1. Accelerating Scalable Community Emergency Network Demonstration
Ascend links regional healthcare facilities with
private and public assets under a unified vision
that results in an integrated, scalable medical
evacuation solution during a regional emergency.

2. Agenda
 Introduce U.S. Air Ambulance
 Provide historical context for discussion
 Discuss our concept for a regional approach to emergency management
 Outline steps we will take to implement ASCEND for Indiana

3. U.S. Air Ambulance Corporate Overview
 Headquartered in Sarasota, FL
 23 years experience
 Licensed ground and air ambulance provider
 180 employees
 97,000 patients, 100% safety record

4. Relevant Corporate Experience
 Preferred provider for U.S. Department of State
 Contractor EMS program for Iraq, DoD
 Consultant to cruise line industry
 Last five years for DHS – evacuations of foreign
nationals
 Hurricane Katrina – FEMA
 Hurricane Wilma – U.S. Marshals Service
 Hurricanes Gustav and Ike – four private hospital
evacuations
 Proprietary software development
 Developer of unique service HELP

5. External Emergencies Have an Epicenter
Epicenter
Epicenter – The area of an emergency
which is unsafe or uninhabitable

6. Measures of Emergencies - Scale
Epicenter
EMAC Federal
Local Regional Statewide Border States Interstate
State Interstate
Scale

7. Measures of Emergencies – Scope
General
Population
Transportation
Disadvantaged
Population
Nonmedical
Assisted
Living
Long Term
Care
Scope Epicenter
Medical Long
Term Care
Medical
General
Medical
Medical
ALS / ICU
Medical Special
Needs
EMAC Federal
Local Regional Statewide Border States Interstate
State Interstate
Scale

8. Our Products - HELP
General
Population
Transportation
Disadvantaged
Population
Nonmedical
Assisted
Living
Long Term
Care
Scope
Medical Long
Term Care
Medical
General
Medical
Medical
HELP
ALS / ICU
Medical Special
Needs
EMAC Federal
Local Regional Statewide Border States Interstate
State Interstate
Scale

9. HELP Provides Additional Resources for Large Scale Disaster
HELP provides access to transportation assets and receiving
hospitals outside the Region
Second Tier Providers Hospital Network Outside
Mobilized for Hospital of Emergency Zone

10. Our Products - SPEAR
Special Patients Emergency Ambulance Response
General
Population
Transportation
Disadvantaged
Population
Nonmedical
Assisted
Living
Long Term
Care
Scope
Medical Long
Term Care
Medical
General
HELP
Medical
Medical
ALS / ICU
Medical Special
Needs SPEAR
EMAC Federal
Local Regional Statewide Border States Interstate
State Interstate
Scale

11. SPEAR Program
Special Patient Emergency Ambulance Response Program
Patients Dispersed From a Major
Burn Incident to Verified Burn Centers
Many special needs patients cases
cannot be transferred at the regional
level. For instance, a large burn
incident may require coordinating
the transfer of multiple patients
throughout the United States to
verified burn centers.
Verified Burn Center

12. Our Products - ASCEND
Accelerating Scalable Community Emergency Network Demonstration
General
Population
Transportation
Disadvantaged
Population
Nonmedical
Assisted
Living
Long Term
Care
Scope
Medical Long
Term Care
Medical
General
ASCEND HELP
Medical
Medical
ALS / ICU
Medical Special
Needs SPEAR
EMAC Federal
Local Regional Statewide Border States Interstate
State Interstate
Scale

13. Are Local Communities Ready For Accelerating Emergency?
January 6, 2005 2:40 AM
• Two trains collided in Graniteville, South Carolina,
- Small population 7,000
• 1 train carried 92 tanks of chlorine gas,1 tank ruptured
– Upgraded tank
• 90 tons of chlorine gas forms a deadly cloud that
flowed toward a sleeping public
- Low wind speed 2 mph
• 3:00 AM - Sheriff notified
• 3:45 AM - State Emergency Management Notified
• 5:09 AM - Local emergency system notified residents to
evacuate
• 9:00 AM - Local EOC set up and available to assist
• 5,400 people evacuated
• 330 people self presented to the hospital ER for treatment
- ER was unable to identify the chemical for several hours
• 525 people were treated in ER, 300 in first three hours
• 71 hospitalized, 25 ICU, 8 vented, 9 people died

