principle! Save your
hide! Dr. Lana Kass April 04


10
Weak Link
Medicine may be the Weakest Link!
11
Weak Link
We could see collapse of our health care system
in any bio event! Chuck
Ludlam, Chief of Staff
Senator Lieberman
15 April 05
12
Weak Link
We are totally unprepared medically! We have
none of the vaccines nor antibiotics that we
would need in a bio event. Defense Contract
model will not work in this situation.
Chuck
Ludlam, Chief of Staff
Senator Lieberman
15 April 05
13
Weak Link
Medicine is our weak link and that is where, I
am afraid, we will break.
Ed Eberhart CINC
NORTHCOM May 3, 2004

14
Rural Hospital Design Network 14 June
These people could be wrong but I doubt it
15
Medical Response
Different worlds they do not understand each
other
16
Medical Response
Different worlds they do not understand each
other
17
Medical Response

• NO OWNED ASSETS
• ALL PRIVATE
• REQUIRES BETTER COOPERATION and UNDERSTANDING
  THAN WE HAVE EVER SEEN!

18
Threats
Medicine, as we know it, is in danger of failing.
19
The Current Hospital Environment

• Key component of consequence management is timely
  medical care for victims of mass casualty
  incidents
• Incorrect assumptions made about existing
  medicalcapabilities to treat mass casualties
• Hospital surge capacity has never been more
  restricted
• Medical community struggling just to maintain
  everyday capacity
• Majority of preparedness issues are financially
  (revenue vs cost) based
• Without prompt action, the nation carries the
  risk thatvictims of a mass-casualty disaster
  might end up in ambulances to nowhere."

Source Barbera, Macintyre, and DeAtley Mar 2002
20
Ambulances to Nowhere

• Funding shortfalls
• Decline in government support for public and
  privatehospitals
• Increasing number of expensive, unfunded, or
  under-funded regulatory mandates
• Continued expectation that hospitals will
  maintain highlevels of charity medical care
• National shortage of nurses for acute care
  hospitals, resulting in need for special
  compensation packages to attract personnel
• Results -- closure, downsizing, consolidation,
  reconfiguration, and partnering
• Abolition or downsizing of specialty services
  crucial todisaster preparedness!

Source Barbera, Macintyre, and DeAtley , Mar
2002
21
Ambulances to Nowhere

• Delivery of acute medical care evolved beyond
  ordinary business relationship to "trust" with
  patients
• Trust has extended to current threat
  environment
• Move from individual patient to community as a
  whole
• Financial support to hospitals by community
  create expectation hospitals will address
  community's health/medical needs, including
  disaster preparedness
• Reasonable cost for hospital preparedness for
  mass casualtieswas assumed to be necessary cost
  of doing business
• Financing costs
• Old Medicare and fee for service
• New Managed care payment system (capitation)
• Bottom line Disconnect between expectations and
  funding!

Source Barbera, Macintyre, and DeAtley , Mar
2002
22
Troubled Medical System

• Growing concern over projected shortage of
  healthcare providers in coming years
• Other factors aging population, increased
  demand, and increased costs
• Troubled specialties -- orthopedics, radiology,
  dermatology, cardiology, ophthalmology and
  anesthesiology
• Bleak future forecast
• Shortage of 200,000 doctors,
• 157,000 pharmacists
• 20 shortfall in nursing
• requirements by 2020
• Quality of life greatest deterrent

Kiplinger, Mar 05
23
A Strained System

• Hospital capacity continues to be main limiting
  factor in disaster medical response
• Critical care services and intensive care units
  most affected
• Recent examples
• Only 25 ICU beds usable for 27 patients in Madrid
  bombing
• Only 12 ICU beds available for 20 patients in
  Bali bombing
• 2001 Houston floods reduced ICU capacity by 75
• More challenges
• Toxic chemical scenario 1200 bed hospital could
  handle only two patients at one time
• Poor staffing levels for critical care areas

Dara, Ashton Farmer, Feb 05
24
A Strained System

• Possible surge solutions
• Pre-emptive education Increased disaster
  response awareness, improved skill sets,
  comprehension of roles and responsibilities,
  alternate communication styles, and expertise in
  cooperation during chaos
• Interfacility cooperation Creation of flexible
  plans for interchanging resources to supplement
  existing capacity of hospitals
• Dual usage of resources Critical care units
  respond outside geographical locations merge
  training and education

Dara, Ashton Farmer, Feb 05
25
Meeting the Medical Need

• HHS memo dated 14 Sep 04 outlines plan for
  increased medical staffing during surge
• Creation of Federal Public Health and Medical
  Ready Reserve
• Comprises civilian physicians, nurses, and
  healthcare professionals
• Details developing
• Effective deployments through Office of Public
  Health Emergency Preparedness
• Necessary equipment, training, and material
  provided
• Service strictly voluntary
• Must be civilian hold professional license,
  certification, or registration

Source HHS, Nov 04
26
Rural Hospital Design Network 14 June
Senator Daniel Patrick Moynihan, NY Everyone is
entitled to his opinions. He is not entitled to
his own facts!
Facts are presented above!
27
Modular Medical Response CapabilityA Possible
Future
Local Infrastructure Baseline Capability
Units of Medical Capability
Emergency Room Operating Rooms ICU Beds Inpatient
Beds Physical Space
Day to Day Patient Capacity
Local Response
Time
28
Tools Must have
response units to solve problems
Requires Tools in the Toolbox
NO Tools NO Response
29
DANGER

