Emergency department

From Wikipedia, the free encyclopedia

The main patient area inside the Mobile Medical Unit operated in Belle Chasse, Louisiana

 

An emergency department (ED), also known as an accident & emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center. 

Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care. 

The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to reflect patient volume.

History

Accident services were already provided by workmen's compensation plans, railway companies, and municipalities in Europe and the United States by the late mid-nineteenth century, but the first specialized trauma care center in the world was opened in 1911 in the United States at the University of Louisville Hospital in Louisville, Kentucky, and was developed by surgeon Arnold Griswold during the 1930s. Griswold also equipped police and fire vehicles with medical supplies and trained officers to give emergency care while en route to the hospital.

Today, a typical hospital has its emergency department in its own section of the ground floor of the grounds, with its own dedicated entrance. As patients can present at any time and with any complaint, a key part of the operation of an emergency department is the prioritization of cases based on clinical need. This process is called triage. 

Triage is normally the first stage the patient passes through, and consists of a brief assessment, including a set of vital signs, and the assignment of a "chief complaint" (e.g. chest pain, abdominal pain, difficulty breathing, etc.). Most emergency departments have a dedicated area for this process to take place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is fulfilled by a triage nurse, although dependent on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or physicians. Triage is typically conducted face-to-face when the patient presents, or a form of triage may be conducted via radio with an ambulance crew; in this method, the paramedics will call the hospital's triage center with a short update about an incoming patient, who will then be triaged to the appropriate level of care.

Most patients will be initially assessed at triage and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department. 

The resuscitation area, commonly referred to as "Trauma" or "Resus", is a key area in most departments. The most seriously ill or injured patients will be dealt with in this area, as it contains the equipment and staff required for dealing with immediately life-threatening illnesses and injuries. Typical resuscitation staffing involves at least one attending physician, and at least one and usually two nurses with trauma and Advanced Cardiac Life Support training. These personnel may be assigned to the resuscitation area for the entirety of the shift, or may be "on call" for resuscitation coverage (i.e. if a critical case presents via walk-in triage or ambulance, the team will be paged to the resuscitation area to deal with the case immediately). Resuscitation cases may also be attended by residents, radiographers, ambulance personnel, respiratory therapists, hospital pharmacists and/or students of any of these professions depending upon the skill mix needed for any given case and whether or not the hospital provides teaching services.

Patients who exhibit signs of being seriously ill but are not in immediate danger of life or limb will be triaged to "acute care" or "majors", where they will be seen by a physician and receive a more thorough assessment and treatment. Examples of "majors" include chest pain, difficulty breathing, abdominal pain and neurological complaints. Advanced diagnostic testing may be conducted at this stage, including laboratory testing of blood and/or urine, ultrasonography, CT or MRI scanning. Medications appropriate to manage the patient's condition will also be given. Depending on underlying causes of the patient's chief complaint, he or she may be discharged home from this area or admitted to the hospital for further treatment.

Patients whose condition is not immediately life-threatening will be sent to an area suitable to deal with them, and these areas might typically be termed as a prompt care or minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing. 

Children can present particular challenges in treatment. Some departments have dedicated pediatrics areas, and some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.

Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental health nurses and social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal).

Fast decisions on life-and-death cases are critical in hospital emergency departments. As a result, doctors face great pressures to overtest and overtreat. The fear of missing something often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomach aches, with a high cost on the health care system.

Nomenclature in English

Emergency department became commonly used when emergency medicine was recognised as a medical specialty, and hospitals and medical centres developed departments of emergency medicine to provide services. Other common variations include 'emergency ward,' 'emergency centre' or 'emergency unit'. 

'Accident and Emergency' or 'A&E' is still the accepted term in the United Kingdom, some Commonwealth countries, and the Republic of Ireland, as are earlier terms such as 'Casualty' or 'casualty ward', which continue to be used informally. The same applies to 'emergency room' or 'ER' in North America, originating when emergency facilities were provided in a single room of the hospital by the department of surgery.

Signage

Regardless of naming convention, there is a widespread usage of directional signage in white text on a red background across the world, which indicates the location of the emergency department, or a hospital with such facilities.

Signs on emergency departments may contain additional information. In some American states there is close regulation of the design and content of such signs. For example, California requires wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty", to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.

In some countries, including the United States and Canada, a smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24-hour basis. Very large clinics may operate as "free-standing emergency centres", which are open 24 hours and can manage a very large number of conditions. However, if a patient presents to a free-standing clinic with a condition requiring hospital admission, he or she must be transferred to an actual hospital, as these facilities do not have the capability to provide inpatient care.

• Examples of emergency department signage
• 

  Santa Clara Valley Medical Center.
  
• 

  Mayo Clinic Hospital in Rochester.
  
• 

  Trilingual signage in French, Dutch and English at an emergency department in Brussels, Belgium.
  

United States

The Centers for Medicare and Medicaid Services (CMS) classified emergency departments into two types: Type A, the majority, which are open 24 hours a day, 7 days a week, 365 days a year; and those who are not, Type B. Many US emergency departments are exceedingly busy. A study found that in 2009, there were an estimated 128,885,040 ED encounters in US hospitals. Approximately one-fifth of ED visits in 2010 were for patients under the age of 18 years. In 2009–2010, a total of 19.6 million emergency department visits in the United States were made by persons aged 65 and over. Most encounters (82.8 percent) resulted in treatment and release; 17.2 percent were admitted to inpatient care.

The 1986 Emergency Medical Treatment and Active Labor Act is an act of the United States Congress, that requires emergency departments, if the associated hospital receives payments from Medicare, to provide appropriate medical examination and emergency treatment to all individuals seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay. Like an unfunded mandate, there are no reimbursement provisions.

Rates of ED visits rose between 2006 and 2011 for almost every patient characteristic and location. The total rate of ED visits increased 4.5% in that time. However, the rate of visits for patients under one year of age declined 8.3%.

A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused by excessive waits for hospital beds by ED patients. A 2005 patient survey found an average ED wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.

