n response to hurricanes Katrina and Rita, the American people showed their generosity, philanthropy and personal commitment to those in need on an unprecedented scale. Thousands of volunteers flocked to the affected areas to lend assistance. News coverage highlighted the disaster zones, the government response and the successful rescues. There was criticism of the failures of our system, the bureaucracy and its impediments, and the occasional story of heroism — but the efforts put forth by so many in other parts of the country received little coverage.

There were many silent heroes. Displaced residents were housed with family members, at second homes, in college dorms with students and in church facilities. On their way from New Orleans to Birmingham, my brother’s family spent the night in a Montgomery hotel. The next morning at checkout, the desk clerk said an anonymous man wanting to help those in need paid the hotel bills of all guests from Louisiana and Mississippi. There are countless examples of volunteers such as these.

For health care workers, volunteering also begins at home. We have seen many wonderful examples of medical volunteers sent to disaster zones in the form of Disaster Medical Assistance Teams (DMATs) or simply volunteers flocking to the scene to lend a hand. These first-responders provided initial needed care for many patients. A concerted effort, though, in all parts of the country enabled delivery of health care services to thousands of displaced and evacuated patients as a part of the National Disaster Medical System (NDMS). Formed by presidential order in 1983, its stated goal is to deliver quality health care services to victims of military conflict and domestic disasters. NDMS is a partnership between the departments of Veterans Affairs, Health and Human Services, Defense, the Federal Emergency Management Agency (FEMA) and hundreds of hospitals, health systems and state health departments across the country. The three components of the NDMS are: 1) medical response to a disaster area in the form of teams, supplies and equipment; 2) patient movement from a disaster site to unaffected areas of the nation; and 3) definitive medical care at participating hospitals in unaffected areas. DMATs and first-responders are responsible for initial treatment and triage.

If a disaster requires evacuation of casualties or patients from health care facilities in the disaster area, FEMA activates Federal Coordinating Centers (FCCs) located in major metropolitan centers surrounding the disaster area. Participating hospitals report beds available to receive transfers, and local FCC directors implement a plan for acceptance, immediate treatment and triage, transport and assignment of patients to local hospitals. The Department of Defense (DOD) is responsible for transport of patients using the DOD Aeromedical Evacuation System. The Global Patient Movement Requirements Center (GPMRC) at Scott Air Force Base in Illinois dispenses an Immediate Response Assessment Team (IRAT). The IRAT coordinates patient movement to various FCCs. Patients are transported from the airport closest to the disaster site via C-130 or C-141 aircraft. Transport of patients to the airport at the disaster site is the responsibility of state and local governments. When patients arrive at FCC areas, they are dispersed to local participating hospitals. All medical care provided is reimbursed through the Medicare program.

When the system was activated, an enormous and coordinated volunteer activity began. In Birmingham, all participating hospitals, emergency personnel and patient transport services were notified. Our FCC director at the Birmingham VA Medical Center and the director of the Birmingham Regional Emergency Medical System coordinated the activation. Each participating hospital identified the number of hospital and critical care beds available to accept transfers. At UAB we initiated our hospital disaster plan, identified patients of less acuity that could be transferred to other local hospitals to make room for critically ill patients, and developed a schedule of volunteer faculty physicians, residents and nurses to staff a triage center at the Birmingham airport. We organized a system to evaluate and triage patients in our emergency department and increased staffing in critical care units. More than 100 people staffed a triage center set up in an aircraft hangar at the Birmingham Air National Guard base on an eight-hour shift basis. Ambulances and UAB Critical Care Transport vehicles were dispatched to the airport to await landing military aircraft. After arrival patients received an initial evaluation and were triaged to the appropriate Birmingham facility for the level of care anticipated in an equitable fashion.

The system worked quite well for both hurricane events with only a few glitches. Physicians, nurses and other medical personnel from all over the city readily volunteered for long hours at the airport, emergency department, intensive care units and the operating rooms. For Katrina, 2,749 patients were moved through the system in the southern states [Table 1]. Birmingham received 159 patients during Katrina in three missions. There was a larger coordinated response for Rita, but fewer patient transports were necessary. Our greatest problem was a sparsity of accurate medical records. Some patients arrived without any identification or records, which delayed appropriate management. During the Hurricane Rita evacuation, we received a group of nursing home residents with namebands only. Each patient required a greater evaluation and investigation that consumed more resources than necessary. A simple working diagnosis and medication list would have been helpful.

The personal stories were chilling. One of my patients described being trapped in the attic of his home while the water level rapidly rose. He was able to chop a hole in the roof using a hand ax, allowing his escape. He was so appreciative of the help received from everyone, including the police in the rescue boat, DMAT doctors, military transport personnel and finally for the medical treatment received in Birmingham.

In retrospect it was impressive to see the outpouring of support and volunteerism for both of these disasters. Local responses, like that in Birmingham, were duplicated all over this country. We can all help in such situations. The rewards are beyond words.

Arthur M. Boudreaux, M.D., is Professor and Vice Chair for Clinical Affairs and Associate Chief of Staff, University of Alabama School of Medicine, Birmingham, Alabama.