". . . and the lady in the orange shirt, in the wheelchair, Mrs Mamie, is from New Orleans. She was in the water for a few days; now she's got rales." I think what I'd just finished at the St Anthony's special needs shelter was what is known as rounds. After the meeting on Thursday I had met up with about 80 first- and second year Texas A&M medical students at a local family medicine clinic. The director had us self-assemble into four groups of about 20. We were supposed to pick two co-leaders and a name for our team. Everyone in our group mingled about these things for a few minutes. I spent that time collecting everyone's name. If you're really lucky, sometimes, in an amorphous situation like that, a natural leader, a charismatic leader, will emerge. I'm not a charismatic leader, but the military beat some leadership training into me so once I had everyone's name I raised my voice, gave my qualifications, and asked if anyone objected to me leading the group. They were generally receptive, so I asked for a co-leader who knew the area, we figured that out, and, after some other administrative details we got our shelter assignment, St Anthony's church, and some initial supplies. Twenty-one people in twelve cars; off we went.
If you're going to lead people in a crisis, remember one mnemonic:
C4I:
Command
Control
Communications
Computers
Intelligence
It's not mine. I used to make fun of it, along with a lot of other acronyms I learned in the Navy. I honestly didn't remember it until late in the first day. Peter JP Holden recently wrote about a very similar mnemonic he learned and implemented as he led the response after a bus exploded outside the meeting of the British Surgical Society in the recent attack on London (New England Journal of Medicine, Improvising in an Emergency). In retrospect I was doing the same thing without realizing it, thanks to over a decade of military training. I made mistakes, which we'll go over, but the roving nurse practitioners and physicians regularly commented on how organized our shelter was, how other shelters were doing. I went back a day after being relieved to see how things were going and the team from the Temple VA hospital that took our place was still using what we put in place. The facility manager definitely had fond memories of us. I've also gone to all but one of the other shelters and I think we met our particular challenges particularly well. Based on that feedback and those observations I thought I'd review here what I think was the core of our success.
Command. This is at once the goal and the central feature of the whole thing. For right now, don't worry about it. We'll talk about it after everything else.
Control. Control, in the human sense, is an illusion, but an extremely useful one. Control is simply the ability to cause something to happen by doing something else. For example, there's a key on this keyboard with the letter Y. If I extend my right index finger just so, I can press that key, which causes a series of electron cascades to traverse the innards of this laptop, and a y appears on the screen. That's all control is. As every parent knows, you can't control a person in that sense. However, if people believe someone is in control, they feel more comfortable. They believe there's a central authority to turn to so that central authority tends to have access to the resources of all stakeholders. For example: we had oxygen in little one liter E bottles and some meds which were ours by the authority of the central director of the special needs shelters (Dr Dorsey at the family medicine clinic). The facility manager was providing food, shelter, cots, and a steady stream of his own volunteers. The doctor was the nominal director of the shelter but could only be there interminantly. He also had the power to prescribe. The nurses were on a shift rotation established by the family medicine clinic and had skill but were undirected, just running around putting out fires, without any visibility to determine which fire was biggest. The police (and eventually the National Guard) were providing security but couldn't provide manual labor because they were armed. So these are all stakeholders: they each bring resources, and, with those resources, concerns about those resources.
Computers. The City of College Station Emergency Operations Center had an Access database set up on a computer at each shelter. It had cramped little web form style windows to enter some very limited information, and that was it. Some computer wizard from the Emergency Operations Center was supposed to come around and download the database from every shelter's computer and somehow make it available to those that needed it. But the computers didn't even have internet connections. We had no way to see the information we were supposed to laboriously put in. At least not without some database skills. I can muddle my way through Access, but this wasn't the time for a novice. We needed something that could flex to our needs as they emerged, something that different operators could learn and use, something common and simple. We used Excel. At least one other shelter used Excel, but not like we did. They had full names and ages. With full name in the cell you can't even sort by last name to identify families. Thanks to a lot of hard work on my laptop by a few savvy volunteers from the medical school, we had cot number, last name, first name, social security number, address, past medical history, diagnoses, medications, blood pressure, blood sugar, perscriptions ordered, perscriptions recieved, perscriptions that needed to be ordered, a flag indicating patients we thought the next available doctor needed to see, etc, etc. This is what we would eventually turn over to the professional team from the Temple VA hospital, and which they continued to use (I went back a day later to follow up).
