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Disaster medical assistance teams: A key role
EDITORIALS
holding treatment from patients who were previously in good health. 11 Moreover, most prudent physicians would instinctively recognize, as Dr Iserson does not, that there are real legal risk(s) in the Arizona system that would be difficult to overstate or "'overplay." Litigation has already resulted from analogous and far less dangerous activities including both claims for civil rights violation and EMS negligence, t2,z3 One may rightly ask. exactly what "valuable public services" are being withheld from the public to justify the care and feeding of this monstrous statute? Conspicuous for its absence from Dr Iserson's article are the supporting data and underlying intellectual and scientific foundation on which to justify so radical a departure from prevailing medical, ethical, and legal standards. Surprisingly, he does not discuss many of the major l~ublications and authorities in this area. t4-18 Moreover. the one authoritative study he cites does not seem to support his assessment of the problem or its solution. Indeed. Dr Sachs' nationwide study found widespread interest in developing prehospital DNR policies, that most existing DNR policies were "'practical and adequate for local EMS directors needs" and that "living wills are iflappropriate for communicating DNR status." While calling for an urgentlyneeded legal review. Dr Sachs' study concluded that "prehospital DNR policies can be implemented on the state and local levels, even without enabling legislation." Thus. there would appear to be no compelling medical, legal, or ethical need for Arizona's radical approach. Ironically, certain of Arizona's circumstances may be demographically unique. In Arizona. there are two major metropolitan areas that can and do function much as other major metropolitan EMS systems do throughout the country. These systems previously have been analvzed in detail by well-trained and respected emergency physicians.t9 They have seemed to operate very efficiently w i t h n o published indication of any of the serious problems described by Dr Iserson. We do from time to time attempt to resuscitate truly terminally ill patients or those who may in good faith have executed otherwise valid advance care directives. This is a situation we would like to avoid: however, the Arizona statute does not seem to be the answer. If a specific problem now exists with overutilization or prolonged response time to hospitals from certain rural areas in Arizona, such a problem may best be addressed directly by members of the local or state medical and/or EMS community who are most familiar with that particular problem and its solution. Neither isolated problems of rural Arizona providers caused by disparate geography nor anything in Dr Is'erson's article supports the leap in logic necessary to embrace the Arizona approach. Far
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from serving as a"model" for others, the Arizona statute is a monument only to confused and incomplete thinking. Good intentions in Arizona have created a medical, ethical, and legal design for disaster. R JackAyres, Jr, JD, REMT-P EmergencyLegal Assistance Program Parkland Memorial Hospital University of Texas Southwestern Medical Center at Dallas 1. Vol 36, Arizona Revised Civil Statutes, Chapter 32: Living Wills and Health Care Directions (1992). 2. Hastings Center: Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, A Report by the Hastings Center. New York, The Hastings Center, 1987:48. 3. American Heart Association: Standards and guidelines for cardiopuimonary resuscitation and emergency cardiac care. JAMA 1986;255:2841. 4. American Heart Association: Textbook of Advanced Cardiac Life Support, ed 2. Dallas, AHA, 1990. 5. American College of Emergency Physicians: Position Summaries, 1990. Dallas, ACEP, 1990, p 11. 6. American College of Emergency Physicians: 6uidelines for "do not resuscitate" orders in the prehospital setting. Ann Emerg Med 1988;17:1106-1108. 7. American Academy of Orthopaedic Surgeons: YourFirst Response in Emergency Care. Chicago, AAOS, 1990, p 16, 17, 57. 8. Crimmons TJ: Ethical issues in adult resuscitation. Ann Emerg Med 1993;22:495,501. 9. Landwirth J: Ethical issues in pediatric and neonatal resuscitation. Ann Emerg Med 1993;22:502-507. 10. Values in Conflict: Resolving Ethical Issues in Hospital Care. Report of the Special Committee on Biomedical Ethics. American Hospital Association, 1985, p 19. 11. Sachs GA: Limiting resuscitation: Emerging policy in the emergency medical system. Ann Intern Med 1991;114:151-154. 12. Kranson v Valley Crest Nursing Home,755 F2d 46 (3rd Cir 1985), 13. Ayres RJ: Current controversies in prehospital resuscitation of the terminally ill patient. Prehosp Disaster Med 1990;5:49-58. 14. Siner DA: Advance directives in emergency medicine: Medical, legal, and ethical implications. Ann Emerg Med 1989;18:1364-1369. 15. Eisenberg MS: Termination of CPR in the prehospital arena. Ann Emerg Med 1985;14:1106-1107. 16. Gray WA: Unsuccessful emergency medical resuscitation--Are continued efforts in the emergency department justified? NEnglJ Med1991;325:1393-1398. 17. Weaver WD: Resuscitation outside the hospital--What's lacking? N Engl J Med 1991;325:1437-1439. 18. Koenig KK: Do-not-resuscitate orders, where are they in the prehospital setting? Prehosp Oisaster Med 1993;8:51-54. 19. Valenzuela TD, Criss EA: Cost-effectiveness analysis of paramedic emergency services in the treatment of prehospital cardiopulmonary arrest. Ann Emerg Med 1990;19:1407-1412.