• Mass Casualty Events Terrorism
  Natural disasters
• Cost containment

30
Danger
Medicine, as we know it, is in danger of failing.
31
Overview

• Danger Terrorism Runaway cost
• Solutions

32
Medical Threats
Noise level is deafening. Drives you to
act! What are you to do?
33
5 Ps

• Prior
• Planning
• Prevents
• Poor
• Performance

34
Hospitals are AT RISK
35
Hospitals Targeted?

• Counter-terrorism officials warned New Jersey
  hospitals of possible attack after large-scale
  attack
• Secondary targets unable to treat victims of
  earlier attack
• Hospitals forced to plan to protect facilities
  and supplies
• Must provide aid during attack
• Other warnings
• Report suspicious behavior
• Two rescue squads and one emergency rooms
  reported strange inquiries

Source Star Ledger, Aug 04
36
Fake Hospital Inspectors

• Hospitals in Detroit, Boston and Los Angeles had
  people enter masquerading as hospital inspectors
• Each asked to see hospital records, admittance to
  non-public areas and watched people work
• In all three incidents imposters stated they were
  Joint Commission (JCAHO) surveyors
• All three hospitals have been named terrorist
  targets Joe Cappiello, Vice President, JCAHO

Source Washington Post 22
April 2005
Joe Cappiello - 25 April 2005
37
Hospitals Targeted?
Hospitals Concerned! Recent threats to hospitals
outlined! Hospitals in Detroit, Boston, and Los
Angeles have been tested for their
security! Persons posing as JCAHO inspectors
tried to get more details on the involved
hospitals in the wee hours of the morning when
questioned they fled! Authorities are
investigating!
CNN 25 April 05
38
Hospitals Targeted?And More
27 Mar 05 New Jersey hospital experienced its
fourth separate incident in a six week period
3 male subjects in 30s and 40s, Middle Eastern
descent presented themselves as representative
of JCAHO inquired about capacity, services and
operations left when questions were not
answered 26 Feb to 10 March 2005 Boston, Los
Angeles, and Detroit hospitals had similar
events Oct 2004 two hospitals in Phoenix, Az
reported suspicious activity Phoenix, Az St
Josephs Hospital had three men inquire about
antidote medicines for biological attacks 7 Feb
05 Middletown Regional Hospital, NY had two men
with proper identification badges ask about
capacity for cardian care, trauma care,
heliport, and private rooms staff suspicion
raised and suspects left business card
fraudulent
DHS Information Bulletin Title False Hospital
Inspection Date April 22, 2005
39
Questionable Inspectors

• 3 U.S. hospitals approached in Feb-Mar 05 by
  individuals posing as JCAHO inspectors
• Hospitals in Boston, Detroit, and Los Angeles
• Inspections occurred over 2-week span
• Motives unknown
• Presented credentials similar to JCAHO
• South Asian and Middle Eastern descents
• All fled when further questioned
• Policy change all inspectors now carry signed
  letter

Washington Post, May 05
40
Hospitals Targeted?And More
Total of 11 separate incidents across the USA in
the last 6 months Only historical hospital event
occurred in Russia in 1995 Known terrorist
Shamil Basayev and Chechen rebels led a
hostage taking raid at Budennovsk in Southern
Russia 2000 hostages were taken at a hospital
150 died when Russian forces stormed the
building Basayev escaped
DHS Information Bulletin Title False Hospital
Inspection Date April 22, 2005
41
TOPOFF 3 Analyzed

• DHS analyzing results of 16M TOPOFF 3 exercise
• 2 years to plan findings released in 4-6 months
• Collaborative efforts
• Involved 27 federal agencies, state/local
  governments, private sector, and foreign
  countries
• Measured ability to prevent/respond to terrorist
  attacks
• System tested
• we expect failure, because we'reseeking to
  push to failure, and that isthe best way to get
  a lessons learned.
• -- DHS Secretary

JCS observations We got to 100K dead with no
options for response and stopped the medical play!
Govexec.com, May 05
42
Threat
Cost Containment
43
Percentage of Healthcare Expenditures to GDP
30
Prediction
20
14
13
10
5
2010
2000
2005
1985
1970
1900
1960
Potential to Break the Country!
44
Affordability

• Less expensive facility
• Better training
• More efficiency
• Healthier life style
• Not just more money

45
Threats
Man-made
Biological

• List is large
• Still growing
• You must be prepared!

