How to Conduct EMS Exercises and Drills

The scene is chaotic, with fire, law enforcement and EMS personnel seeming to sweep in from all directions. As you clear the scene and begin to transport to a local hospital, you turn to your partner and say, “Wow, seemed like a lot of people there didn’t know what to do.” He looks back at you and says, “They should have … we exercised on this exact scenario less than a year ago.”

Introduction

For many of us in EMS, exercising often seems like a tedious and often repetitive process which can potentially feel like a waste of time and resources. However, as budgets and staffing begin to shrink, the threat of natural and manmade disasters remains as strong as ever. As a matter of fact, 2011 marked a record for the United States with at least 12 disasters which caused at least $1 billion in damages, according to the National Oceanic and Atmospheric Administration (NOAA). Therefore it’s essential for EMS agencies big and small to continue emphasizing training and exercise as a means to prepare for tomorrow’s next challenge. It’s also important for exercise planners to understand the fundamentals of planning an effective exercise, as well as identify innovative means to make those exercises more cost-effective and—dare we say it—fun.

To begin planning an effective exercise one must understand the basics. Exercise planning takes patience, consistency, flexibility and—the word not many people like to hear—time. Anyone who has attended a few exercises as a player can tell you the difference between those exercises which were planned well and those which weren’t. To help with planning effective exercises, the U.S. Department of Homeland Security (DHS) has developed a standardized methodology to exercise planning and evaluation. The Homeland Security Exercise and Evaluation Program (HSEEP) can be an exercise designer’s best friend, as it provides a standardized methodology and terminology for exercise design, development, conduct, evaluation and improvement planning. The following is a crash course in the HSEEP method of exercise planning.

Define Your Goals

Contrary to what many people think, the first step in designing an exercise is not coming up with a scenario. Rather, the most important first step is determining what you actually wish to test. To assist with this, DHS and the Federal Emergency Management Agency (FEMA) have identified 37 target capabilities, or universal capabilities emergency responders will likely encounter when responding to a disaster. These capabilities are broken up into five categories, or mission areas: common target capabilities, prevent mission area capabilities, protect mission area capabilities, respond mission area capabilities and recovery mission area capabilities. Inevitably, most emergency responders will opt to exercise those capabilities in the respond mission area because these tend to be the most interesting topics. It’s highly advisable for you to conduct a needs assessment of your agency or jurisdiction before choosing which target capabilities to exercise. To assess your needs, first look at those capabilities you use often, then ask yourself honestly, “Is there room for improvement?” If you feel comfortable with these capabilities, move on to some of the other capabilities you might not use as often. Planning and conducting an exercise can be time consuming and, at times, expensive. Therefore you should try to maximize the benefit of that investment and exercise those areas which are of particular concern to your jurisdiction. It’s strongly recommended when choosing your target capabilities to avoid choosing more than five whenever possible. As these are what you will be evaluating, you do not want to overload your team.

Understanding Exercises

Once you decide what you want to test, you can begin to determine how you want to test it. Depending on what you want to test, you may decide that a low-stress, discussion-based exercise would be an excellent first step. There are a few exercises to choose from and the key is determining which one(s) best suit your needs. HSEEP defines the following types of exercises:

• Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function in a single agency. EMS providers are often most familiar with these because they (hopefully) routinely train on equipment and standard operating procedures within the department.
• Game: A game is a simulation of operations often involving two or more teams, usually in a competitive atmosphere, using rules and procedures designed to depict an actual or assumed real-life situation. Emergency response simulation software is becoming quite advanced and definitely should be explored.
• Building Block Approach: This type of exercise approach utilizes a series of exercises which progress in type and complexity.
• Seminar: A seminar orients participants to authorities, strategies, plans, policies, procedures, protocols, resources, concepts and ideas. Seminars are a great way to begin the building block approach.
• Workshop: Similar to seminars, workshops involve more participant interaction and focus on achieving or building a product, such as a plan or policy.
• Tabletop Exercise: This type of exercise stimulates discussion of various issues regarding a hypothetical situation. It can be used to assess plans, policies and procedures, or to assess types of systems needed to guide the prevention, response to or recovery from a defined incident. Tabletops are generally low-stress, and actions and decisions do not take place in real time.
• Functional Exercise:  A functional exercise can be either a single or multi-agency activity designed to evaluate capabilities and multiple functions using a simulated response. A main characteristic of a functional exercise is the simulated deployment of resources, rapid problem solving and a high stress environment.
• Full-Scale Exercise: A full-scale exercise is a multi-agency, multi-jurisdictional exercise which tests many facets of an emergency response. This involves the deployment of real resources, rapid problem solving and a high stress environment.

The building block approach is exceptionally useful when trying to tackle a multitude of target capabilities. Say, for example, your jurisdiction would like to test its ability to provide medical care to prehospital patients exposed to some type of chemical agent. A good building block approach may be to have a seminar on chemical agents and treatment, followed by a workshop to develop a standard operating guideline, then a tabletop to discuss a response and ending with a full-scale exercise to test those guidelines.