Communication. We had internet, cell phone, land line, and enough bodies to make some runners. So comms were deep and robust. We had room to degrade gracefully. I knew from Katerina that text messaging on cell phones would probably be the most robust form of communications if everything went to pot, so with all the comms resources at hand I wasn't worried. My biggest mistake here was not getting the phone numbers of all the group members immediately. Never know when an emergency recall will be necessary. I spent an inordinate amount of time getting their phone numbers throughout the next couple of days.
Intelligence. Intel is a funny thing. It's every piece of information that comes in, much of which is useless. Some appears useless until other information is properly displayed nearby. Some is utterly trivial until it becomes the lynchpin in the big picture. Sorry for the mixed metaphor. The name and phone number of the shelter, the visual identity and name of the doctor, the first case reports from the nurses in the gymnasium, the thorough notes on every patient that were taken by the end of the second day, reports of other shelters from roving physicians and nurses, and first hand observations of other shelters, these were all information. The challenge is to reduce information to actionable intelligence. Another mnemonic I learned as a tactical action officer: the role of the combat information center is to gather, collect, analyze, display, and disseminate information. From the outset there were too many patients to prioritize them and track their needs (like regular blood pressure and blood sugar measurements) without gathering information about everyone and then displaying in such a way that it could be analyzed. Thus our spreadsheet.
Command, Again. By the evening of the first day I had gone to one other shelter, the first fifty or so patients were in the database, and the lines of communication were established. I had a general notion that the Emergency Operation Center was coordinating all the facilities and directing evacuees to the most appropriate shelters (normal or special-needs-capable) and a second chain of command was handling the medical aspect of the special needs shelters. I still have this vague notion that my boss, the family medicine clinic at 1301 Memorial, was answering to a central medical authority at the largest special needs shelter (the vetrinary school's large animal facility, which had been converted to a 700+ bed nursing home and Shriner burn unit). In addition to this developing intelligence, the stakeholders were developing a sense of who had communications, computers, and intelligence. Everyone had identified me as the person in charge of the medical student volunteers. My concern was managing them (after the arrival I established a four hour rotation schedule and let them sign up for whenever they wanted). The facilities manager had identified me as someone who could talk to the nurses, the nurses had identified me as someone with who could get things from the facilities manager, Dr Dorsey and the other folks at the family medicine clinic had identified me from the get go as their point of contact for this shelter, and the doctor, an ENT, had identified me as the best source of patient information and someone who could get done most of what he needed.
So command starts as a combination of comportment, how one carries oneself, especially under stress, and caring. Everyone will see through a leader who doesn't care about the situation. If you don't care, give up the reins to someone else. As soon as anyone identifies you as a leader, command begins to include control with enough of everything else to make useful things happen in a reliable, predictable manner. It requires knowledge of the situation (intelligence), the ability to communicate your requests and orders to seniors, peers, and subordinates, and, in today's information-dense world, enough computer power to collect, analyze, display, and disseminate what you need to.
I'm going to take the model one step further, I'm about to add a complication. What happened at the special needs shelters, possibly all the shelters, was a decentralized operation. The singular difference between the US military and the Soviet military was that the US advocated decentralized operations. What made this possible was best described by Vice Admiral Henry C Mustin III, Commander US Second Fleet, in his 1986 Fighting Instructions to Joint Task Force 120: "The basic requirement of decentralized operations in general war is preplanned response in accordance with commonly understood doctrine. Lord Nelson did not win at Trafalgar because he had a great plan, although his plan was great. He won because his subordinate commanders thoroughly understood that plan and their place in it well in advance of plan execution." Similarly, before we executed at St Anthony's we had been briefed by the deans of A&M on the city's big picture response to Rita and by Dr Dorsey at the family medicine clinic on our particular role in the response.
In the military we introduce pre-formed units into situations. We bring command and control, so comms, computers, and intel are the things we work on. Walking into St Anthony's was different. There was no command or control, at least it was limited to command within the various stakeholder organizations (the church facility manager, the individual nurses who were acting autonomously, us medical students, the doc waiting for scripts to fill, a random EMT, random security elements, etc). By focusing on comms, computers and intel, the medical students established a reputation for competence among the stakeholders and were able to develop a decentralized but well-coordinated command and control structure. By the time the professional team from Temple VA Hospital arrived, consisting of a doctor and four nurses, on the second evening, we had blood sugar and blood pressure measurements, medications, and wound dressings on a regular, tracked schedule with historical data. I was able to give them each a 7 page printout, in six point font, of everything we knew about these 185 patients and review the most significant cases, including the last one, Mrs Mamie, in an orange shirt, in a wheelchair, from my hometown.