Chemical
Natural
Nuclear
Bird Flu
Train Wrecks
Tsunami
Hurricanes
Earthquakes
Oil processing explosions
11
Aging population
12
Cost containment
13
ALL HAZARD!
46
Rural Hospital Design Network 14 June
Lets look at our medical assets!
47
Medical Readiness
P (people) MRC E (equipment) MRC T
(training) MRC O (organization) - MRC
48
Umbrella of Authority Master
Plan
People
Equipment
Training
Organization
Local Regional National - International
49
People
People
Local Regional National - International
50
People Gap Analysis
Need 1. 2. 3. 4. To stop the leaks
People
Local Regional National - International
51
Equipment
Local Regional National - International
52
Equipment Gap Analysis
Need 1. 2. 3. 4. To stop the leaks
Local Regional National - International
53
Training
Local Regional National - International
54
Training Gap Analysis
Need 1. 2. 3. 4. To stop the leaks
Local Regional National - International
55
Organization
Local Regional National - International
56
Organization Gap Analysis
Need 1. 2. 3. 4. To stop the leaks
Local Regional National - International
57
Master Plan
Local Regional National - International
58
Master Plan
Local Regional National - International
59
Master Plan
Local Regional National - International
60
Goal Leak Proof Umbrella
P
E
T
O
ALL HAZARD ENVIROMENT
Local Regional National - International
61
Rural Hospital Design Network 14 June
NEW ASSETS
62
Rural Hospital Design Network 14 June
I will show you what is on the horizon! Developed
in response to current shortfalls/ challenges!
63
Rural Hospital Design Network 14 June
Modularity has been proven to be Effective and
Efficient In every scenario tested
64
Rural Hospital Design Network 14 June
Effective in terms of saving lives Efficient in
terms of whatever transportation is required In
every scenario tested
65
Rural Hospital Design Network 14 June
World Today Has Many Challenges That Demand a
Mobile Medical Solution -- tsunamis that kill
hundreds of thousands and destroy Medical
facilities --earthquakes, as in Bam, Iran --wars
in the Sudan -- any humanitarian response
operation --many peace keeping operations --terror
ist events
66
Rural Hospital Design Network 14 June
The difficult questions to answer are -- should
we respond? --how should we respond? --do we go
by ground, air, or sea? --how much can we
afford? --are we counting the total cost? --how
can we save precious lives?
67
Rural Hospital Design Network 14 June
The Key to All of These Questions Is Flexibility!
68
Rural Hospital Design Network 14 June
Flexibility means With the same equipment You
can go by -ground -air -sea AT AN AFFORDABLE COST
69
Today
Areas for Improvement
-not fully modular -not self contained
-difficult to erect -not hardened CW/BW
70
Cost of Deployment
P People E Equipment T- Transportation T -
Training
All must be factored in for total cost
71
New Equipment
History of This Concept

• -Requested by US Army for future combat systems
• -Being studied in USA by
• USAF
• USA
• USN
• Department of Homeland Security
• Other countries interested
• Saudi Viet Nam
  Romania Norway
• Oman Kuwait
  Poland Denmark
• Australia Qatar
  Bulgaria Sweden
• UAE Brazil
  Germany UK
• Malaysia Greece
  Turkey Slovenia
• Countries who have bought equipment
• USA
• Saudi
• Armenia

72
Response Equipment
Yesterday GP Medium tents, DepMeds,
Temper Tents, Iso-shelters
Today EMEDS, MFST, FST, CCATT, Theater
Hospitals, Alaska tents, complex to put together,
not all hardened
Tomorrow MSU-I, MSU-II, USS, LSU, Lab/pharm,
Xrayall hardened all self contained
73
Mobile Solutions
Opportunity exists to skip Today and go
straight to Tomorrow!
74
Oak Ridge Unit

• New response unit
• War time only
• Meets no U.S. standards

Seen at Camp Bullis 12
August 2005
75
North Carolina Unit

• 18 wheeler based
• Not certified
• Meets no U.S. standards
• Cheaper
• Cannot dual use

76
Vermont Unit

• 18 wheeler
• Certified and licensed in 9 states
• Used last 10 years
• Can be used everyday for peacetime

77
21st Century Military Hospital System
Mobile Medical International Corporation
78
Red Wedge Concept - Equipment
Red Wedge at both ends ofconflict to enable
assembly/disassembly of stable operations
Contingency Ramp up
Contingency Cessation
79
Schematic of USS
Universal Support System
TOTALLY SELF
CONTAINED
Mechanical Room
Right Ramp Door
Left Ramp Door
BW/CW Hard
Troop Door
One Seavan size
80
Mobile Medical International Corporation
Universal Support System Mobile Surgery Unit
II

• Power Systems
• Integrated Diesel Generators
• Shore Connection of both AC and DC Power
• Integrated Emergency Power System

81
Mobile Medical International Corporation
Universal Support System Mobile Surgery Unit
II
Power Systems
82
Mobile Medical International Corporation
Universal Support System Mobile Surgery Unit
II

• ECU Systems
• Staged for optimum efficiency reliability
• Meet AIA Guidelines (Hospital Healthcare
  Facilities)
• Filtration HEPA in OR 95 in Patient Wards
• Exceed minimum air change requirements
• Sealed air handling system w/NBC Filtration
• Utilization of reject generator heat
• (10 KW in OR 20 KW in Patient Wards)

83
Mobile Medical International Corporation
Universal Support System Mobile Surgery Unit
II ECUs
84
Schematic of USS
Universal Support System
TOTALLY SELF
CONTAINED
Mechanical Room
Right Ramp Door
Left Ramp Door
BW/CW Hard
Troop Door
One Seavan size
85
One Pallet Hospital-MMI
108
DUE June 2005
Cut down USS To one pallet size
Height 88
HVAC, generator
96
20 KW Power
Temp range -20 to 120 F
HVAC, generator
OR
600 sq ft shelter
86
Soft Sided Scenario 1st Step
Self Contained
Universal Support System-- USS
OR
87
Push a Button and Inflation Is Automatic with
Air System
88
Step 2- Add MSU-II 24 Beds
89
MSU-II Mobile
Surgical Unit-II/ICU
90
MSU-II Mobile Medical International Corporation
Rigid-Wall Re-locatable Shelter Design
Verification