Disaster Medical Assistance Teams: A Key Role See related article, p 1721. Alson et al, authors of "Analysis of Medical Treatment at a Field Hospital Following Hurricane Andrew, 1992," in this issue of Annals, depict a natural disaster that had an effect on the lives of nearly a quarter of a million people and resulted in requests for more than $7.2 billion in disaster relief. The response subsequently mounted by the federal government was the largest disaster response in the history of our country, with more than 34,000 National Guard and secular military persons and 18,000 organized volunteers. Tens of
ANNALS OF EMERGENCY MEDICINE
22:11
NOVEMBER 1993
EDITORIALS
thousands of other individuals and volunteer groups also responded. In fact, the latest version of the plan had been distributed only three to four weeks before the hurricane struck southern Florida. Under the Robert T Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288 (The Stafford Act--1988), the President is authorized to direct federal agencies to provide emergency assistance to save lives and protect property, public health, and safety in emergencies. The Federal Response Plan is the actual operational document for this implementation. The plan uses a problem-oriented or "functional" approach to identify the types of federal assistance that a state(s) is most likely to need. There are 12 of these emergency support functions. Each emergency support function has an assigned lead agency with primary responsibility to carry out that function. The 12 emergency support functions with their lead agencies are transportation, Department of Transportation; communications, National Communication System; public works/ engineering, US Army Corp of Engineers; firefighting, Department of Agriculture; information/planning, Federal Emergency Management Agency; mass care, American Red Cross; resource support, General Services Administration; health and medical services, Department of Health and Human Services; urban search and rescue, Department of Defense; hazardous material, Environmental Protection Agency; food, Department of Agriculture; and energy, Department of Energy, The authors successfully identify the benefit of rapid assessment in response to a disaster of this magnitude. When so many lives are at stake, this is the least useful time for dealing with political struggles within a state and between states and the federal government. A predetermined agreement as to what should occur in a speedy fashion should be in existence before any catastrophic event. The Department of Health and Human Services through the Centers for Disease Control and Prevention has been identified as the agency that will concern itself with the initial assessment and health and medical response following a disaster. Although there had been much criticism of slow response efforts, activities actually began before the storm hit. The National Disaster Medical System had sent several members of their assessment team to Florida to begin liaison efforts in anticipation of the disaster. The authors correctly identified the importance of strong logistical support for disaster medical assistance teams as they function in austere conditions. Delivery of health care, whether routine or sophisticated, in a hospital setting is a normal process that tens of thousands of physicians and nurses practice daily. The
NOVEMBER1993
22:11
ANNALSOFEMER6ENCYMEBICINE
attempt to deliver equivalent highrquality medical services in an environment in which there are minimal, if any, resources poses an incredible challenge. We take for granted the tremendous effort by hospital administrators to support these efforts. Certain individuals on each disaster medical assistance team must be dedicated to focus solely on provision of food, water, shelter. energy needs, and resupply for the team itself and are crucial for the successful completion of these teams' mission. Being self-sufficient in all of the above areas for at least 72 hours is absolutely essential as these teams enter the disaster area. The authors also note that the type of health care delivered by the disaster medical assistance teams in southern Florida following the