The Hampton Roads Metropolitan Medical Strike Team (HRMMST) is trained and equipped to provide operational assistance and expertise to the Incident Commander/Unified Command regarding the medical effects of an incident whether CBRNE, conventional, or weather-related. As need or threat levels change, composition, organization, and mission of the team may change to meet the threat or need. The HRMMST mission is to close these gaps identified using regional threat and capability assessments. Consequently, the HRMMST has developed and continues to strengthen the following seven capabilities:

• Chemical Weapon and Toxic Industrial Chemical Antidote Administration
• Warm Zone Triage, Decontamination, and Monitoring & Detection
• Medical Casualty Management and Patient Movement Coordination
• Rehabilitation and Medical Force Protection
• Medical Consultation and Coordination
• Functional/Medical Needs Sheltering Assistance
• Mass Fatality Assistance

It is the mission of the HRMMST to supplement and enhance the local and mutual aid response to all-hazards incidents within the region, for up to 96 hours, with limited logistical support. This time frame allows state and federal assets time to mobilize and integrate into incident operations. 

The first capability of the Hampton Roads Metropolitan Medical Strike Team’s (HRMMST) is Chemical Weapon and Toxic Industrial Antidote Administration. In the
mid to late 90’s, the emphasis of the Metropolitan Medical Response System (MMRS) was to respond to a terrorist attack involving chemical weapons; specifically, nerve agents.
Nerve agents are chemicals that affect the nervous system. The health effects are similar to those produced by some pesticides. The main nerve agents are the chemicals sarin (GB),
soman (GD), tabun (GA) and VX. These agents are man-made and have been manufactured for use in chemical warfare.

The Hampton Roads Metropolitan Medical Response System (HRMMRS) oversees a regional cache of Weapons of Mass Destruction (WMD) Antidote Kits. Each kit contains
30 – DuoDote Auto-Injectors (pralidoxime 600 mg/2 ml + atropine 2.1 mg/0.7 ml) and three – sets of TEMS/PEMS Regional Medical Protocols on CBRNE (Nerve Agents –
Adult; Nerve Agents – Pediatric). The WMD Antidote Kits are issued to licensed emergency medical services agencies and stored in locked cabinets in stations, EMS vehicles or HRMMST equipment trailers, or in hospital pharmacies without CHEMPACKs. Additional information regarding the WMD Antidote Kits can be found by visiting http://education.tidewaterems.org/moodle/ and clicking on the 2013 WMD Antidote Familiarization Course.

Nerve agent poisoning can be treated by all members of the HRMMST, who are trained in using DuoDote autoinjectors. This autoinjection quickly injects the antidotes into muscular areas like the thigh or buttock. Repeated use of antidotes may be needed to treat some nerve agent victims. It might also be necessary to give nerve agent victims other drugs to control seizures or other effects. The HRMMST is also positioned to deploy assets from the CHEMPACKs located throughout the region. The CHEMPACK program is an ongoing initiative of the Centers for Disease Control and Prevention's (CDC) Division of Strategic National Stockpile (SNS) launched in 2003, which provides antidotes to nerve agents for pre-positioning by state, local, and/or tribal officials throughout the United States. The CHEMPACK Program is envisioned as a comprehensive capability for the effective use of medical countermeasures in the event of an attack on civilians with nerve agents.

Additionally, the HRMMST, in cooperation with the Southside and Peninsula Regional Hazardous Materials Teams, helped to review and revise the contents of the regional hazardous materials drug box and support box. Antidotes are stored in these boxes and are readily available to treat members of the hazardous materials (HAZMAT) teams from exposure to chemicals such as, cyanide, fluoric acid, and phenol. Guidance on the use of these antidotes can be found in Appendix J of the TEMS Regional Protocols.

The HRMMST is trained and equipped to provide warm zone triage, decontamination, and provide monitoring and detection services and supplement the capabilities of the regional hazardous materials teams and healthcare facilities in responding to a WMD/TIC incident. The HRMMST is available to all Hampton Roads’ public safety agencies and healthcare facilities when mass casualty support is required. It is critically important that victims exposed to nerve agents are decontaminated in addition to having the nerve agent antidote administered to them. HRMMST members are trained to provide WARM ZONE triage of, and lifesaving interventions to, victims exposed to WMD agents and toxic industrial chemicals. Interventions include antidote administration, airway management and hemorrhage control.

The HRMMST is also trained and equipped to operate a “decontamination corridor.” The decontamination corridor is a transition area from the HOT ZONE to WARM ZONE, an undress area, a decontamination area, a redress area, and finally a transition area from WARM ZONE to COLD ZONE. All HRMMST members have been trained in donning and doffing personal protective equipment with respiratory protection ranging from Level IV ensembles through Level II ensembles (IAW NFPA 1994) using N95, PAPR and SCBA respirators. The team is equipped with four ASAP Shelters, which serve as undress and redress facilities.