• Mobility
• Rapid Deployability
• Modularity

91
MSU-II Mobile
Surgical Unit-II/ICU
92
21st Century Military Hospital System
Mobile Medical International Corporation
93
MSU-II Mobile Surgical Unit/4 Bed ICU
Open Unit Ready To Set Up
94
MSU-II Mobile Surgical Unit/4 Bed ICU
Two OR Configuration
95
MSU-II Mobile Surgical Unit/4 Bed ICU
One OR And Two ICU Beds
96
Red Wedge Concept - Equipment
Red Wedge at both ends ofconflict to enable
assembly/disassembly of stable operations
Contingency Ramp up
Contingency Cessation
97
Soft Sided Solution
Building the Hospital

• Start with one- USS
• Link OR(MSU-II) as step two
• Start linking together to reach desired size

98
Link units to make larger asset 3rd Step
Available Today
Side to side
USS
USS
USS
End to end
99
For Example
Professional Equipment for 32 Bed 6 ICU
patients 1,200 lbs 26 ward patients
2,600 lbs 1 MFST
300 lbs Total 4,100 lbs
Professional Equipment for
50 Bed 10 ICU patients 2,000 lbs 40
ward patients 4,000 lbs 2 MFST
600 lbs Total
6,600 lbs
Professional Equipment for 116 Bed 10 ICU
patients 2,000 lbs 100 ward patients
10,000 lbs 4 MFST
1,200 lbs Total
13,200 lbs
All EMEDS Equipment
100
32 bed
Medical Only
Component Quantity Weight Total
Weight/lb MSU II 1
11,900 11,900 USS
1 13,240
13,240 Professional Equipment 4,100
4,100 2 Sea Vans 29,240
Fits in single C-130
101
50 Bed
COT
COT
Medical Only
Component Quantity Weight Total
Weight/lb MSU II 1
11,900 11,900 USS
2 13,240 26,480 LSU
1 9,800
9,800 Professional Equipment 6,600
6,600 4 Sea Vans
64,780
Fits in two C-130s Or two of these in single C-17
102
116 Bed Complete Hospital
Component Quantity Weight Total
Weight MSU II 1
11,900 11,900
USS
5 13,240 66,200

LSU 4 9,800
39,200
Kitchen 1
11,130 11,130
Power/water 1
12,540 12,540
Lab/Pharmacy 1
11,900 11,900
Laundry
1 7,700 7,700

Refrig/Freezer 1 11,900
11,900
Water/disposal 8 11,900
95,200
19 Sea Vans
267,670 plus pro gear
Fits in single C-5
103
Rural Hospital Design Network 14 June
Mobility Ground
104
Mobile Medical International Corporation
Rigid-Wall Re-locatable Shelter Design
Verification

• Mobility
• Rapid Deployability
• Modularity

Standard Seavan Container Is Army request To be
heart of system
105
ISO Mobilizer
55mph
5 MPH Version
106
Low Speed Mobilizer
16 MPH Version
107
High Speed Mobilizer
55 MPH Version
108
USS Transport System
Tilt flatbed trailer
109
Rural Hospital Design Network 14 June
Mobility Air
110
One C-130

• Full up hospital with 2 Sea Vans
• 1st sea van provide 2 x 600 sq.ft. of hardened
  patient care, air, HVAC, power, compressor (USS)
• 2nd sea van OR standard of care (MSU-II)
• 32 bed hospital

111
Airlift Build-up Summary
5 Pallets
2 Seavans
2,000 Miles
18 Pallets
9 Seavans
3,000 Miles
36 Pallets
18 Seavans
2,600 Miles
36 Pallets
18 Seavans
2,600 Miles
Aviation Week and Space Technology, Jan 05
112
Equipment
Airlift C-130 5 pallet/50K lbs
5,000 hr AN 124 36 pallet/250K lbs
15,000 hr C-5 36 pallet/250K lbs
21,000 hr
113
Transportation- Mission Only
Must pay positioning cost, mission cost, and
repositioning cost
C-130_at_ 250 kts 5,000 hr
AN-124_at_ 450 kts 15,000 hr
From To
Hours/Cost Hours/Cost
Dubai Saudi Saudi
Bosnia Bam Sumatra
8.4/42,400
4.7/70,500
2.8/14,320
1.59/23,850
15.8/79,240
8.8/132,00
UAE recently deployed hospital to Bosnia They
required 200 missions to do so 14M for actual
lift to theater Times 2 to 3 28M- 42M airlift
cost
So real number is some multiple of this
114
Vermont Solution
Would have cost one AN 124 load _at_ 140K per round
trip
115
21st Century Military Hospital System
Mobile Medical International Corporation
116
Rural Hospital Design Network 14 June
Surge Hospital/ Facility Definition A facility
that can be used to provide sufficient medical
care when a primary medical facility is
-destroyed -contaminated and thus denied
-overwhelmed
117
Rural Hospital Design Network 14 June
Surge Hospital

or

Community
Health Center
118
MSU I - Equipment Concept

• 18-wheeler response vehicles!
• Equipment already exists/covers OR renovation
• Used to deliver surgical care in prisons in FL
  (2.8 M saved first year!)
• Public Health use in AZ (Breast Care)
• Response unit to cover surge requirement in DC
• Designed to be stand alone ASU

119
MSU I - Surgical Care/ICU
120
MSU I - Surgical Van/ICU

• Off the shelf
• 18 Wheeler
• Medicare approved
• Licensed in California, Virginia, Louisiana and
  Florida
• Been used for 9 years