One inspection of Los Angeles area hospitals by Congressional staff found the EDs operating at an average of 116% of capacity (meaning there were more patients than available treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the 2004 Madrid train bombings. Three of the five Level I trauma centres were on "diversion", meaning ambulances with all but the most severely injured patients were being directed elsewhere because the ED could not safely accommodate any more patients. This controversial practice was banned in Massachusetts (except for major incidents, such as a fire in the ED), effective 1 January 2009; in response, hospitals have devoted more staff to the ED at peak times and moved some elective procedures to non-peak times.there were 1,800 EDs in the country. In 2011, about 421 out of every 1,000 people in the United States visited the emergency department; five times as many were discharged as were admitted. Rural areas are the highest rate of ED visits (502 per 1,000 population) and large metro counties had the lowest (319 visits per 1,000 population). By region, the Midwest had the highest rate of ED visits (460 per 1,000 population) and Western States had the lowest (321 visits per 1,000 population).

Most Common Reasons for Discharged Emergency Department Visits in the United States, 2011

Age (in years)	Reason for Visit	Visits
less than 1	Fever of unknown origin	270,000
1–17	Superficial injury, contusion	1.6 million
18–44	Sprains and Strains	3.2 million
45–64	Nonspecific chest pain	1.5 million
65–84	Nonspecific chest pain	643,000
85+	Superficial injury, contusion	213,000

Freestanding

In addition to the normal hospital based emergency departments a trend has developed in some states (including Texas and Colorado) of emergency departments not attached to hospitals. These new emergency departments are referred to as free standing emergency departments. The rationale for these operations is the ability to operate outside of hospital policies that may lead to increased wait times and reduced patient satisfaction.

These departments have attracted controversy due to consumer confusion around their prices and insurance coverage. In 2017, the largest operator, Adeptus Health, declared bankruptcy.

United Kingdom

The emergency department at The Royal Infirmary of Edinburgh

 

A&E sign common in the UK.

 

UK road sign to a hospital with A&E

 

All A&E departments throughout the United Kingdom are financed and managed publicly by the NHS of each constituent country (England, Scotland, Wales and Northern Ireland). As with most other NHS services, emergency care is provided to all, both resident citizens and those not ordinarily resident in the UK, free at the point of need and regardless of any ability to pay. 

In England departments are divided into three categories:

• Type 1 A&E department – major A&E, providing a consultant-led 24 hour service with full resuscitation facilities
• Type 2 A&E department – single specialty A&E service (e.g. ophthalmology, dentistry)
• Type 3 A&E department – other A&E/ minor injury unit/ walk-in centre, treating minor injuries and illnesses 

Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the Department of Health introduced a four-hour target in emergency departments that required departments in England to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary. It was expected that the patients would have physically left the department within the four hours. Present policy is that 95% of all patient cases do not "breach" this four-hour wait. The busiest departments in the UK outside London include University Hospital of Wales in Cardiff, The North Wales Regional Hospital in Wrexham, the Royal Infirmary of Edinburgh and Queen Alexandra Hospital in Portsmouth.

In July 2014, the QualityWatch research programme published in-depth analysis which tracked 41 million A&E attendances from 2010 to 2013. This showed that the number of patients in a department at any one time was closely linked to waiting times, and that crowding in A&E had increased as a result of a growing and ageing population, compounded by the freezing or reduction of A&E capacity. Between 2010/11 and 2012/13 crowding increased by 8%, despite a rise of just 3% in A&E visits, and this trend looks set to continue. Other influential factors identified by the report included temperature (with both hotter and colder weather pushing up A&E visits), staffing and inpatient bed numbers. 

A&E services in the UK are often the focus of a great deal of media and political interest, and data on A&E performance is published weekly. However, this is only one part of a complex urgent and emergency care system. Reducing A&E waiting times therefore requires a comprehensive, coordinated strategy across a range of related services.

Many A&E departments are crowded and confusing. Many of those attending are understandably anxious, and some are mentally ill, and especially at night are under the influence of alcohol or other substances. Pearson Lloyd's redesign – 'A Better A&E' – is claimed to have reduced aggression against hospital staff in the departments by 50 per cent. A system of environmental signage provides location-specific information for patients. Screens provide live information about how many cases are being handled and the current status of the A&E department. Waiting times for patients to be seen at A&E have been rising.

Critical conditions handled

Cardiac arrest

Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses.

Heart attack

Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (GTN or NTG) will be given, unless contraindicated by the presence of other drugs. 

An ECG that reveals ST segment elevation suggests complete blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

Trauma

Major trauma, the term for patients with multiple injuries, often from a motor vehicle crash or a major fall, is initially handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency medicine (which is itself a medical specialty, and has certifications in the United States from the American Board of Emergency Medicine).

Trauma is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles.

The services that are provided in an emergency department can range from x-rays and the setting of broken bones to those of a full-scale trauma centre. A patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour". 

Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma centre. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.

Mental illness

Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many US states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. The emergency department conducts medical clearance rather than treats acute behavioral disorders. From the emergency department, patients with significant mental illness may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD

Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Noninvasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe exacerbations of COPD.

Special facilities, training, and equipment

An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information.

ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as military anti-shock trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such specialists. 

ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items. 

Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars and fire apparatus, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls. 

Because time is such an essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. Nearly all have radiographic examination rooms staffed by dedicated Radiographer, and many now have full radiology facilities including CT scanners and ultrasonography equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its own "STAT Lab" for basic labs (blood counts, blood typing, toxicology screens, etc.) that must be returned very rapidly.

Non-emergency use

Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by nursing groups, physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement. Health information exchanges can reduce nonurgent ED visits by supplying current data about admissions, discharges, and transfers to health plans and accountable care organizations, allowing them to shift ED use to primary care settings.

In all Primary Care Trusts there are out of hours medical consultations provided by general practitioners or nurse practitioners. 