hurricane was of a more routine nature. This has been the experience of disaster medical assistance relief teams following three hurricanes--Hugo in 1989, Andrew in 1992, and Iniki in 1991.1 The types of health care needs in all three responses were remarkably similar. The hurricanes affected health care for the local populations only indirectlY. The infrastructures for delivery of health care, however, were affected to the extent that individuals not only were unable to receive routine primary care or inpatient tertiary care. but could not even fill a prescription at a pharmacy. Much of the teams' activity, therefore, was to provide these types of services while the local health care system became functional. There are, however, specific epidemiological characteristics associated with each type of natural and manmade disaster. For example, Sklar 2 described the types of injuries sustained following various natural and manmade disasters and showed that they are very different than those following hurricanes. Therefore. disaster medical assistance teams should be prepared adequately for emergency and routine patient care--underscoring the necessity for emergency physicians to play a leadership role in this system. I believe that the authors successfully have described what will become a routine response on the part of the United States for domestic disasters. Their article also underscores the powerful impact of a joint venture between government agencms, officials, and the civilian sector. Disaster medical assistance teams are all-volunteer civilian health care, administrative, and logistic support personnel. These individuals function daily in the civilian world and are called on during emergencies to respond to community needs in distant areas of the country during times of overwhelming need. Developing a productive and effective response using individuals from the civilian sector in concert with the assets of the federal government sector has never been so dramatically effective with this type of response. The futures of the National Disaster Medical System and disaster medical
1751
121
EDITORIALS
assistance teams currently are being studied. To what extent the system and these teams will evolve and participate in future responses is open to question. I hope that reason and not politics will prevail, and that these disaster medical assistance teams will not only continue but expand to respond to international needs as these types of events strike the populations of foreign countries. PaulBRoth, MD, FAAFP,FACEP Universityof New Mexico Medical Center Albuquerque 1. Levy LJ, Toulamin LM: Improving Disaster Planning and Response Efforts: Lessons From Hurricanes,4ndrew and Iniki. New York, Boa>Allan and Hamilton, I nc, 1993. 2. Sklar [3: Disaster planning and organization: Casualty patterns in disasters. JW,4EDM 1987;3:49-51.
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holding treatment from patients who were previously in good health. 11 Moreover, most prudent physicians would instinctively recognize, as Dr Iserson does not, that there are real legal risk(s) in the Arizona system that would be difficult to overstate or "'overplay." Litigation has already resulted from analogous and far less dangerous activities including both claims for civil rights violation and EMS negligence, t2,z3 One may rightly ask. exactly what "valuable public services" are being withheld from the public to justify the care and feeding of this monstrous statute? Conspicuous for its absence from Dr Iserson's article are the supporting data and underlying intellectual and scientific foundation on which to justify so radical a departure from prevailing medical, ethical, and legal standards. Surprisingly, he does not discuss many of the major l~ublications and authorities in this area. t4-18 Moreover. the one authoritative study he cites does not seem to support his assessment of the problem or its solution. Indeed. Dr Sachs' nationwide study found widespread interest in developing prehospital DNR policies, that most existing DNR policies were "'practical and adequate for local EMS directors needs" and that "living wills are iflappropriate for communicating