uring last year's Hurricane Katrina disaster in the Gulf States, there was an outpouring of both personal and financial support for the victims. Physicians also wanted to help and, in many cases, tried to find a method to volunteer their services in the area. In fact, more than 3,500 physicians signed up through the Internet with the U.S. Department of Health and Human Services (HHS) as available for immediate deployment. Few of these volunteers were actually used. Many individual physicians simply went to the Gulf and pitched into the chaos with varying results. Most physicians, however, found that their desire to lend their medical skills could not be fulfilled. Many physicians who wanted to help were very frustrated at their inability to do so.

A number of volunteer civilian physicians and other health care providers were, in fact, deployed under federal auspices within two days of the disaster and served under very harrowing, dangerous and frustrating (yet gratifying) conditions. How did this happen?
Because of this disaster, the federal government and state governments now realize that it is vitally important to have a group of precredentialed and trained health care professionals available in case of a future emergency. Much attention is being paid to the possibility of a flu pandemic and the need for surge capacity of hospital beds, drugs, supplies and, most importantly, health care providers.

The question this article will answer is: How can physicians and other health care providers become preregistered, precredentialed and pretrained to respond to a future disaster or community emergency? How can they fit into a plan to provide surge capacity to augment local health care facilities that have been overwhelmed by patients?

Fitting Into a Plan for Future Disasters
The first fact to understand is that emergency agencies usually do not want individual, unsolicited and uncredentialed physicians to just show up for work. Physicians who try this are usually sent home. If they do actually work, they are subjecting themselves to extreme liability risk since they are usually not covered by one of the federal liability protection programs. Also, since they are not usually credentialed to practice medicine in other states, they are sometimes actually violating state law if they do practice without a license. Good Samaritan laws covering medical volunteers vary widely from state to state and cannot be counted on to protect an individual physician from liability. Organized federally credentialed groups are working as federal agents or employees and are exempt from these problems under the Federal Tort Claims Act. Having said this, there were many individual physicians who managed to contribute their skills under very difficult circumstances in the Katrina disaster.

The American College of Emergency Physicians and the National Association of EMS Physicians have published a “Policy on Unsolicited Medical Volunteers”¹ which states that an organized approach is needed for all medical volunteers in a disaster [Table 1, page 25]. They advise that medical personnel should not respond to an emergency unless officially requested by the jurisdiction’s emergency medical services agency.

The federal government divides the responsibility for various medically related areas in major disasters and emergencies among at least seven different agencies¹ [Table 2]. All of these agencies participated in various ways during the Katrina disaster. Physician volunteers were recruited under HHS and the Department of Homeland Security (DHS), Division of Emergency Preparedness and Response [Federal Emergency Management Agency (FEMA)]. Some Veterans Administration hospitals also were tasked to contribute medical volunteers to the effort.

Some medical volunteers were asked to deploy to the Gulf area with the Red Cross. Reports from some physicians were that they were not allowed to use their medical skills in shelters because of Red Cross liability concerns.

Methods for Civilian Physicians to Volunteer
It turns out that there are several effective methods for civilian physicians to volunteer their skills to join an organized group of physicians and other health care workers in case of a major national disaster. Much of the content below has been obtained from public Web sites. The Web sites are listed for the convenience of the reader.

There are varying levels of commitment and effort for volunteers. The four methods are listed in order of increasing commitment, effort and time commitment.

1. Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) Plan
The ESAR-VHP program is a national mandate funded by the federal Health Resources and Services Administration (HRSA).² It provides multiyear grants to states for bioterrorism preparedness. The program is on a “fast track” since federal funding ends August 2007. Most states are planning to complete registrations before 2007.

The grant mandate is to develop a system that provides for the advanced registration and credentialing of clinicians in order to augment a hospital or other medical facility and thereby meet the increased patient/victim care needs during a declared emergency. The program hopes to capture, in advance, the historically large stream of health care personnel who wish to volunteer their expertise during a disaster or emergency.