In the United States, high costs are incurred by non-emergency use of the emergency room. The National Hospital Ambulatory Medical Care Survey looked ath the ten most common symptoms for which giving rise to emergency room visits (cough, sore throat, back pain, fever, headache, abdominal pain, chest pain, other pain, shortness of breath, vomiting) and made suggestions as to which would be the most cost-effective choice among virtual care, retail clinic, urgent care or emergency room. Notably, certain complaints may also be addressed by a telephone call to a person's primary care provider.

In the United States, and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as Fast Track or Minor Care units. These units are for people with non-life-threatening injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions. To reduce the strain on limited ED resources, American Medical Response created a checklist that allows EMTs to identify intoxicated individuals who can be safely sent to detoxification facilities instead.

Overcrowding

Emergency department overcrowding is when function of a department is hindered by an inability to treat all patients in an adequate manner. This is a common occurrence in emergency departments worldwide. Overcrowding causes inadequate patient care which leads to poorer patient outcomes. To address this problem, escalation policies are used by emergency departments when responding to an increase in demand (e.g., a sudden inflow of patients) or a reduction in capacity (e.g., a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying ‘normal’ processes.

Emergency department waiting times

Emergency department (ED) waiting times have a serious impact on patient mortality, morbidity with readmission in less than 30 days, length of stay, and patient satisfaction. A review of the literature bears out the logical premise that since the outcome of treatment for all diseases and injuries is time-sensitive, the sooner treatment is rendered, the better the outcome. Various studies reported significant associations between waiting times and higher mortality and morbidity among those who survived. It is clear from the literature that untimely hospital deaths and morbidity can be reduced by reductions in ED waiting times.

Exit block

While a significant proportion of people attending emergency departments are discharged home after treatment, many require admission for ongoing observation or treatment, or to ensure adequate social care before discharge is possible. If people requiring admission are not able to be moved to inpatient beds swiftly, "exit block" or "access block" occurs. This often leads to crowding and impairs flow to the point that it can lead to delays in appropriate treatment for newly presenting cases ("arrival access block"). This phenomenon is more common in densely populated areas, and affects pediatric departments less than adults ones.

Exit block can lead to delays in care both in the people awaiting inpatient beds ("boarding") and those who newly present to an exit blocked department. Various solutions have been proposed, such as changes in staffing or increasing inpatient capacity.

Frequent presenters

Frequent presenters are persons who will present themselves at a hospital multiple times, usually those with complex medical requirements or with psychological issues complicating medical management. These persons contribute to overcrowding and typically require more hospital resources although they do not account for a significant number of visits. To help prevent inappropriate emergency department use and return visits, some hospitals offer care coordination and support services such as at-home and in-shelter transitional primary care for frequent presenters and short-term housing for homeless patients recovering after discharge.

In the military

Emergency departments in the military benefit from the added support of enlisted personnel who are capable of performing a wide variety of tasks they have been trained for through specialized military schooling. For example, in United States Military Hospitals, Air Force Aerospace Medical Technicians and Navy Hospital Corpsmen perform tasks that fall under the scope of practice of both doctors (i.e. sutures, staples and incision and drainages) and nurses (i.e. medication administration, foley catheter insertion, and obtaining intravenous access) and also perform splinting of injured extremities, nasogastric tube insertion, intubation, wound cauterizing, eye irrigation, and much more. Often, some civilian education and/or certification will be required such as an EMT certification, in case of the need to provide care outside the base where the member is stationed. The presence of highly trained enlisted personnel in an Emergency Departments drastically reduces the workload on nurses and doctors.

Violence against health care workers

According to a survey at an urban inner-city tertiary care centre in Vancouver, 57% of health care workers were physically assaulted in 1996. 73% were afraid of patients as a result of violence, almost half, 49%, hid their identities from patients, 74% had reduced job satisfaction. Over one-quarter of the respondents took days off because of violence. Of respondents no longer working in the emergency department, 67% reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies cited by those surveyed.

Medication errors

Emergency Department of Dartmouth General Hospital

 

Medication errors are issues that lead to incorrect medication distribution or potential for patient harm. As of 2014, around 3% of all hospital-related adverse effects were due to medication errors in the emergency department (ED); between 4% and 14% of medications given to patients in the ED were incorrect and children were particularly at risk.

Errors can arise if the doctor prescribes the wrong medication, if the prescription intended by the doctor is not the one actually communicated to the pharmacy due to an illegibly-written prescription or misheard verbal order, if the pharmacy dispenses the wrong medication, or if the medication is then given to the wrong person.

The ED is a riskier environment than other areas of the hospital due to medical practitioners not knowing the patient as well as they know longer term hospital patients, due to time pressure caused by overcrowding, and due to the emergency-driven nature of the medicine that is practiced there.

Federal Emergency Management Agency

From Wikipedia, the free encyclopedia

The Federal Emergency Management Agency (FEMA) is an agency of the United States Department of Homeland Security, initially created by Presidential Reorganization Plan No. 3 of 1978 and implemented by two Executive Orders on April 1, 1979. The agency's primary purpose is to coordinate the response to a disaster that has occurred in the United States and that overwhelms the resources of local and state authorities. The governor of the state in which the disaster occurs must declare a state of emergency and formally request from the president that FEMA and the federal government respond to the disaster. The only exception to the state's gubernatorial declaration requirement occurs when an emergency or disaster takes place on federal property or to a federal asset—for example, the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, or the Space Shuttle Columbia in the 2003 return-flight disaster.

While on-the-ground support of disaster recovery efforts is a major part of FEMA's charter, the agency provides state and local governments with experts in specialized fields and funding for rebuilding efforts and relief funds for infrastructure by directing individuals to access low-interest loans, in conjunction with the Small Business Administration. In addition to this, FEMA provides funds for training of response personnel throughout the United States and its territories as part of the agency's preparedness effort.

History

Federal emergency management in the U.S. has existed in one form or another for over 200 years.

Prior to 1930s

A series of devastating fires struck the port city of Portsmouth, New Hampshire, early in the 19th century. The 7th U.S. Congress passed a measure in 1803 that provided relief for Portsmouth merchants by extending the time they had for remitting tariffs on imported goods. This is widely considered the first piece of legislation passed by the federal government that provided relief after a disaster.

