I’ll give you the example of Las Vegas. What was amazing was that in some circumstances the civilians were first responders, police were first responders, and fire and EMS were first responders. Many of the interventions they made at the point of injury, as we witnessed in the battlefields of Iraq and Afghanistan, were the difference between life and death for many of those people.

RM: What was interesting in Katrina was that many of the physician offices simply closed. It was the emergency physicians who stayed and manned their post for days at a time. How do you think emergency medicine can best support your vision?

RK: I think they need to be part of the conversation. What I described is kind of a work in progress, it is not finalized. I think we would be very interested to hear from your colleagues about not only how to create a system, but how to sustain it over time. One of the areas that we’re very interested in is, what are the reimbursement issues, the incentives that would work to make not only a trauma system but a disaster system sustainable over time. The second thing is what would be the role of your colleagues to do local outreach with community groups and others, like with “Stop the Bleed” or “Until Help Arrives.”

Obviously, EMS is another critical piece of this, and there’s no better group of individuals than your colleagues and your profession to intervene in this way to ensure that the tip of the spear for medical response is capable to respond to events that could involve chemical, biological, radiological, and nuclear threats, for example. How do we do that? Obviously, in the local health care coalitions, emergency departments play an essential role in terms of managing and coordinating care across hospital systems, as well as managing the flow and triaging where people need to go in a region.

RM: You made a great point about using all these different resources. The National Academy of Science is looking at integrating the private sector to be better responsive. One of the interesting examples was the role of the satellite emergency departments in response to Harvey where hospitals closed. The distributive nature of those satellite emergency departments allowed a lower staffed EMS unit to easily pick up patients, drop them off, and then get back into the community. After the first couple of hours, you start moving toward a search and rescue.

RK: The benefit of your satellite emergency departments is that you’re trained and equipped to do that, right? The question is how do we expand that capability to other places that are not naturally trained and equipped? Can you do it through just-in-time training? Probably not. I think that’s the opportunity. As people evaluate locally how their system is set up, they need the right kind of touch points, whether those are satellite emergency departments or neighborhood health clinics, because they can be vital in any disaster response.