DNR status." While calling for an urgentlyneeded legal review. Dr Sachs' study concluded that "prehospital DNR policies can be implemented on the state and local levels, even without enabling legislation." Thus. there would appear to be no compelling medical, legal, or ethical need for Arizona's radical approach. Ironically, certain of Arizona's circumstances may be demographically unique. In Arizona. there are two major metropolitan areas that can and do function much as other major metropolitan EMS systems do throughout the country. These systems previously have been analvzed in detail by well-trained and respected emergency physicians.t9 They have seemed to operate very efficiently w i t h n o published indication of any of the serious problems described by Dr Iserson. We do from time to time attempt to resuscitate truly terminally ill patients or those who may in good faith have executed otherwise valid advance care directives. This is a situation we would like to avoid: however, the Arizona statute does not seem to be the answer. If a specific problem now exists with overutilization or prolonged response time to hospitals from certain rural areas in Arizona, such a problem may best be addressed directly by members of the local or state medical and/or EMS community who are most familiar with that particular problem and its solution. Neither isolated problems of rural Arizona providers caused by disparate geography nor anything in Dr Is'erson's article supports the leap in logic necessary to embrace the Arizona approach. Far
120
1 7 50
from serving as a"model" for others, the Arizona statute is a monument only to confused and incomplete thinking. Good intentions in Arizona have created a medical, ethical, and legal design for disaster. R JackAyres, Jr, JD, REMT-P EmergencyLegal Assistance Program Parkland Memorial Hospital University of Texas Southwestern Medical Center at Dallas 1. Vol 36, Arizona Revised Civil Statutes, Chapter 32: Living Wills and Health Care Directions (1992). 2. Hastings Center: Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, A Report by the Hastings Center. New York, The Hastings Center, 1987:48. 3. American Heart Association: Standards and guidelines for cardiopuimonary resuscitation and emergency cardiac care. JAMA 1986;255:2841. 4. American Heart Association: Textbook of Advanced Cardiac Life Support, ed 2. Dallas, AHA, 1990. 5. American College of Emergency Physicians: Position Summaries, 1990. Dallas, ACEP, 1990, p 11. 6. American College of Emergency Physicians: 6uidelines for "do not resuscitate" orders in the prehospital setting. Ann Emerg Med 1988;17:1106-1108. 7. American Academy of Orthopaedic Surgeons: YourFirst Response in Emergency Care. Chicago, AAOS, 1990, p 16, 17, 57. 8. Crimmons TJ: Ethical issues in adult resuscitation. Ann Emerg Med 1993;22:495,501. 9. Landwirth J: Ethical issues in pediatric and neonatal resuscitation. Ann Emerg Med 1993;22:502-507. 10. Values in Conflict: Resolving Ethical Issues in Hospital Care. Report of the Special Committee on Biomedical Ethics. American Hospital Association, 1985, p 19. 11. Sachs GA: Limiting resuscitation: Emerging policy in the emergency medical system. Ann Intern Med 1991;114:151-154. 12. Kranson v Valley Crest Nursing Home,755 F2d 46 (3rd Cir 1985), 13. Ayres RJ: Current controversies in prehospital resuscitation of the terminally ill patient. Prehosp Disaster Med 1990;5:49-58. 14. Siner DA: Advance directives in emergency medicine: Medical, legal, and ethical implications. Ann Emerg Med 1989;18:1364-1369. 15. Eisenberg MS: Termination of CPR in the prehospital arena. Ann Emerg Med 1985;14:1106-1107. 16. Gray WA: Unsuccessful emergency medical resuscitation--Are continued efforts in the emergency department justified? NEnglJ Med1991;325:1393-1398. 17. Weaver WD: Resuscitation outside the hospital--What's lacking? N Engl J Med 1991;325:1437-1439. 18. Koenig KK: Do-not-resuscitate orders, where are they in the prehospital setting? Prehosp Oisaster Med 1993;8:51-54. 19. Valenzuela TD, Criss EA: Cost-effectiveness analysis of paramedic emergency services in the treatment of prehospital cardiopulmonary arrest. Ann Emerg Med 1990;19:1407-1412.