Between 1803 and 1930, ad hoc legislation was passed more than 100 times for relief or compensation after a disaster. Examples include the waiving of duties and tariffs to the merchants of New York City after the Great Fire of New York (1835). After the collapse of the John T. Ford's Theater in June 1893, the 54th Congress passed legislation compensating those who were injured in the building.

Piecemeal approach (1930s–1960s)

After the start of the Great Depression in 1929, President Herbert Hoover had commissioned the Reconstruction Finance Corporation in 1932. The purpose of the RFC was to lend money to banks and institutions to stimulate economic activity. RFC was also responsible for dispensing federal dollars in the wake of a disaster. RFC can be considered the first organized federal disaster response agency. 

The Bureau of Public Roads in 1934 was given authority to finance the reconstruction of highways and roads after a disaster. The Flood Control Act of 1944 also gave the U.S. Army Corps of Engineers authority over flood control and irrigation projects and thus played a major role in disaster recovery from flooding.

Department of Housing and Urban Development (1973–1979)

Federal disaster relief and recovery was brought under the umbrella of the Department of Housing and Urban Development (HUD), in 1973 by Presidential Reorganization Plan No. 2 of 1973, and the Federal Disaster Assistance Administration was created as an organizational unit within the department. This agency would oversee disasters until its incorporation into FEMA in 1978.

Prior to implementation of Reorganization Plan No. 3 of 1978 by E.O. 12127 and E.O. 12148, many government agencies were still involved in disaster relief; in some cases, more than 100 separate agencies might be jockeying for control and jurisdiction of a disaster.

Over the years, Congress increasingly extended the range of covered categories for assistance, and several presidential executive orders did the same. By enacting these various forms of legislative direction, Congress established a category for annual budgetary amounts of assistance to victims of various types of hazards or disasters, it specified the qualifications, and then it established or delegated the responsibilities to various federal and non-federal agencies.

In time, this expanded array of agencies themselves underwent reorganization. One of the first such federal agencies was the Federal Civil Defense Administration, which operated within the Executive Office of the President. Functions to administer disaster relief were then given to the President himself, who delegated to the Housing and Home Finance Administration. Subsequently, a new office of the Office of Defense Mobilization was created. Then, the new Office of Defense and Civilian Mobilization, managed by the EOP; after that, the Office of Civil and Defense Mobilization, which renamed the former agency; then, the Office of Civil Defense, under the Department of Defense (DoD); the Department of Health, Education and Welfare (HEW); the Department of Agriculture; the Office of Emergency Planning (OEmP); the Defense Civil Preparedness Agency (replacing the OCD in the DoD); the Department of Housing and Urban Development (HUD) and the General Services Administration (GSA) (upon termination of the OEmP).

These actions demonstrated that, during those years, the nation's domestic preparedness was addressed by several disparate legislative actions, motivated by policy and budgetary earmarking, and not by a single, unifying, comprehensive strategy to meet the nation's needs over time. Then, in 1978 an effort was made to consolidate the several singular functions; FEMA was created to house civil defense and disaster preparedness under one roof. This was a very controversial decision.

FEMA as an independent agency (1979–2003)

The FEMA seal before 2003.

The FEMA flag before 2003.

FEMA was established under the 1978 Reorganization Plan No. 3, and activated April 1, 1979, by President Jimmy Carter in an Executive Order. 

In July, Carter signed Executive Order 12148 shifting disaster relief efforts to the new federal-level agency. FEMA absorbed the Federal Insurance Administration, the National Fire Prevention and Control Administration, the National Weather Service Community Preparedness Program, the Federal Preparedness Agency of the General Services Administration and the Federal Disaster Assistance Administration activities from HUD. FEMA was also given the responsibility for overseeing the nation's Civil Defense, a function which had previously been performed by the Department of Defense's Defense Civil Preparedness Agency.

One of the disasters FEMA responded to was the dumping of toxic waste into Love Canal in Niagara Falls, New York, in the late 1970s. FEMA also responded to the Three Mile Island nuclear accident where the nuclear-generating station suffered a partial core meltdown. These disasters, while showing the agency could function properly, also uncovered some inefficiencies.

In 1993, President Bill Clinton appointed James Lee Witt as FEMA Director. In 1996, the agency was elevated to cabinet rank. This was not continued by President George W. Bush. Witt initiated reforms that would help to streamline the disaster recovery and mitigation process. The end of the Cold War also allowed the agency's resources to be turned away from civil defense to natural disaster preparedness.

After FEMA's creation through reorganization and executive orders, Congress continued to expand FEMA's authority by assigning responsibilities to it. Those responsibilities include dam safety under the National Dam Safety Program Act; disaster assistance under the Stafford Disaster Relief and Emergency Assistance Act; earthquake hazards reduction under the Earthquake Hazards Reduction Act of 1977 and further expanded by Executive Order 12699, regarding safety requirements for federal buildings and Executive Order 12941, concerning the need for cost estimates to seismically retrofit federal buildings; emergency food and shelter under the Stewart B. McKinney Homeless Assistance Act of 1987; hazardous materials, under the Emergency Planning and Community Right-to-Know Act of 1986.

In addition, FEMA received authority for counterterrorism through the Nunn-Lugar-Domenici amendment under the Weapons of Mass Destruction Act of 1996, which was a response to the recognized vulnerabilities of the U.S. after the sarin gas attack on the Tokyo subway in 1995.

Congress funded FEMA through a combination of regular appropriations and emergency funding in response to events.

FEMA under Department of Homeland Security (2003–present)

President George W. Bush signs the Homeland Security Appropriations Act of 2004.

Following the September 11, 2001, attacks, Congress passed the Homeland Security Act of 2002, which created the Department of Homeland Security (DHS) to better coordinate among the different federal agencies that deal with law enforcement, disaster preparedness and recovery, border protection and civil defense. FEMA was absorbed into DHS effective March 1, 2003. As a result, FEMA became part of the Emergency Preparedness and Response Directorate of Department of Homeland Security, employing more than 2,600 full-time employees. It became the Federal Emergency Management Agency again on March 31, 2007, but remained in DHS. 