When choosing which exercise type is best for you, it’s important to take into account time and budget. A tabletop exercise takes about a month to effectively plan and can be somewhat inexpensive. Conversely, a full-scale exercise can take up a year to plan—if you want to do it right—and can be very expensive. How much an exercise will cost is hard to gauge in the initial planning stages. But remember someone will have to pay for salaries, overtime, fuel, food, supplies and simulation aids. And don’t forget administrative costs, such as printing and copying.

Now that you’ve decided what you want to test and what type of exercise you want to run, it’s time to determine your objectives. Just like when developing incident objectives under the incident command system, you want your objectives to specific, measurable, action-oriented, realistic and time sensitive.

• Specific: You want your objective to relate to a specific target capability.
• Measurable: You have to be able to evaluate whether that objective was achieved.
• Action-oriented: There must be something happening within this exercise for you to be able to evaluate. If it’s a discussion-based tabletop exercise, you need to make sure that objective is covered in the discussion.
• Realistic: You must be able to realistically test that capability within the confines of your scenario. Also, you must realistically have that capability to test. In other words, you can’t test your ability to rapidly detect and decontamination victims of a chemical agent when your agency does not have the ability to detect or decontaminate to begin with.
• Time Sensitive: You must be able to test that capability within the time frame of the exercise you are running.

There should be at least one objective for each target capability you plan to test. Similar to managing a large incident, the fewer objectives you have to evaluate, the easier it is for you to manage the exercise.

Now it’s time to have some real fun—the scenario. Designing a scenario can be interesting and challenging. But it’s important to remember to keep it simple! Look at what can realistically occur in your area, what occurs frequently and has the highest impact on your area, or what could provide a realistic scenario to test your target capabilities. We can’t tell you how many meetings we’ve been in where someone will say, “So, should we have a terrorist attack on top of the hurricane landfall?” Seriously? Why? When did al-Qaeda develop a weather machine? Your exercise will be challenging enough without extraneous complications. Remain flexible with your scenario, as the storyline may need to change a few times throughout the planning process.

Next we want to identify the agencies which should be planning the exercise. There is an important distinction to make here between who’s planning and who’s playing in the exercise. You should really avoid allowing people who plan the exercise to play in the exercise. You’ll need all the help you can get with conducting the exercise, plus you want to have an honest evaluation of the capability. Having a player plan the exercise would unfairly stack the deck in favor of success—and that’s not very sportsman-like, now is it? Which agencies you invite to participate is strictly up to you. However, we will caution you to make sure there’s something for those agencies to do when developing the scenario. While you can’t, and shouldn’t, control what the decision makers do in the exercise, you want to make sure you did everything possible to ensure there would be enough work to go around.

With everything else in place, we need to address meetings. You should have a minimum of two meetings for each exercise, but do not limit yourself. Also, conference calls and smaller meetings become increasingly important when you plan complex exercises such as functionals and full-scales. A template for meetings can be found on the HSEEP website listed at the end of the article. In these pre-exercise meetings, you’ll discuss logistics, venue concerns, personnel to control and personnel to evaluate. During these meetings, you will also develop some of the documents necessary for exercise success. These include:

• Situation Manual (SITMAN): This is the participant manual for a tabletop exercise. It provides the scenario, supplemental information and questions for discussion.
• Exercise Plan (ExPlan): This is the complete “how-to” manual for the people conducting the functional or full-scale exercise.
• Scenario Injects: These are the supplemental information you provide to players in a functional or full-scale exercise to stimulate action and heighten stress and realism. For example, you may call a bomb threat into the command post to test their reaction.
• Master Scenario Events List (MSEL): This is the list of the scenario injects you plan to use, when you plan to use them and the expected reaction(s).
• Exercise Evaluation Guides (EEG): These specifically outline the areas you want to evaluate. The HSEEP website has templates for evaluating each target capability which you can edit to meet the needs of your exercise.

The Actual Exercise

All of your meetings have been completed and your materials have been developed. Now it’s exercise day (or days). No exercise ever goes exactly the way you want it to. Try to maintain control of your exercise but remember to ask yourself, “Is something  going wrong because of the exercise design, or is it going wrong because of decisions the players are making?” If it’s a design flaw, try to correct it on the fly. If it’s a decision making issue, do not stress. That’s exactly what you came here to test. And it’s OK for an exercise to fail. As long as the exercise design did not fail, you’ve done your job. If the players failed to make the right decisions, make sure you discuss it after the exercise. For example, in one major exercise we conducted, the local fire department insisted on bringing in dozens of additional fire apparatus to participate, but failed to request them from the staging area during the exercise. While those bored firefighters instinctively blamed the exercise planners, the exercise planners cannot make the decisions for those people in the command post.