The HRMMST also deploys a TVI three-lane decontamination shelter (male ambulatory, nonambulatory, and female ambulatory). The decontamination corridor is supplemented with
barrier fencing, lighting, and a flash water heater and propane heaters for the undress/redress facilities. The HRMMST is equipped to provide both WET and DRY decontamination.
The HRMMST uses FIBERTECT Dry Decon wipes/pads, which are also used by the military.

The HRMMST decontamination equipment also includes monitoring and detection equipment that is expressly used for the purpose of identifying whether a victim is free of contamination. (Less emphasis is placed on recognition of the contaminate.) HRMMST members are also trained in the use and operation or pH paper, M8 paper, Photo Ionization Detectors (PID), AP2Cs, Gamma Rae dosimeters, Ludlum Response Kits, and Radiological Portal Monitors.

Finally, the HRMMST, in cooperation with the Southside and Peninsula Regional Hazardous Materials Teams and area hospitals, developed a regional Mass Casualty Decontamination Guide. The deconatmination guide provides a concise reference to set up and execute mass decontamination, by aligning terminology and operating procedures among public safety agencies and healthcare facilities. 

The HRMMST is trained in Mass Casualty Incident (MCI) response and follows the guidelines set forth in the Hampton Roads Mass Casualty Incident Response Guide. In a declared MCI, the HRMMST is capable of providing resources to supplement and the response of the local jurisdiction. For large, complex incidents, the HRMMST is capable of staffing and equipping the Medical Branch to perform the functions of triage, treatment, transportation, and morgue operations.

HRMMST members are trained in S.T.A.R.T and JumpS.T.A.R.T. triage, using medical equipment to address life threats, such airway management and hemorrhage control (using tourniquets and hemostatic products like Quick Clot). The HRMMST has uniquely packaged medical equipment and supplies to support patient treatment in Immediate (red),
Delayed (yellow), and Minimal (green) Treatment Areas. For example, the HRMMST designed a “Patient Self-Care Kit” for those victims with minor injuries. This allows victims
to engage in self-care until sufficient manpower arrives. The HRMMST equipment cache can be supplemented by one or more of the 11 Disaster Medical Support Units (DMSU) sustained by HRMMRS, as each DMSU carries the same medical equipment. TO support patient/victim transportation, the HRMMST will usually respond with four of the 10 Mass Casualty/Evacuation Transport Units (MCI buses) located throughout the Hampton Roads region.

Use of the Mass Casualty/Evacuation Transport Units (MCI buses) allows for the transportation of 70 stretcher victims and another 40 seated victims to area hospitals. The HRMMST
is also trained and equipped to assist the Chief Medical Examiner’s Office and local law enforcement with morgue operations, decontamination of the deceased and/or the recovery of remains.

The HRMMST is also capable of providing patient movement coordination and assistance in three distinct patient movement categories:

1. Physical patient movement – the MMST will use equipment and manpower to relocate patients to a treatment area or to transportation assets as directed by the Medical Branch Director.
2. Coordination of patient movement – the MMST and the Regional Healthcare Coordinating Center (RHCC) will develop a transportation plan that will distribute patients from the scene to the appropriate health care facilities throughout the region by incorporating a variety of transportation assets.
3. National Disaster Medical System (NDMS) – Patient Reception Area (PRA) – the MMST in coordination with the Federal Coordinating Center (FCC) will assist with PRA operations, which includes; triage, treatment, physical patient movement, and coordination of patient movement with the FCC and RHCC.

The HRMMST is capable of responding to large, complex all-hazard incident types, which in turn require a large number of first responders and first receivers to resolve the incident. Working for extended periods and exposed to austere environments, responders need rest and recovery periods and access to medical care. Emergency incident rehabilitation (rehab) is the process of providing rest, rehydration, nourishment, and medical evaluation to responders who are involved in extended or extreme incident scene operations. Proper rehabilitation operations preserves and ensures that the physical and mental condition of responders does not deteriorate to a point that jeopardizes the safety or effectiveness of responders or incident operations.

The HRMMST members (emergency medicine physicians, nurse practitioners, physician assistants, paramedics, and EMTs) are trained in accordance with the National Fire Protection Agency Standard 1584: Standard on the Rehabilitation Process For Members During Emergency Operations And Training Exercises. The Team also incorporates the Tidewater EMS Council Rehabilitation protocol in our rehabilitation operations.

The HRMMST is capable of providing medical expertise and resources to assess and treat first responders and first receivers at the scene of the incident. The HRMMST equipment cache includes medical supplies, durable medical equipment, pharmaceuticals, suture kits for wound closure, tourniquets and hemostatic agents for hemorrhage control, ophthalmic kits for foreign bodies in the eye, ultrasound for conducting Focused Assessment with Sonography in Trauma (FAST) exams for traumatic injuries, video laryngoscopy and 12-Lead ECG for cardiac arrest management. This equipment coupled with an emergency physician and physician extenders provide the highest level of care possible to our first responder and first receivers in the pre-hospital environment.