President Bush appointed Michael D. Brown as FEMA's director in January 2003. Brown warned in September 2003 that FEMA's absorption into DHS would make a mockery of FEMA's new motto, "A Nation Prepared", and would "fundamentally sever FEMA from its core functions", "shatter agency morale" and "break longstanding, effective and tested relationships with states and first responder stakeholders". The inevitable result of the reorganization of 2003, warned Brown, would be "an ineffective and uncoordinated response" to a terrorist attack or a natural disaster.

Hurricane Katrina in 2005 demonstrated that the vision of further unification of functions and another reorganization could not address the problems FEMA had previously faced. The "Final Report of the Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina", released February 15, 2006, by the U.S. Government Printing Office, revealed that federal funding to states for "all hazards" disaster preparedness needs was not awarded unless the local agencies made the purposes for the funding a "just terrorism" function. Emergency management professionals testified that funds for preparedness for natural hazards were given less priority than preparations for counter-terrorism measures. Testimony also expressed the opinion that the mission to mitigate vulnerability and prepare for natural hazard disasters before they occurred had been separated from disaster preparedness functions, making the nation more vulnerable to known hazards, like hurricanes.

In fall 2008, FEMA took over coordination of the Ready Campaign, the national public service advertising (PSA) campaign in collaboration with the Ad Council to educate and empower Americans to prepare for and respond to emergencies including natural and man-made disasters. The Ready Campaign and its Spanish language version Listo asks individuals to do three things: build an emergency supply kit, make a family emergency plan and be informed about the different types of emergencies that can occur and how to respond. The campaign messages have been promoted through television, radio, print, outdoor and web PSAs, as well as brochures, toll-free phone lines and the English and Spanish language websites.

Organization

During the debate of the Homeland Security Act of 2002, some called for FEMA to remain as an independent agency. Later, following the failed response to Hurricane Katrina, critics called for FEMA to be removed from the Department of Homeland Security. Today FEMA exists as a major agency of the Department of Homeland Security. The Administrator for Federal Emergency Management reports directly to the Secretary of Homeland Security. In March 2003, FEMA joined 22 other federal agencies, programs and offices in becoming the Department of Homeland Security. The new department, headed by Secretary Tom Ridge, brought a coordinated approach to national security from emergencies and disasters – both natural and man-made.

FEMA manages the National Flood Insurance Program. Other programs FEMA previously administered have since been internalized or shifted under direct DHS control.

FEMA is also home to the National Continuity Programs Directorate (formerly the Office of National Security Coordination). ONSC was responsible for developing, exercising, and validating agency-wide continuity of operations and continuity of government plans as well as overseeing and maintaining continuity readiness including the Mount Weather Emergency Operations Center. ONSC also coordinated the continuing efforts of other Federal Executive Agencies.

FEMA began administering the Center for Domestic Preparedness in 2007.

Budget

FEMA has an annual budget of $18 billion that is used and distributed in different states according to the emergencies that occur in each one. An annual list of the use of these funds is disclosed at the end of the year on FEMA's website.

Regions

• Regional map
  • Region I, Boston, MA – Serving CT, MA, ME, NH, RI, VT
  • Region II, New York, NY Serving NJ, NY, PR, USVI
  • Region III, Philadelphia, PA Serving DC, DE, MD, PA, VA, WV
  • Region IV, Atlanta, GA Serving AL, FL, GA, KY, MS, NC, SC, TN
  • Region V, Chicago, IL Serving IL, IN, MI, MN, OH, WI
  • Region VI, Denton, TX Serving AR, LA, NM, OK, TX
  • Region VII, Kansas City, MO Serving IA, KS, MO, NE
  • Region VIII, Denver, CO Serving CO, MT, ND, SD, UT, WY
  • Region IX, Oakland, CA Serving AZ, CA, HI, NV, GU, AS, CNMI, RMI, FM
  • Region IX, PAO Serving AS, CNMI, GU, HI
  • Region X, Bothell, WA Serving AK, ID, OR, WA

Pre-disaster mitigation programs

FEMA's Mitigation Directorate is responsible for programs that take action before a disaster, in order to identify risks and reduce injuries, loss of property, and recovery time. The agency has major analysis programs for floods, hurricanes and tropical storms, dams, and earthquakes.

FEMA works to ensure affordable flood insurance is available to homeowners in flood plains, through the National Flood Insurance Program, and also works to enforce no-build zones in known flood plains and relocate or elevate some at-risk structures.

Pre-Disaster Mitigation grants are available to acquire property for conversion to open space, retrofit existing buildings, construct tornado and storm shelters, manage vegetation for erosion and fire control, and small flood control projects.

The safe room construction plans and specifications from FEMA P-320, Taking Shelter From the Storm, are available in pdf format.

Response capabilities

FEMA's emergency response is based on small, decentralized teams trained in such areas as the National Disaster Medical System (NDMS), Urban Search and Rescue (USAR), Disaster Mortuary Operations Response Team (DMORT), Disaster Medical Assistance Team (DMAT), and Mobile Emergency Response Support (MERS).

National Response Coordination Center (NRCC)

FEMA's National Response Coordination Center (NRCC) is a multiagency center located at FEMA HQ that coordinates the overall Federal support for major disasters and emergencies, including catastrophic incidents in support of operations at the regional level. The FEMA Administrator, or his or her delegate, activates the NRCC in anticipation of, or in response to, an incident by activating the NRCC staff, which includes FEMA personnel, the appropriate Emergency Support Functions, and other appropriate personnel (including nongovernmental organization and private sector representatives). During the initial stages of a response, FEMA will, as part of the whole community, focus on projected, potential, or escalating critical incident activities. The NRCC coordinates with the affected region(s) and provides needed resources and policy guidance in support of incident-level operations. The NRCC staff specifically provides emergency management coordination, planning, resource deployment, and collects and disseminates incident information as it builds and maintains situational awareness—all at the national-level. FEMA maintains the NRCC as a functional component of the NOC for incident support operations.