2.7 M
121
MSU-II Mobile
Surgical Unit-II/ICU
1M
122
MSU-II Mobile Surgical Unit/4 Bed ICU
Two OR Configuration
123
Make Any Clinic an ASU
Carlton Avenue
Clinic Existing structure
ASU Pad 40,000 Cover (roof) Concrete, Water,
Sewer, Electrical Hook ups
124
Make Any Clinic an ASU
Carlton Avenue
Clinic Existing structure
ASU Pad 40,000 Cover (roof) Concrete, Water,
Sewer, Electrical Hook ups
Birthing Center
125
Next Step More Service
Partner with Hotel Own Hotel
Pros and Cons for each Dont pay for what you
dont use!
Dual Revenue Stream is CRITICAL!
126
Clinic Existing Structure
Carlton Avenue
Ambulatory Surgical Unit 20,000 sq. ft. _at_ 400
8M
Rest Recovery (Hotel) Facility 100,000
Sq.ft. _at_100 10M
Birthing Center 15,000 Sq.ft. _at_ 250 3.75 M

Hotel
Construction costs by Madison Construction
Bryan,TX 10 Aug 04
Pt
135,000 Sq Ft Total Cost 21.75 M
Hospital Construction
135,000 X 400 54M
127
Today- June 05
On verge of starting At two sites -McAllen,
Texas -New South Wales, Australia
128
El Milagro Clinic Addition McAllen, Texas
Old El Milagro
NEW
129
First Floor 135 per square foot 21,000 Square
feet 3.1 million
MSU - l
130
First Floor 135 per square foot 21,000 Square
feet 3.1 million
MSU - ll
131
Small Clinic Option Thursday Hospital
5,000 Sq. Ft Options _at_ 700K per Clinic
MSU - l
132
Small Clinic Option Thursday Hospital
5,000 Sq. Ft Options _at_ 700K per Clinic
MSU - ll
133
Modular Hospital Proposal
Carlton Avenue
Recovery/Rest Facility (Hotel)
MSU - l
Thursday Hospital 5,000 sq. ft. _at_
135 per sq. ft. 675,000
134
Modular Hospital Proposal
Carlton Avenue
Recovery/Rest Facility (Hotel)
MSU - ll
Thursday Hospital 5,000 sq. ft. _at_
135 per sq. ft. 675,000
135
ASU and Birthing Center
100,000 x 100 10M 15,000 x 250 3.75 M
20,000 x 135 2.7M 4 M (Vans)
20.45 M
LDRP
Rest/ recovery (Hotel) Facility 100,000 sq.ft.
_at_100 sq.ft. 10M
LDRP

Offices
storage
LDRP
20,000 sq ft _at_ 135 per sq ft 2.7M
15,000 sq ft _at_ 250 per sq ft 3.75M
Van
Van
Reception area
LDRP
storage
LDRP
LDRP
LDRP
LDRP

136
Construction Cost
Facility Square Feet
Cost per SF Total Cost
Hospital 135,000 400
54 M ASU
20,000 135
2.7 M Birthing 15,000
250 3.75 M MSU
l (Ground response option)
5.4M
Hotel 100,000
100 10 M


21.85 M
Typical
Modular
11.85 M
Modular construction without hotel is 21 of
typical hospital cost. Modular construction with
hotel is 40 of typical hospital cost.
137
ASU and Birthing Center
100,000 x 100 10M 15,000 x 250 3.75 M
20,000 x 135 2.7M 2 M (MSU ll)
18.45 M
LDRP
Rest/ recovery (Hotel) Facility 100,000 sq.ft.
_at_100 sq.ft. 10M
LDRP

Offices
storage
LDRP
20,000 sq ft _at_ 135 per sq ft 2.7M
15,000 sq ft _at_ 250 per sq ft 3.75M
MSU ll
MSU ll
Reception area
LDRP
storage
LDRP
LDRP
LDRP
LDRP

138
Construction Cost
Facility Square Feet
Cost per SF Total Cost
Hospital 135,000 400
54 M ASU
20,000 135
2.7 M Birthing 15,000
250 3.75 M
MSU-ll (Airborne response option)
2M
Hotel
100,000 100
10 M

18.45 M
Typical
Modular
8.45 M
Modular construction without hotel is 15 of
typical hospital cost. Modular construction with
hotel is 34 of typical hospital cost.
139
ASU and Birthing Center
100,000 X 100 10 M 35,000 x 135 4.725 M 4
M (Vans) 18.75 M Clinic
Construction Cost
LDRP/ ICU
Rest/ recovery (Hotel) Facility
LDRP/ ICU
Offices

storage
LDRP/ ICU
SURGE FACILITY 4 operating rooms
8 LDRP/ICU beds 100 patient beds
108 bed Surge hospital
Van
Van
8 LDRP/ICU Beds
Reception area
LDRP/ ICU
storage
100,000 sq.ft. _at_ 100 sq.ft. 10,000,000
LDRP/ ICU
LDRP/ ICU
100 rooms 100 beds
2 ORs
2 ORs
LDRP/ ICU
LDRP/ ICU

140
Hospital, ASU, Birthing Center
10M 7.375M 2M 2M 21.375 M
Hospital Construction Cost


OFFICES
Rest Recovery (Hotel)
Facility

20 LDRP/ICU beds 5,000 sq.ft._at_ 400 per sf
2,000,000
ASU 25,000 sq ft _at_135 per sf 3,375,000
4,000.000 7,375,000
100,000 sq.ft. _at_ 100 sq.ft. 10,000,000
Van
Van
Hospital Standard 20 ICU/ward/holding 5,000
sq.ft. _at_ 400 per sf 2,000,000