This is a wonderful segue into the next point—evaluation. There are a few tools you can use to properly evaluate your exercise. The first is to have at least one evaluator for every target capability you’re testing. Make sure these evaluators understand the capability they’re evaluating and use the EEG templates or take very good notes. Another tool is the “player hot wash.” Immediately after the exercise, get the main participants together and ask them how they felt things went. Inevitably, they’ll criticize the exercise design. That’s OK. Take what they say and see how you can incorporate it into your next exercise. However, you should try to steer them back to the topic at hand, which is identifying strengths and areas for improvement. Ask each participate to give you one or two things they think went well (strengths) and one or two things they think didn’t go well (areas for improvement). From these responses and the notes of the evaluators, you can develop an after action report detailing your findings and an improvement plan, which outlines recommendations for improving those areas that need it.

Conclusion

Now that we’ve discussed the how of exercise design, let’s talk about the why. Plain and simple, exercising pays off. As mentioned in the sidebar, many of the challenges New Jersey faced in the August Surge/Eagle Flag 2010 exercise resurfaced in 2011 during the actual response to Hurricane Irene. For example, one component of the exercise series was the healthcare evacuation tabletop exercise. The local, county and state EMS and health agencies examined the response to a hurricane making landfall in New Jersey and forcing the evacuation of thousands of patients and residents from dozens of hospitals and long-term care facilities. Similarly, in August 2011, these very same players were operating together in the state health emergency operations center to plan and execute the pre-landfall evacuation of thousands of patients and residents from dozens of hospitals and long-term care facilities. Challenges such as requesting ambulances through the emergency management assistance compact, activating the FEMA National Ambulance Contract, statutory waivers, patient tracking, resource management and financial reimbursement were all discussed during the exercise. Although everything didn’t go according to plan, many of the issues were mitigated against so when the actual event took place it was managed more effectively in real life.

We cannot afford to become complacent and lackadaisical with our exercise planning, even as budgets and staffing shrink. We owe it to each other and those residents in the communities we serve to do our best to continue planning and conducting effective exercises.

Sidebar:

August Surge/Eagle Flag 2010—A Case Study of the Building Block Approach

In 2010, FEMA worked with the U.S. Air Force, New Jersey Office of Emergency Management, and the New Jersey Department of Health and Senior Services to test the air medical evacuation of patients in response to a major hurricane. A building block approach was used for the exercise series, which included the following exercises:

• State/federal medical support seminar
• Healthcare facility evacuation tabletop exercise
• Interoperable communications drill
• State/federal functional exercise
• Defense support to civil authorities and military air medical evacuation seminar
• Full-scale exercise

The full-scale exercise consisted of the New Jersey EMS Task Force deploying its Mobile Acute Care Hospital (MACH) system and maintaining operation for 72 hours. In that time, more than 200 simulated casualties were treated and transferred to a disaster air-medical staging facility team from the U.S. Air Force to simulate transfer out of state under the national disaster medical system. The exercise series was a huge success for healthcare in New Jersey, as many of the challenges faced in the exercise were later faced in the 2011 response to Hurricane Irene.

Sidebar:

Hanging Up Your Exercises

It’s important to continue finding new ways to make your exercises fun, exciting and cost effective for your players. Here are some best practices for EMS agencies:

• Human patient simulators: In the Eagle Flag 2010 exercise in New Jersey, 35 dynamic mannequins were utilized to simulate real patients. These computerized mannequins stressed the medical surge target capability of New Jersey’s Mobile Acute Care Hospital (MACH) with conditions such as cardiac arrests, tension pneumothoraxes and even child birth.
• Secondary explosive devices: In the Red Zone 2011 exercise at MetLife Stadium in New Jersey, the Transportation Security Administration (TSA) deployed simulated secondary explosive devices to test responders’ reactions.
• Patient simulation cards: During the 2007 Exchange Place Response exercise in New Jersey, ambulances were given cards with patient profiles on them to simulate a real patient. As the tracking—not the treatment—of large numbers of patients was being evaluated, this provided a surge of 275 patients on local EMS.
• Simulated hospitals: In the Red Zone 2011 exercise, the ability of the local EMS system to manage the surge following an explosion at a sold-out football game was tested. Local hospitals were simulated, so ambulances drove patients to a simulated facility at the stadium. This allowed exercise controllers to “recycle” victims. Seventy-five volunteers were able to simulate 100 victims in this manner.

Sidebar:

Federal Exercise Support

In order to assist state and local governments with planning and conducting effective exercises, FEMA provides the following forms of exercise support:

• HSEEP Training & Toolkit: FEMA provides standardized templates and training for conducting effective exercises through the HSEEP Toolkit (www.hseep.dhs.gov).
• Regional Exercise Support Program: FEMA provides contractor support to large “all-hazards” tabletop, functional and full-scale exercise projects within each FEMA region.
• Terrorism Prevention Exercise Program: FEMA provides contractor support to law enforcement-based terrorism prevention exercise projects within each FEMA region.

More information on these programs can be obtained by contacting your state exercise officer or FEMA regional exercise officer.

References

• Homeland Security Exercise and Evaluation Program, hseep.dhs.gov
• FEMA Emergency Management Institute, www.training.fema.gov/emi
• Responder Knowledge Base, www.rkb.us/hspd8.cfm
• National Oceanic and Atmospheric Administration, www.noaa.gov