ESAR-VHP plans to enroll the following professionals: M.D., D.O., R.N., N.P., D.D.S., pharmacists, paramedics, respiratory care and behavioral health. All volunteers must have an active, unencumbered license.

Although this program is the least formal of all the programs, it does plan to determine how the ESAR-VHP volunteers will be integrated, insured, trained, housed, supervised and managed during the emergency incident.

Physicians and other health care providers should expect to receive information soon about volunteering for this program. Since there is really no formal time commitment incurred by signing up, it is probably a good idea to do so since it will give you the opportunity to help in case of a future disaster or emergency.

2. Medical Reserve Corps (MRC)
The second method concerns joining a Medical Reserve Corps (MRC).³ There are currently more than 300 MRCs in the United States. Your closest one can be located on the MRC Web site.³

An MRC is a community-based network of volunteers that assists public health efforts in times of special need or disaster, e.g., during a major communicable disease outbreak, an earthquake, flood or an act of terrorism. Members of an MRC also may volunteer their time throughout the year in order to promote community public health and education.

The MRC program office is headquartered in the Office of the Surgeon General. It functions as a clearinghouse for information and best practices to help communities establish, implement and maintain MRC units across the nation. The MRC program office sponsors an annual leadership conference, hosts a Web site and coordinates with local, state, regional and national organizations and agencies to help communities achieve their local visions for public health and emergency preparedness.

MRCs bring volunteers together to supplement existing local emergency plans and resources. In order to be effective during times of emergency, volunteers must be organized and trained to work in emergency situations. The MRC is designed to provide that organizational structure and to promote appropriate training of volunteers according to local community needs and vulnerabilities.

Any variety of individuals depending on community need may comprise MRCs. Volunteers may include, but are not limited to, current or retired health professionals (such as physicians, nurses, mental health professionals, dentists, dental assistants, pharmacists and veterinarians), social workers, communications/public relations professionals, health care administrators, clergy, etc. Each MRC can customize its membership to fit community needs.

MRC volunteers can choose to support communities in need nationwide. When the Southeast was battered by hurricanes in 2004, MRC volunteers in the affected areas and beyond helped communities by filling in at local hospitals, assisting their neighbors at local shelters and providing first-aid to those injured by the storms. Over this two-month period, more than 30 MRC units worked as part of the relief efforts, including those whose volunteers were called in from across the country to assist the American Red Cross and FEMA. MRCs also are tied into most states’ emergency medical services authority and can be activated by either state or county EMS agencies as well as by the federal government. All deployments are voluntary.

3. Disaster Medical Assistance Team (DMAT)
The next and most organized method is the DMAT.⁴ Many of these units were, in fact, immediately deployed to the Katrina disaster under HHS/FEMA.

As an example, the San Francisco Bay Area DMAT (CA-6)⁵ was mobilized within two hours of the disaster and deployed a 35-member team directly to New Orleans by air within eight hours. Support supplies were moved by ground transport. The team, however, simply relieved another DMAT and used their prepositioned supplies. The San Francisco DMAT took more than a half million dollars worth of supplies and equipment to the disaster, including a complete tented field hospital.

The DMAT program is a federal program under the National Disaster Medical System (NDMS)⁶ that organizes and pretrains medical and paramedical volunteers. Nationally there are currently more than 29 deployable teams, each with 50 to 150 civilian volunteers⁷ [Table 3]. Deployed teams usually consist of 35 medical and paramedical professionals and support personnel.

NDMS, under the Department of Homeland Security, fosters the development of DMATs. A DMAT is a group of professional and paraprofessional medical personnel (supported by a cadre of logistical and administrative staff) designed to provide emergency medical care during a disaster or other event.

Each team has a sponsoring and funding organization such as a major medical center, public health or safety agency, nonprofit, public or private organization. The DMAT sponsor organizes the team and recruits members, arranges training and coordinates the dispatch of the team.

In addition to the standard DMATs, there are highly specialized DMATs that deal with specific medical conditions such as crush injuries, burns and mental health emergencies. Other specialty teams include Disaster Mortuary Operational Response Teams that provide mortuary services, Veterinary Medical Assistance Teams that provide veterinary services and National Medical Response Teams that are equipped and trained to provide medical care for victims of weapons of mass destruction.

DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site. In mass casualty incidents, their responsibilities include triaging patients, providing austere medical care and preparing patients for evacuation. In other types of situations, DMATs may provide primary health care and/or may serve to augment overloaded local health care staffs. Under the rare circumstance that disaster victims are evacuated to a different locale to receive definitive medical care, DMATs may be activated to support patient reception and disposition of patients to hospitals.

DMATs are designed to be a rapid-response element to supplement local medical care until other federal or contract resources can be mobilized or the situation is resolved.

DMAT members are required to maintain appropriate certifications and licensure within their discipline. When members are activated as federal employees, licensure and certification are recognized by all states. Additionally DMAT members are paid while serving as part-time federal employees and have the protection of the Federal Tort Claims Act in which the federal government becomes the defendant in the event of a malpractice claim.

DMAT teams are expected to be deployable within 12 hours and wear insignia and military-style uniforms while deployed. An individual is expected to complete extensive, free online and field training before being qualified for deployment. There are immunization, training and meeting attendance requirements to maintain membership. Meetings of DMATs are held regularly with some overnight or multiday field exercises.

DMATs need more physicians. In order to join, simply find the unit closest to you and contact the unit commander. In order to be qualified for temporary federal service, it is necessary to complete extensive federal application forms. The application process takes from one to four months to go through the various federal approvals. In the meantime, the new member can take the required online training and participate fully with the unit with the exception of federal deployment.

It is important to stress that DMATs are civilian, volunteer organizations. All deployments and participation are fully voluntary.

Conclusion
It is interesting that FEMA, in August 2001, predicted the three most likely catastrophes that might hit the United States. First was a terrorist attack in New York City, second was a full-strength hurricane hitting New Orleans and third was a major earthquake in California along the San Andreas fault. Two of these predictions have already come true — is California next?

Will our communities be stressed by a flu pandemic? If so, health care facilities will be overwhelmed and will need help from a volunteer group of health care providers.

Since it appears that the United States will continue to face major natural and manmade disasters in the future, it is important for a flexible disaster medical response system to be available for immediate activation and deployment. Most physicians are willing and perhaps even enthusiastic about being involved in these efforts. It is important for the medical community to understand that a preorganized and formal structure will allow a more expeditious and effective response than individual efforts. A pool of trained and organized physician volunteers are needed for future disasters.

Individuals can, and probably will, be registered and participate in multiple volunteer organizations. For example an individual could be registered in the ESAR-VHP program, be a member of a local MRC and a member of a Federal deployable DMAT.

If there is no DMAT unit or MRC in your area, it is possible for individuals or organizations to organize one of these units. Both the DMAT⁶ and MRC³ Web sites have extensive information available on how to join, organize and run one of these organizations.


References:
1. Medical Reserve Corps Technical Assistance Series, Coordinating with Your Local Response Partners, page 6. Web Document: <www.medicalreservecorps.gov/page.cfm?pageID=77>.
2. Technical White Paper on ESAR-VHP program, Health Resources and Services Administration, U.S. Department of Health and Human Services, <www.hrsa.gov/bioterrorism/esarvhp>.
3. Medical Reserve Corps Web site: <www.medicalreservecorps.gov>.
4. Disaster Medical Assistance Team Web site: <www.oep-ndms.dhhs.gov/dmat.html>.
5. California DMAT CA-6 Web site: <www.dmatca6.org>.
6. National Disaster Medical System Web site: <www.oep-ndms.dhhs.gov>.
7. DMAT Team Sites Web site: <www.oep-ndms.dhhs.gov/team_sites.html>.

J. Kent Garman, M.D., M.S., is Associate Professor of Anesthesia, Stanford University School of Medicine, and President, Stanford University Hospital Medical Staff, Stanford, California. He is a member of the San Francisco Bay Area Disaster Medical Assistance Team (DMAT CA-6) and the Director of the San Mateo County Coastside Medical Reserve Corps.