The premise for the Metropolitan Medical Response System (MMRS) was to provide enhanced plans, equipment resources, and personnel specially trained in CBRNE to respond
to large, complex incidents of all hazard types. As previously explained, the magnitude of these incidents likely exceed the capabilities of routine mutual-aid. A Type 4 HRMMST (an
eight member team) is trained in Medical Consultation and Coordination and may serve in an advisory role for the local Incident Commander/Unified Commander, Medical Branch
Director, or Hazmat Branch Director.

Medical Consultation involves detecting medical symptoms or other indicators when a large number of patients are encountered with symptoms that may be associated with
exposure to CBRNE materials and providing advice to health care entities following a release.

The Type 4 Team is trained to provide assessment of immediate medical needs, coordination of disaster medical resources, coordination of patient distribution, medical evaluation, and coordinating the establishment of temporary field treatment sites. Upon arriving on-scene, the Type 4 Team will immediately obtain a briefing from the Incident Commander/Unified Commander.

The focus of the HRMMST will be the collection, evaluation, dissemination and use of the medical information related to the incident and determining the availability of regional resources to address the following:

• Current Situation, use of Weapons of Mass Destruction
• CBRNE Agent(s) involved/signs and symptoms of patients
• Victim rescue issues
• Patient decontamination issues
• Local EMS/Medical issues (Triage, treatment and transportation)
• Hospital issues
• Physical location of the Incident Command Post
• Location of the HRMMST Base of Operations
• Current meteorological conditions
• Develop protective measures for the region’s medical infrastructure
• Predict probable courses of incident events and develop protective measures and or medical care for the affected population(s)
• Prepare alternative strategies and medical control options for the incident

The HRMMST can be incorporated into existing shelter plans to assist emergency managers and shelter planners in meeting access and functional needs in general population shelters and medical needs in medical shelters. Functional Needs Support Services (FNSS) are services that enable children and adults with or without disabilities who have access and functional needs to maintain their health, safety, and independence in a general population shelter. This includes personal assistance services (PAS), durable medical equipment (DME), consumable medical supplies (CMS), and reasonable modification to common practices, policies and procedures.

Individuals requiring FNSS may have sensory, physical, mental health, cognitive and/or intellectual disabilities affecting their ability to function independently without assistance.
Additionally, the elderly, women in the late stages of pregnancy, and individuals requiring communication assistance and bariatric support may also benefit from Functional Needs Support Services.

The HRMMST In conjunction with ESF #6 (Mass Care, Housing, and Human Resources) and ESF #8 (Public Health and Medical Services) the HRMMST can supplement and enhance existing capabilities to provide care to those with medical and functional needs before, during, and after an incident. To enhance this capability, the HRMMST when deployed with one or more Shelter Support Units (SSU) will provide much needed equipment and personnel to provide these essential services.

When incorporating the HRMMST and the SSU operations into a shelter, additional considerations should include:

• Easy access for those that are stretcher bound to be brought in and out of the facility
• Areas for the plcement of surge beds to include a cot for care-givers
• Privacy areas to provide medical interventions
• A designated “emergent care” area
• A staging area for placing medical equipment and medications
• A triage/medical screening area
• Communications procedures
• The provision of additional power outlets for medical equipment

The HRMMST can be incorporated into existing mass fatality plans to assist medical examiners and local law enforcement agencies in processing human remains in reponse to a mass fatality incident. The HRMMST is capable of providing a public trust work force of physicians, physician extenders, law enforcement officers, paramedics and EMT’s, durable medical equipment, consumable medical supplies, and logistics support equipment that can assist the Chief Medical Examiner to create the infrastructure needed to process a large number of human remains, both contaminated and non-contaminated.

The HRMMST, with guidance from the Chief Medical Examiner, is can provide human remains and personal effects tracking at an incident morgue. The HRMMST is can also assist morgue personnel with document management and assist with human remains accountability and tracking. HRMMST personnel HRMMST can assist with the progress and movement of remains through morgue stations.

HRMMST personnel are trained to operate in Class 2 Ensemble PPE to provide for support work in rotating shifts. Additionally, the HRMMST can provide decontamination equipment, water resistant triage tags to assist in remains tracking, remains pouches in various sizes and tents that will keep the remains from public view.

When incorporating the HRMMST into remains processing, some additional capabilities are:

• Recovery
    – Able to perform remains recovery under Medical Examiner supervision
    – Able to triage remains
    – Able to establish and manage an Entry Control Point
• Holding Morgue
    – Able to establish private area to perform evidence collection, identification check, etc.
    – Able to collect samples for monitoring and detection of hazardous materials
    – Able to establish an area and perform decontamination, and mitigate run-off from the decontamination operations
    – Able to double bag remains
• Transportation and Storage
    – Able to move remains to and from storage
    – Assist in obtaining transportation resources
• Morgue Operations
    – Able to perform detailed decontamination and monitoring of remains for hazardous materials
• Family Assistance Center
    – Hotline/Helpline support
    – Assist with information dissemination
    – Assist establishing security for all aspects of morgue operations