100 rooms 100 beds
141
Construction Cost
Facility Square Feet
Cost per SF Total Cost
Hospital 135,000 400
54 M Hospital
5,000 400
2 M ASU 20,000
135 2.7 M Birthing
5,000 400
2 M MSU-I (Ground response option)
5.4 M
Hotel 100,000
100 10 M


22.1 M
Typical
Modular
12.1M
Modular construction without hotel is 22 of
typical hospital cost. Modular construction with
hotel is 41 of typical hospital cost.
142
Hospital, ASU, Birthing Center
10M 5.375M 2M 2M 19.375 M
Hospital Construction Cost


OFFICES
Rest Recovery (Hotel)
Facility

20 LDRP/ICU beds 5,000 sq.ft._at_ 400 per sf
2,000,000
ASU 25,000 sq ft _at_135 per sf 3,375,000
2,000.000 5,375,000
100,000 sq.ft. _at_ 100 sq.ft. 10,000,000
MSU ll
MSU ll
Hospital Standard 20 ICU/ward/holding 5,000
sq.ft. _at_ 400 per sf 2,000,000

100 rooms 100 beds
143
Construction Cost
Facility Square Feet
Cost per SF Total Cost
Hospital 135,000 400
54 M Hospital
5,000 400
2 M ASU 20,000
135 2.7 M Birthing
5,000 400
2 M MSU-II (Airborne response
option) 2 M
Hotel 100,000
100 10 M


18.7 M
Typical
Modular
8.7M
Modular construction without hotel is 16 of
typical hospital cost. Modular construction with
hotel is 35 of typical hospital cost.
144
Hospital, ASU, Birthing Center
10M 7.375M 2M 2M 31.375 M
Hospital Construction Cost


OFFICES
Rest Recovery (Hotel)
Facility

20 LDRP/ICU beds 5,000 sq.ft._at_ 400 per sf
2,000,000
ASU 25,000 sq ft _at_135 per sf 3,375,000
4,000.000 7,375,000
SURGE FACILITY 4 operating rooms
40 LDRP/ICU beds 100 patient beds
140 bed Surge hospital
100,000 sq.ft. _at_ 100 sq.ft. 10,000,000
Van
Van
20 ICU beds 5,000 sq.ft. _at_ 400 per sf 2,000,000
100 rooms 100 beds

145
Potential

• Surge equipment MSU I and MSU II being looked
  at by the Blues for indigent care
• Potentially Available to Guard in contingency and
  for weekend training

146
Rural Hospital Design Network 14 June
MODEL? PILOT?
147
New South Wales, Australia
Thursday Hospital
Tuesday
Tuesday
Starts Summer 2005
148
Thursday Hospital Australian Style
Operate 4 days per week
47 weeks per year
149
Rural Hospital Design Network 14 June
Bring the Future into Reality Today!
150
Rural Hospital Design Network 14 June
Surge Hospital/ Facility Definition A facility
that can be used to provide sufficient medical
care when a primary medical facility is
-destroyed -contaminated and thus denied
-overwhelmed
151
Today Rural
Community Option

Rest Recovery (Hotel) Facility
OFFICES
Consider Mobile Hospital Concept for Rural
Communities
LDRP 5,000 sq.ft
ASU 20,000 sq ft
5,000 sq.ft.
Van
Van
Hospital/ ICU Ward
This could be done today at
15-40 of traditional cost!
152
Time for Making a Better America

• "I will ensure every poor county in America has
  a community or rural health center.
• - President George W. Bush
• Recognizes needs of uninsured and medically
  underserved communities
• Promises to open/expand 1,200 health center
  sites to serve additional 6.1 million Americans
  by 2006
• Provides primary/preventive health care services
  to low-income individuals, migrant farm workers,
  homeless individuals, and children regardless of
  ability to pay

Source Agendaforchange.com, Sep 04
153
SURGE CONCEPTS
154
SURGE CONCEPTS
Convert to reality for hotel and motel
155
Low Hanging Fruit for
future dual use facilities

• Least expensive
• Wider hallways
• Wider elevators
• Back up power
• Wider doorways

New Building Codes to Consider
156
Medium Level Fruit for future
dual use facilities

• A little more expensive
• Ability to quickly make
  clean room
• HVAC emergency power

New Building Codes to Consider
157
Higher Level Fruit for future
dual use facilities

• Most expensive
• Additional communication infrastructure
• More survivable building

New Building Codes to Consider
158
Standards Will Change
Mass casualty incidents when facilities/equipment/
people are overwhelmed
Sufficient care
Standard of Care
159
Moscow Theater TerrorThe Facts

• 23 Oct 02, 40-50 gunmen take 700 hostages in
  Moscow Theater
• Identified themselves as members of Chechen Army
• Demand end to war in Chechnya
• 27 Oct 02, opiate fentanyl gas discharged by
  Russian Special Forces into theater
• Result All gunmen and 118 hostages killed
• Gas intended to prevent terrorists from
  triggering explosives strapped to their
  waists/rigged around the theater
• Rumored other substances in gas
• Sources CNN, Fox News, Late Line News