An example of NRCC activity is the coordination of emergency management activities that took place in connection with the 2013 Colorado floods.

National Disaster Medical System (NDMS)

DMAT team deployed for Hurricane Ike in Texas

The National Disaster Medical System (NDMS) was transferred from the Department of Homeland Security to the Department of Health and Human Services, under the Pandemic and All-Hazards Preparedness Act, signed by President George W. Bush, on December 18, 2006. 

NDMS is made of teams that provide medical and allied care to disaster victims. These teams include doctors, nurses, pharmacists, etc., and are typically sponsored by hospitals, public safety agencies or private organizations. Also, Rapid Deployment Force (RDF) teams, composed of officers of the Commissioned Corps of the United States Public Health Service, were developed to assist with the NDMS. 

Disaster Medical Assistance Teams (DMAT) provide medical care at disasters and are typically made up of doctors and paramedics. There are also National Nursing Response Teams (NNRT), National Pharmacy Response Teams (NPRT) and Veterinary Medical Assistance Teams (VMAT). Disaster Mortuary Operational Response Teams (DMORT) provide mortuary and forensic services. National Medical Response Teams (NMRT) are equipped to decontaminate victims of chemical and biological agents.

Urban Search and Rescue (US&R)

The Urban Search and Rescue Task Forces perform rescue of victims from structural collapses, confined spaces, and other disasters, for example, mine collapses and earthquakes.

Mobile Emergency Response Support (MERS)

Presidential mobile phone alert for national emergencies.

FEMA vehicle provides communications support after a major hurricane.

These teams provide communications support to local public safety. For instance, they may operate a truck with satellite uplink, computers, telephone, and power generation at a staging area near a disaster so that the responders can communicate with the outside world. There are also Mobile Air Transportable Telecommunications System (MATTS) assets which can be airlifted in. Also, portable cell phone towers can be erected to allow local responders to access telephone systems.

The first test of the national wireless emergency system by FEMA was broadcast to an estimated 225 million electronic devices at 14:18 EDT on 3 October 2018. The text message was accompanied by a flashing warning sign and warning tone. The president may direct FEMA to broadcast such alerts only for national emergencies or if the public is in danger. The facility may not be used for personal messages from the president. Mobile phone owners can not opt out of these warnings.

Preparedness for nuclear incidents

On August 1, 2008, FEMA released "Planning Guidance for Protection and Recovery Following Radiological Dispersal Device (RDD) and Improvised Nuclear Device (IND) incidents", which provide an action guide in the case of radioactive contamination. This guidance is specified as action guide for Radiological Dispersal Devices (RDD) and Improvised Nuclear Devices (IND) involving high levels of radiation. According to the Federation of American Scientists, during the Cold War FEMA prepared assessments of the likely consequences of a full-scale Soviet nuclear attack on the United States for use in planning mitigation and recovery efforts. FEMA also prepared plans for evacuating major U.S. cities in response to a nuclear war, dubbed CRP-2B.

Training

FEMA offers a large number of training classes, either at its own centers, through programs at the state level, in cooperation with colleges and universities, or online. The latter are free classes available to anyone, although only those with U.S. residency or work eligibility can take the final examinations. More information is available on the FEMA website under the "Emergency Personnel" and "Training" subheadings. Other emergency response information for citizens is also available at its website. 

FEMA runs the Incident Workforce Academy, a two-week emergency preparedness training program for FEMA employees. The first class of the academy graduated in early 2014.

The Training and Education Division within FEMA's National Integration Center directly funds training for responders and provides guidance on training-related expenditures under FEMA's grant programs. Information on designing effective training for first responders is available from the Training and Education Division. Emergency managers and other interested members of the public can take independent study courses for certification at FEMA's online Emergency Management Institute.

Emergency Management Institute training and certifications

EMI offers credentials and training opportunities for United States Citizens. Note that students do not have to be employed by FEMA or be a federal employee for some of the programs. However, they do need to create a FEMA SID to take the final exams

EMI maintains a strategic partnerships with Frederick Community College. FCC has contracted with the Emergency Management Institute to provide college credit for the Independent Study Program (ISP). FCC offers eight specialized Letters of Recognition, an Undergraduate Certificate, and an Associate of Applied Science degree in Emergency Management.

FEMA Corps

FEMA Corps, who range in age from 18 to 24 years old, is a cadre dedicated to disaster response and recovery. It is a new partnership between The Corporation for National and Community Service's AmeriCorps NCCC and FEMA. The Corps described as a "dedicated, trained, and reliable disaster workforce" works full-time for 10 months on federal disaster response and recovery efforts. Over 150 members of the inaugural FEMA Corps class graduated in June 2013, at the AmeriCorps NCCC campus in Vicksburg, Mississippi. The Corps work on teams of 8 to 12 people and follow the traditional NCCC model of living together and traveling together. In addition to working with FEMA, corps members must perform AmeriCorps responsibilities such as Physical Training three times a week, National Days of Service, and Individual Service Projects in communities throughout the United States. The Corps receives $4.75 a day for food and a living stipend of approximately $4,000 over 10 months. An education award is distributed to corps members who successfully serve 10 months of service, completing 1,700 total hours.

FEMA Corps Pacific Region Blue Unit

Donations management

FEMA has led a Public-Private Partnership in creating a National Donations Management Program making it easier for corporations or individuals not previously engaged to make offers of free assistance to States and the Federal Government in times of disaster. The program is a partnership among FEMA, relief agencies, corporations/corporate associations and participating state governments. The technical backbone of the program is an online technology solution called The Aidmatrix Network which is managed by the independent nonprofit organization, Aidmatrix.