14. Accident or Terrorism – Major Local Implications
National Planning Scenarios
• Chlorine Tank Explosion – National Planning Scenario 1 Improvised Nuclear Device
2 Major Earthquake
• In 2007, terrorists used chlorine gas 7 times on U.S. troops 3 Aerosol Anthrax
4 Major Hurricane
• In urban area – 100,000 hospitalized 5 Pandemic Influenza
6 Radiological Dispersal Device
• 10,000 vents required
7 Plague
8 Improvised Explosive Device
• 10,000 people die
9 Blister Agent
10 Food Contamination
11 Toxic Industrial Chemicals
12 Foreign Animal Disease
13 Nerve Agent
14 Cyber Attack
15 Chlorine Tank Explosion

15. Natural Disasters Have Accelerated During Last Four Decades
1993 Midwest Floods
1994 Northridge Earthquake
2005 Hurricane Katrina

16. Terrorism Against Americans Has Escalated
Probability of Dirty Bomb Attack in Next Decade – 40 percent
Terrorism Against Americans
Iran
1961 – First U.S. Aircraft Hijacking 1979
1974 – Patty Hearst Kidnapping
1979 – Iran, U.S. Embassy Hostages Oklahoma City
1983 – Lebanon and Kuwait 1979
U.S. Embassy Bombings
1988 – Pan Am Flight 103
1993 – World Trade Center Bombing
1995 - Oklahoma City Bombing
1996 – Saudi Khobar Towers Bombing
1996 – Centennial Olympic Park Bombing
1998 - Unabomber U.S.S. Cole
1998 - Kenya and Tanzania 2000
U.S. Embassy Bombing
2000 - U.S.S. Cole Bombing
2001 – 9/11 Coordinated Attacks
World Trade Center and Pentagon
2001 – Anthrax Attacks New York
2002 – Beltway Sniper Attacks 2001
2009 – Fort Hood Shootings

17. Possibility of Unprecedented Disaster is Very Real
2002 Analysis - Dirty Cobalt Bomb in Manhattan:
• 400 square Miles Contaminated
• Manhattan uninhabitable
• 1 in 100 Die from Cancer
Hurricane Katrina Not Unprecedented:
• Hurricane Katrina: 200 B Kobe, Japan 1995 7.2 Richter Scale
• Kobe, Japan Earthquake: 500 B
2009 New Madrid Earthquake Study (6.9 R):
• Trillion dollars in losses
• 130 hospitals destroyed
• 80,000 lives lost
New Madrid Earthquake 1811 8.3 Richter Scale
1895 6.8 Richter Scale

18. Nation is Not Ready to Combat New Madrid Earthquake
• Reliance on NDMS assets for evacuations
• will not arrive for 72 hours
• limited capacity
• not fully effective for special needs
patients
• National ambulance contract inadequate
• musters 600 ambulances
• relies on unplanned coordination
of the Joint Field Office
• EMACs were not effective in coordinating 66,000
personnel during Hurricane Katrina and have not
yet built that capability
• Multiple jurisdictional, technical, and regulatory
roadblocks that inhibit an effective response
must be overcome
• As late as 2008 Hurricane Gustav:
Our four customers in New Orleans were all told
by FEMA and the State that they could not get
ambulances for four days

19. Through Grants, DHS and HHS are Influencing National Direction
1997-Metropolitan Medical Response System (MMRS)
• Emergency preparedness systems
• Respond to public health crisis
2001-Emergency Management Performance Grants (EMPG)
• Expanded to all-hazards planning
• Fill gaps not covered by other federal programs
2002-Hospital Preparedness Program (HPP)
• Bio-terror attacks and pandemics
• Primary focus expanded to all-hazards
2002-Bioterrorism Training and Curriculum Development Program
(BTCDP)
• Train healthcare workforce
• Bioterrorism to all-hazards
2003-Urban Area Security Initiative (UASI)
• High-risk, high-threat urban areas
• Prepare, response and prevent all emergencies
2005-Regional Catastrophic Preparedness Grant Program (RCPGP)
• Catastrophic incident preparedness
• Regional all-hazard planning