160
Moscow Theater TerrorWhat If...

• Condition of hostages
• Starved of oxygen, dehydrated, hungry, stressed
• Lack of appropriate medical response
• On scene doctors not informed of type of gas used
• Wrong type of antidote administered
• Effects of large dose of Fentanyl not known
• Bottom Line Medical Responders must receive
  proper training and be privy to all information
  to be effective!
• Its clear that perhaps with a little more
  information at least a few more of the hostages
  may have survived.
• 
  Alexander Vershbow,
  US Abassador to Moscow
• 
  Source Late Line News

161
Moscow Theater Terror
118 hostages dead 80 with no injury Why - died
of asphyxiation
162
Alternative

• No problem with putting terrorist to sleep
• No problem with head shots to avert self
  detonation
• But other hostages died needlessly

163
Option

• Have medical antidotes naloxon- right behind
  shooters to inject into survivors reverse
  fentynal
• Have medics give antidotes narcotics- right
  behind shooters
• Have intubation team right behind shooter to
  intubate and give antidote and breathe for
  patients until they wake up
• Have full medical/surgical team behind shooters
  to intubate, give antidote and surgically
  stabilization

164
Standard of Care/ Sufficiency of
Care
Sufficient care
10 surgeries in hallway
Demands
Smooth transition
Standard of Care
7 Open laparotomies
9 operations in OR

Care Capability
165
The Red Wedge Concept
Sufficient care
Plan B
At some point we will go to sufficient care ,
not standard of care
Soft sided solutions may apply
Standard of Care
Surge from outside sources
Peacetime Surge - within

Care Capability
166
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Standard of Care
Care Standards
???
Plan B Operations
Sufficiency of Care
Demand
MORAL IMPERATIVE
167
Equipment
Local Regional National - International
168
Dual Benefit
Earning their keep everyday in regular
use Emergency use when and if needed
169
Medical readiness for terrorist attack must be
built into a medical system which deals with the
much higher probability of natural disease
outbreaks, an aging population, and a growing
population of uninsured and underinsured
individuals.
Possible Option
Consider the model of the Civil Reserve Air Fleet
170
Civil Reserve Air Fleet (CRAF)
1950

• Troops brought home from Europe and Japan
• Air Force given tasking to have troops in place
  in less than 72 hours in event for contingency
• Required multiples of air lifts we owned
• UNAFFORDABLE TASKING

171
Civil Reserve Air Fleet (CRAF)

• Required different thinking
• Air Force went to airlines and asked them for
  airlift insurance
• Come when called
• Pay with business funnel
• Became known as the Civil Reserve Air Fleet

172
Civil Reserve Air Fleet (CRAF)An Example

• History of CRAF
• Established in 1952
• Civil air commits passenger/cargo aircraft if
  government unable to meet airlift requirements
  during wartime
• CRAF benefits
• Win-Win for civil air carrier and government
• Civil air receives large percentage of government
  peacetime passenger/cargo airlift
• Government not forced to purchase/equip
  additional military aircraft during peacetime
• Civil aircraft developed/modified to
  meet military cargo specs

173
Civil Reserve Air Fleet (CRAF)Surge Capacity

• Surge capacity met
• Is current military air fleet adequate enough to
  meet future wartime needs? NO!
• CRAF filled the gap
• 28 of cargo and 95 personnel flown on civil
  aircraft during wartime DS/DS 90-91
• Similar numbers for GW II
• Equipment readily available
• Military airlift capacity fulfilled by C-141,
  C-5, KC -10, KC-135, C-17
• Civil airlift augmentation include B-747, DC-10,
  B-767, B-777, etc

38 years Before It was Needed
174
Equipment Medical Reserve Corp E-MRC

• Creates a medical surge capacitor using civilian
  resources for contingency augmentation of
  national or defense requirements.
• Like the CRAF, the E-MRC is based on federal or
  state support of an otherwise commercial system.
• The preponderance of the costs of the E-MRC are
  born by commercial markets, and are therefore
  sustainable.
• Like the CRAF, the E-MRC is a self-maintaining,
  self-updating, and sustainable system.

E-MRC could fill the gap!
175
CRAF and E-MRC Analogy

• Similarities
• Both designed to meet civil/government
  requirements
• Both operated by civilian corporations
• Both effective means of transport
• Both readily available
• Bottom Line Just as CRAF answers surge capacity
  at the global level, the 18 wheeler transports
  answer surge capacity at the national level!

176
Analogy is the Same

• Requires surge for mass casualty events and
  epidemics
• To build and store capabilities is unaffordable
• Therefore creating partnerships for health is
  critical

177
Partnership
Governmental Business
Insurance for both!
178
Rural Hospital Design Network 14 June
If We had these resources Then
179
Rural Hospital Design Network 14 June
We Could SURGE
180
Rural Hospital Design Network 14 June
TRATEGIC HARED
S
U
TILIZATION OF
R
ESOURSES FOR
G
EOGRAPHICAL
E
MERGENCIES
181
Built of Units of Capabilities
182
Modular/Surge Hospital
Hotel X
183
Modular/Surge Hospital
Hotel X
Hospital X
184
Modular/Surge Hospital
Hotel X
Hospital X
185
Modular/Surge Hospital
Hotel X
Hospital X
186
Modular/Surge Hospital
Hotel X
Hospital X
187
Modular/Surge Hospital
Hotel X
Hospital X
188
Modular/Surge Hospital
Hotel X
Hospital X
189
Rural Hospital Design Network 14 June
Texas Proposal
190
AHC Equipment Concept