Criticisms

Hurricane Andrew – 1992

In August 1992, Hurricane Andrew struck the Florida and Louisiana coasts with 165 mph (265 km/h) sustained winds. FEMA was widely criticized for its response to Andrew, summed up by the famous exclamation, "Where in the hell is the cavalry on this one?" by Kate Hale, emergency management director for Dade County, Florida. FEMA and the federal government at large were accused of not responding fast enough to house, feed and sustain the approximately 250,000 people left homeless in the affected areas. Within five days the federal government and neighboring states had dispatched 20,000 National Guard and active duty troops to South Dade County to set up temporary housing. This event and FEMA's performance was reviewed by the National Academy of Public Administration in its February 1993 report "Coping With Catastrophe" which identified several basic paradigms in Emergency Management and FEMA administration that were causes of the failed response. 

FEMA had previously been criticized for its response to Hurricane Hugo, which hit South Carolina in September 1989, and many of the same issues that plagued the agency during Hurricane Andrew were also evident during the response to Hurricane Katrina in 2005. 

Additionally, upon incorporation into DHS, FEMA was legally dissolved and a new Emergency Preparedness and Response Directorate was established in DHS to replace it. Following enactment of the Post Katrina Emergency Management Reform Act of 2006 FEMA was reestablished as an entity within DHS, on March 31, 2007.

Southern Florida Hurricanes – 2004

South Florida newspaper Sun-Sentinel has an extensive list of documented criticisms of FEMA during the four hurricanes that hit the region in 2004. Some of the criticisms include:

• When Hurricane Frances hit South Florida on Labor Day weekend (over 100 miles north of Miami-Dade County), 9,800 Miami-Dade applicants were approved by FEMA for $21 million in storm claims for new furniture; clothes; thousands of new televisions, microwaves and refrigerators; cars; dental bills; and a funeral even though the Medical Examiner recorded no deaths from Frances. A U.S. Senate committee and the inspector general of the Department of Homeland Security found that FEMA inappropriately declared Miami-Dade county a disaster area and then awarded millions, often without verifying storm damage or a need for assistance.
• FEMA used hurricane aid money to pay funeral expenses for at least 203 Floridians whose deaths were not caused by the 2004 hurricanes, the state's coroners have concluded. Ten of the people whose funerals were paid for were not in Florida at the time of their deaths.

Hurricane Katrina – 2005

Evacuees taking shelter at the Astrodome in Houston, Texas

FEMA received intense criticism for its response to the Hurricane Katrina disaster in August 2005. FEMA had pre-positioned response personnel in the Gulf Coast region. However, many could not render direct assistance and were only able to report on the dire situation along the Gulf Coast, especially from New Orleans. Within three days, a large contingent of National Guard and active duty troops were deployed to the region. 

The enormous number of evacuees simply overwhelmed rescue personnel. The situation was compounded by flood waters in the city that hampered transportation and poor communication among the federal government, state, and local entities. FEMA was widely criticized for what is seen as a slow initial response to the disaster and an inability to effectively manage, care for, and move those who were trying to leave the city. 

Then-FEMA Director Michael D. Brown was criticized personally for a slow response and an apparent disconnection with the situation. Brown would eventually be relieved of command of the Katrina disaster and soon thereafter resigned. 

According to the U.S. House of Representatives Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina:

• "The Secretary Department of Homeland Security should have designated the Principal Federal Official on Saturday, two days prior to landfall, from the roster of PFOs who had successfully completed the required training, unlike then FEMA Director Michael Brown. Considerable confusion was caused by the Secretary's PFO decisions."
• "DHS and FEMA lacked adequate trained and experienced staff for the Katrina response."
• "The readiness of FEMA's national emergency response teams was inadequate and reduced the effectiveness of the federal response."
• "Long-standing weaknesses and the magnitude of the disaster overwhelmed FEMA's ability to provide emergency shelter and temporary housing."
• "FEMA logistics and contracting systems did not support a targeted, massive, and sustained provision of commodities."
• "Before Katrina, FEMA suffered from a lack of sufficiently trained procurement professionals."

A DMAT member assures a rescued man that the trip to the airport will be safe.

Other failings were also noted. The Committee devoted an entire section of the report to listing the actions of FEMA. Their conclusion was:

For years emergency management professionals have been warning that FEMA's preparedness has eroded. Many believe this erosion is a result of the separation of the preparedness function from FEMA, the drain of long-term professional staff along with their institutional knowledge and expertise, and the inadequate readiness of FEMA's national emergency response teams. The combination of these staffing, training, and organizational structures made FEMA's inadequate performance in the face of a disaster the size of Katrina all but inevitable.

Pursuant to a temporary restraining order issued by Hon. Stanwood R. Duval, United States District Court Judge, Eastern District of Louisiana as a result of the McWaters v. FEMA class-action, February 7, 2006 was set as the deadline for the official end of any further coverage of temporary housing costs for Katrina victims.

After the February 7 deadline, Katrina victims were left to their own devices either to find permanent housing for the long term or to continue in social welfare programs set up by other organizations. There were many Katrina evacuees living in temporary shelters or trailer parks set up by FEMA and other relief organizations in the first months after the disaster hit, but much more were still unable to find housing. 

In July 2007, ice that had been ordered for Katrina victims but had never been used and kept in storage facilities, at a cost of $12.5 million, was melted down.

In June 2008, a CNN investigation found that FEMA gave away about $85 million in household goods meant for Hurricane Katrina victims to 16 other states.

Buffalo snowstorm – 2006

FEMA came under attack for their response to the October Surprise Storm on October 13, 2006, in Buffalo, New York. As FEMA legally cannot interfere with state business unless asked, FEMA responded that as per procedure, the Governor of the state of New York had not asked for FEMA's assistance. FEMA Headquarters had been in constant contact with State congressional offices providing them with the latest information available. Claims state that FEMA officials did not arrive until October 16, three days after the storm hit. The snowstorm damage by this time included downed power wires, downed trees, and structural damage to homes and businesses.

Dumas, Arkansas, tornadoes – 2007

Many people of Dumas, Arkansas, especially victims of February 24, 2007 tornadoes, criticized FEMA's response in not supplying the number of new trailers they needed, and only sending a set of used trailers, lower than the needed quantity. Following the storm, U.S Senator Mark Pryor had criticized FEMA's response to the recovery and cleanup efforts.