Disaster Medical Assistance Teams: A Key Role See related article, p 1721. Alson et al, authors of "Analysis of Medical Treatment at a Field Hospital Following Hurricane Andrew, 1992," in this issue of Annals, depict a natural disaster that had an effect on the lives of nearly a quarter of a million people and resulted in requests for more than $7.2 billion in disaster relief. The response subsequently mounted by the federal government was the largest disaster response in the history of our country, with more than 34,000 National Guard and secular military persons and 18,000 organized volunteers. Tens of
ANNALS OF EMERGENCY MEDICINE
22:11
NOVEMBER 1993
EDITORIALS
thousands of other individuals and volunteer groups also responded. In fact, the latest version of the plan had been distributed only three to four weeks before the hurricane struck southern Florida. Under the Robert T Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288 (The Stafford Act--1988), the President is authorized to direct federal agencies to provide emergency assistance to save lives and protect property, public health, and safety in emergencies. The Federal Response Plan is the actual operational document for this implementation. The plan uses a problem-oriented or "functional" approach to identify the types of federal assistance that a state(s) is most likely to need. There are 12 of these emergency support functions. Each emergency support function has an assigned lead agency with primary responsibility to carry out that function. The 12 emergency support functions with their lead agencies are transportation, Department of Transportation; communications, National Communication System; public works/ engineering, US Army Corp of Engineers; firefighting, Department of Agriculture; information/planning, Federal Emergency Management Agency; mass care, American Red Cross; resource support, General Services Administration; health and medical services, Department of Health and Human Services; urban search and rescue, Department of Defense; hazardous material, Environmental Protection Agency; food, Department of Agriculture; and energy, Department of Energy, The authors successfully identify the benefit of rapid assessment in response to a disaster of this magnitude. When so many lives are at stake, this is the least useful time for dealing with political struggles within a state and between states and the federal government. A predetermined agreement as to what should occur in a speedy fashion should be in existence before any catastrophic event. The Department of Health and Human Services through the Centers for Disease Control and Prevention has been identified as the agency that will concern itself with the initial assessment and health and medical response following a disaster. Although there had been much criticism of slow response efforts, activities actually began before the storm hit. The National Disaster Medical System had sent several members of their assessment team to Florida to begin liaison efforts in anticipation of the disaster. The authors correctly identified the importance of strong logistical support for disaster medical assistance teams as they function in austere conditions. Delivery of health care, whether routine or sophisticated, in a hospital setting is a normal process that tens of thousands of physicians and nurses practice daily. The
NOVEMBER1993
22:11
ANNALSOFEMER6ENCYMEBICINE
attempt to deliver equivalent highrquality medical services in an environment in which there are minimal, if any, resources poses an incredible challenge. We take for granted the tremendous effort by hospital administrators to support these efforts. Certain individuals on each disaster medical assistance team must be dedicated to focus solely on provision of food, water, shelter. energy needs, and resupply for the team itself and are crucial for the successful completion of these teams' mission. Being self-sufficient in all of the above areas for at least 72 hours is absolutely essential as these teams enter the disaster area. The authors also note that the type of health care delivered by the disaster medical assistance teams in southern Florida following the hurricane was of a more routine nature. This has been the experience of disaster medical assistance relief teams following three hurricanes--Hugo in 1989, Andrew in 1992, and Iniki in 1991.1 The types of health care needs in all three responses were remarkably similar. The hurricanes affected health care for the local populations only indirectlY. The infrastructures for delivery of health care, however, were affected to the extent that individuals not only were unable to receive routine primary care or inpatient tertiary care. but could not even fill a prescription at a pharmacy. Much of the teams' activity, therefore, was to provide these types of services while the local health care system became functional. There are, however, specific epidemiological characteristics associated with each type of natural and manmade disaster. For example, Sklar 2 described the types of injuries sustained following various natural and manmade disasters and showed that they are very different than those following hurricanes. Therefore. disaster medical assistance teams should be prepared adequately for emergency and routine patient care--underscoring the necessity for emergency physicians to play a leadership role in this system. I believe that the authors successfully have described what will become a routine response on the part of the United States for domestic disasters. Their article also underscores the powerful impact of a joint venture between government agencms, officials, and the civilian sector. Disaster medical assistance teams are all-volunteer civilian health care, administrative, and logistic support personnel. These individuals function daily in the civilian world and are called on during emergencies to respond to community needs in distant areas of the country during times of overwhelming need. Developing a productive and effective response using individuals from the civilian sector in concert with the assets of the federal government sector has never been so dramatically effective with this type of response. The futures of the National Disaster Medical System and disaster medical
1751
121
EDITORIALS
assistance teams currently are being studied. To what extent the system and these teams will evolve and participate in future responses is open to question. I hope that reason and not politics will prevail, and that these disaster medical assistance teams will not only continue but expand to respond to international needs as these types of events strike the populations of foreign countries. PaulBRoth, MD, FAAFP,FACEP Universityof New Mexico Medical Center Albuquerque 1. Levy LJ, Toulamin LM: Improving Disaster Planning and Response Efforts: Lessons From Hurricanes,4ndrew and Iniki. New York, Boa>Allan and Hamilton, I nc, 1993. 2. Sklar [3: Disaster planning and organization: Casualty patterns in disasters. JW,4EDM 1987;3:49-51.
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NOVEMBER1993