• Currently 8 Academic Health Centers in Texas
• Each AHC would purchase 4 units
• Result 32 units total located at 8 Texas AHCs

191
Responding to a Disaster 4 Vans Per AHC
Denotes AHC
Denotes 6 hour drive time/200 Miles
192
Responding to a Disaster
Proposal
6 Hr Response
12 Hr Response
18 Hr Response
Denotes AHC
Denotes 6 hour drive time/200 Miles
193
Responding to a Disaster
Proposal
6 Hr Response
12 Hr Response
18 Hr Response
Disaster
Denotes AHC
Denotes 6 hour drive time/200 Miles
194
Responding to a Disaster
Proposal
6 Hr Response
12 Hr Response
18 Hr Response
Disaster
Denotes AHC
Denotes 6 hour drive time/200 Miles
195
Responding to a Disaster
Proposal
6 Hr Response
12 Hr Response
18 Hr Response
Disaster
Denotes AHC
Denotes 6 hour drive time/200 Miles
196
Responding to a Disaster
Proposal
6 Hr Response
12 Hr Response
18 Hr Response
Disaster
Denotes AHC
Denotes 6 hour drive time/200 Miles
197
Modular/Surge Hospital
Hotel X
Hospital X
198
Building Block Approach forMedical Response
UNITS OF CAPABILITY
6
TIME
6 hr
18 hr
12 hr
199
Dual Use
If
every state had a program
involving medical response equipment
THEN

we could deal with a
large number of contingencies at one time.
200
For Example

• Lower 48 states each has 20 surgical vans in
  use everyday
• Contingency 1 Pull 20 - total 20 vans and more
  than ½ the states would not be impacted at all
  (400 beds)
• Contingency 2 Pull 20 total 40 vans and each
  state on average would lose only 1 van (800 beds)
• Contingency 3 Pull 20 - total 60 vans and each
  state would have lost one another would lose 2
  minimum impact (1200 beds)
• Contingency 4 Pull 20 total 80 vans and each
  state at most loses two minimum impact (1800
  beds)
• Contingency 5 Pull 20 total 100 vans and each
  state loses only 10 of their total (2000 beds)
• Etc

201
Rural Hospital Design Network 14 June
A Visual Representation of the Region Concept
202
(No Transcript)
203
Resources Shared Within Each Health Zone
204
MSU
MSU
Primary Care Unit
Primary Care Unit
MSU
MSU
Primary Care Unit
Primary Care Unit
205
MSU
MSU
Primary Care Unit
Primary Care Unit
MSU
MSU
Primary Care Unit
Primary Care Unit
206
MSU
MSU
Primary Care Unit
Primary Care Unit
MSU
MSU
Primary Care Unit
Primary Care Unit
207
MSU
MSU
Primary Care Unit
Primary Care Unit
MSU
MSU
Primary Care Unit
Primary Care Unit
208
Resources Shared Within Each Region
209
Womens Health Unit
Diagnostic Unit
210
Womens Health Unit
Diagnostic Unit
211
Diagnostic Unit
Womens Health Unit
212
Diagnostic Unit
Womens Health Unit
213
New South Wales, Australia
Thursday Hospital
Tuesday
Tuesday
Starts Summer 2005
214
P- People E- Equipment T- Training O-
Organization
All pieces must fit at the same time to have a
coherent plan
215
SURGE CONCEPTS
216
Tools Must have
response units to solve problems
Requires Tools in the Toolbox
NO Tools NO Response
217
Now have affordable tools
218
Sacramento Scenario
Disaster Occurs
219
Sacramento Scenario
Disaster Occurs
220
Concepts

• Hotel or motel into hospital
• School buildings into hospital
• Convention or community center into hospital
• Existing out patient clinic into hospital
• Park into surge hospital

221
SURGE CONCEPTS
All based on sophisticated medical equipment
around response vans
mobile surgical units/ICUs/labs/imaging
systems/information/morgues
222
Countries Expressing Interest or Implementation
United States
Australia- New South
Wales Saudia
Arabia Oman

United Arab Emirates Malaysia

Viet Nam
Romania
Norway Kuwait
Poland
Denmark Qatar
Bulgaria
Sweden Brazil
Germany

UK Greece
Turkey
Slovenia Japan Market so far is
over 2,000 facilities
X
X
X
X
X
X
X
X
X
X
X
X
223

No one can afford to have medical equipment
sitting
Van Must Earn Its Keep
HOW?
224
Integral Part
Thursday Hospital
225
The Thursday Hospital
Monday
Tuesday
Wednesday
Thursday
Friday

• On Monday, facility used as
• County court house
• Clinic on side
• Diabetic education

226
The Thursday Hospital
Monday
Tuesday
Wednesday
Thursday
Friday

• On Tuesday, facility used as
• Imaging onsite
• Clinic on side
• Diabetic retinopathy screening

227
The Thursday Hospital
Monday
Tuesday
Wednesday
Thursday
Friday

• On Wednesday, facility used as
• Public meeting site
• Clinic on side
• Health education courses

228
The Thursday Hospital
Monday
Tuesday
Wednesday
Thursday
Friday

• On Thursday, facility used as
• Operating hospital
• Clinics

229
The Thursday Hospital
Monday
Tuesday
Wednesday
Thursday
Friday

• On Friday, facility used as
• County court house
• Clinic on side
• Womens health

230
The Thursday Hospital
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

• On Saturday Sunday facility used as
• National Guard training
• Practice
• Assets are available for