California wildfires – 2007

FEMA came under intense criticism when it was revealed that a press conference on the October 2007 California wildfires was staged. Deputy Administrator Harvey E. Johnson was answering questions from FEMA employees who were posing as reporters. Many of these questions were "softball" questions (i.e., "Are you happy with FEMA's response so far?"), intentionally asked in a way that would evoke a positive response giving the impression that FEMA was doing everything right. In this way, any scrutiny from real reporters (many of whom were only given a 15-minute notice) would have been avoided. Fox News, MSNBC, and other media outlets aired the staged press briefing live. Real reporters were notified only 15 minutes in advance and were only able to call into a conference line, which was set to "listen-only" mode. The only people there were primarily FEMA public affairs employees.

Hurricane Maria – 2017

In September 2017, Hurricane Maria struck Dominica and Puerto Rico with 175 mph (280 km/h) sustained winds. Maria was the fifth-strongest storm to ever strike the United States with stronger winds than those brought by Irma and similar rain brought to Houston by Hurricane Harvey. Despite FEMA's preemptive efforts in Puerto Rico, the island was still devastated beyond expectation. The agency had prepared some provisions for displaced residents before the storm struck, including: roughly 124 FEMA staff members being positioned on the island, food, water, and bedding. However, people reported the FEMA food packages were unhealthy snacks such as the confectionery Skittles. FEMA was widely criticized for its response to Maria, as the island quickly fell into a humanitarian crisis.

The island also experienced a massive loss of power as a result of flood and wind damage sustained during Maria. In the beginning of October 2017, Lieutenant General Todd Semonite, chief and commanding general of the United States Army Corps of Engineers, explained the extent of and necessity of aid for this power crisis. Semonite described some specifics of the outage to reporters, explaining that the island requires "2,700 megawatts of electricity to operate and at last count had 376 megawatts available." This translates to about 14 percent of the grid being functional.

FEMA Administrator William "Brock" Long told reporters in a briefing following the storm that Puerto Rico politics had hindered the ability of the federal government to send aid. He explained that political divisions had prevented unity for leaders in this time of crisis, describing that their issue was "even worse" than the mainland United States' issue between Democrats and Republicans. Residents, in some cases, were required to fill out paperwork in English rather than Spanish with little to no hope of receiving the aid they had requested.

Brigadier General Jose Reyes of the Puerto Rico National Guard discussed a strategy to quicken the arrival of resources via the Port of Ponce, located on the southern coast of Puerto Rico. Reyes also attributed the delay in these services to the unprecedented series of storms that demanded attention from the agency within a short period of time. Regarding this, General Reyes told reporters " We were not even getting back on our feet after Irma, then suddenly we got hit by Maria." He also addressed the disparities between aid sent to mainland disaster stricken areas and Puerto Rico, explaining that in areas such as Florida and Texas, who had recently struck with similar damages, transportation of resources is relatively simpler. This is because they are able to utilize infrastructure to transport aid. Transporting similar resources to Puerto Rico has proved to be more difficult, as they must travel across the ocean, either in aircraft or in ships. Long also mentioned that Puerto Rico's international airport was not able to operate at full capacity, which posed an additional obstacle for federal aid imports.

Hurricane Harvey – 2017

Hurricane Harvey made landfall in late August 2017, as a Category 4 Hurricane. The Hurricane predominantly affected southeast Texas; however, its effects were felt as far as Arkansas, Kentucky, and Tennessee in the form of flash flooding. Harvey slowly progressed around southeast Texas, where it produced heavy precipitation over the region. This caused heavy flooding in residential areas such as Colorado City, Liberty, and Montgomery, Texas.

Harvey was the first of a series of hurricanes and tropical storms to affect the United States between August and September 2017. The effects of these storms included extreme flooding, damage from high speed winds, structural damage, and humanitarian concerns regarding the availability of basic necessities such as food, water, and shelter.

Some recipients were forced to wait up to two months before receiving aid from FEMA, as technical complications held up both their application for it and the processing of said applications. Some residents were denied Federal Aid and have to dispute their denial in efforts to rebuild and repair properties without taking a considerably large financial loss.

Federalism and FEMA

The costs of a disaster to states and localities can pile up quickly. Federal assistance becomes fully available with the approval of the President and at the request of the governor. Public help for governments to repair facilities is 75% federally funded with local governments responsible for covering the rest (unless the state grants aid or loans). FEMA does not compensate for buildings that have been improperly maintained by the state or local government nor does it pay to upgrade or improve facilities. FEMA coordinates but does not fund disaster assistance provided by the Small Business Administration or the Farmers Home Administration. FEMA grant-in aid funds come from revenue sharing, the Department of Housing and Urban Development and the Department of Transportation. Grants for disaster preparedness can be used by flood control districts.

Many states have disaster relief agencies of their own. In the event of a disaster outside of a state's operating capacity, the director of said agency will advise the Governor whether or not to proclaim a state of emergency. Declaring a state of emergency, upon Presidential approval, entitles a state to federal assistance. It is important to note that proclaiming a state of emergency does not guarantee federal assistance. States also rely on mutual aid agreements, such as the Civil Defense and Disaster Compact. A mutual aid agreement can be between neighboring states, cities, counties and cities, states and cities or an entire region. These agreements allow agencies to share resources so they are better prepared for emergencies.

Local governments have the most immediate responsibility. Four factors shape local disaster response:

1. the extent of tax base depletion
2. the scope of lost sales tax revenue
3. access to other forms of revenue
4. amount of city debt

Having a mostly intact tax base allows local governments to maintain steady revenue stream. Business unharmed by a disaster will be able to continue to generate sales tax revenue. Cities with access to large revenue reserves and strong mutual aid agreements will have greater response capacity. While cities with large municipal debt that would be unable to pay back state or federal loans would be in a difficult situation.

U.S. v. Parish of Jefferson et al

This case gave FEMA the right to sue in order to recover funds paid out in flood insurance claims for flood damage as a result of poor decisions by local officials and developers. The case also gave FEMA the power to sue localities who fail to meet flood plain management requirements.