20. America Has Vast Emergency Response Resources
America has the resources to
combat a national catastrophe:
• 45,000 Ground Ambulances
• 50,000 Paratransit Vehicles
• 70,000 Medically Equipped Buses
•150,000 Fire Trucks
• 800 Rotor Wing Ambulances
• 300 Fixed Wing Ambulances
• 525 Military and Reserve C-130 Aircraft
• 5,000 Hospitals
• 17,000 Nursing Facilities
• 3,000 County Emergency Managers
Air Ambulance locations 2009
• 800,000 Police Officers
• 400,000 National Guard troops
• Over 1 million Active Military Personnel
Stationed in the U.S.

21. Two Dimensions of an Emergency – Speed and Scale
SPEED vs. SCALE
Response Static
Time
Velocity
Response
Time
Response Acceleration
Time

22. Effective Medical Response Must Integrate Six Functions
To maximize emergency medical response capability,
regions must integrate six functions into a
Community Emergency Network (CEN)
that acts as one seamless unit
Emergency Management
Health Care Facilities Emergency Medical Service
CEN
Emergency Support Special Needs Transport
Inter-facility Transport

23. Interdependent Medical Response Chain
Interstate
Regional Receiving
Frontline Inter-facility Hospitals Hospitals
Hospital ER Transport Inventory
Pre-hospital Regional Interstate
Inpatient Interstate
Ambulances Hospitals Transport
Hospital Special
Admissions Needs
Transport
Patient Flow
Evacuation Expansion
Emergency Acceleration

24. Link 1 – Pre-hospital Ambulance Network
Pre-hospital
Ambulances
Epicenter
Epicenter – The area of an emergency
which is unsafe or uninhabitable

25. Link 2 – Front Line Hospital Emergency Rooms
Frontline
Hospital ER
Pre-hospital
Ambulances
Front Line Hospitals – Functioning Hospitals nearest the Epicenter
During a community emergency, front line hospitals’ primary emergency
function is to provide stabilization and first definitive medical care to persons
coming from the epicenter that require medical treatment.

26. Net Patient In-Flow Accelerates
In a large scale emergency, the pace of patient arrival to
front line hospitals will accelerate, potentially overwhelming
ERs and creating the need to initiate ER surge capability
Self Present Hospital
Emergency Room Admission
Discharge
Ambulance

27. CEN Responds Early To Shared Info
Frontline
Hospital ER
As the front line hospital’s ER becomes inundated with
self presenters, first respond ambulances react by
diverting. In addition, before a hospital in-patient
levels reach divert status, inter-facility ambulances
Pre-hospital respond to relieve front line hospital of stable patients.
Ambulances Inpatient
Hospital
Admissions
ABC Hospital
ER Hospital
Wait Time hrs: 2.4 Hospital Capacity: 92%
Capacity %: 122 Net Admit RPH: 17
Net Arrival RPH: 21 ER At Capacity: 3.4 Hrs
Acceleration %: 82 Bed Divert: Burn
Critical ER Capacity 85%
Inter-facility Requirement: 20 ALS
11 BLS

28. Links 4-6 Interfacility Transport and Regional Hospitals
Regional
Frontline Inter-facility Hospitals
Hospital ER Transport Inventory
Pre-hospital Inpatient Regional
Ambulances Hospital Hospitals
Admissions

29. All Members of the CEN Share Info Early
As the emergency progresses:
• First response ambulances relay knowledge about
patients coming in the epicenter.
•Front line hospitals relay information about the
conditions they are treating.
•The community network assesses the potential for a
coordinated response and prepare to participate in the
emergency.
Support
Services
Shared Information Special Needs
Patient Transporter
Epicenter
Regional
Front Line Inter-facility Hospital
Hospital Transporter

30. ASCEND Software Component
Management
Software

31. Regional Hospitals Accept Patients, Share Emergency Resources
As the velocity of intake increases at front line hospitals, Inter-facility
transfers must occur. With the aid of a Seamless Emergency Operations
Center (SEOC), the region coordinates patient movement:
• Front line hospitals identify patient transfer needs
• Regional hospitals identify available beds
• Logistics identifies and coordinates inter-facility transfers and
obtains resources from outside the region as needed.
Seamless Emergency
Operations Center
Shared Information,
Analysis, and
Coordination
of Resources
Epicenter Stabilized Patients
Surge Resources
Front Line Regional
Hospital Hospital

32. ASCEND Seamless Operations Center
Command
Center

33. SEOC Assists Local EOC
The SEOC provides the Local EOC invaluable real-time
information to make critical decisions and assists the
EOC with real-time analysis.
Some hospitals may find themselves inside the epicenter
and require full evacuation of their hospitals.
Seamless Emergency
Operations Center
Shared Information, Local Emergency
Analysis, and Operations Center
Shared Information
Coordination
And Coordination
of Resources
of assets
Front Line
Hospital
Epicenter
Stabilized Patients
Surge Resources
Front Line Regional
Hospital
Hospital

34. Regional Response Integrates with Federal Response
Regional Interstate
Frontline Inter-facility
Hospitals Receiving
Hospital ER Transport
Inventory Hospitals
Pre-hospital Inpatient Regional Interstate
Ambulances Hospital Hospitals Transport
Admissions

35. Region Accesses HELP as Need Surpasses Regional Capability
If the velocity of patients entering the regional medical system continues
to exceed the region’s capacity to treat them, SEOC can coordinate
patient movement through HELP:
• Network of interstate ambulances and receiving hospitals
• 24 hour response as opposed to NDMS 72 hour response
Seamless Emergency
Operations Center
Shared Information, Local
Analysis, and EOC
Coordination
of Resources
HELP
Areomedical HELP HELP Receiving
Staging Center Patient Transporters Facility Network
(over 600 companies) (600 Facilities)
Epicenter Stabilized Patients Stabilized Patients
Surge Resources Surge Resources
Front Line Regional Regional Regional
Hospital Hospital Hospital Ambulances

36. SEOC Manages National Special Needs Transfers
Regional Interstate
Frontline Inter-facility
Hospitals Receiving
Hospital ER Transport
Inventory Hospitals
Pre-hospital Inpatient Interstate Interstate
Regional
Ambulances Hospital Transport Special
Hospitals
Admissions Needs
Transport
Patients Dispersed From a Major
Burn Incident to Verified Burn Centers
Many special needs patients cases
cannot be transferred at the regional
level. For instance, a large burn
incident may require coordinating
the transfer of multiple patients
throughout the United States to
verified burn centers.
Verified Burn Center

37. Proposed Steps
1. Unify and Implement Regional goals
2. Codify and Implement Software Solution
3. Prepare and Implement Operations

38. Outline Of ASCEND Service:
Facilitation / consultation
1. Facilitate Unified vision
2. Document current status vs. goal
3. Outline steps to reach unified goals
4. Create Integrated critical path
5. Establish incremental milestones
6. Overcome operational, technical and legislative roadblocks.
7. Develop detailed protocols and procedures
Unified
Region-Wide
Vision Integrated
Critical Path
Local and Integrated Detailed
Hospitals State Incremental Protocols and
EOC’s
Milestones Procedures
Pre-hospital Inter-facility
Ambulances Transporters

39. Outline Of ASCEND Service:
Software Solution
• Outline current enterprise solutions
•Create bridge software solution
•Codify Protocols into an Enterprise Software System
• Provide Training and Exercises on ASCEND software
ASCEND
EWA
Salamander
Phoenix

40. Outline Of ASCEND Service:
Operations
•Provide Logistical Operations Center
• Provide HELP Solution
• Provide Special Needs Patients solutions