Maurice A. Ramirez, DO, CNS, CMRO

One Great Solution for Improving Healthcare Preparedness

Our nation faces two interesting challenges when it comes to the healthcare response to disasters.  The first is that according to an Institute of Medicine report published in June 2006, hospitals have by and large failed to meet even the most basic standards for disaster preparedness.  In other words, they have failed to develop the relationships within their own communities, ignoring even EMS and community-wide Emergency Response Services thus failing to integrate these critical services into the hospital disaster plan.

Further, most hospitals, now six years after 9/11, still fail to provide basic disaster response training to all of their employees. Basic Incident Command training that would allow their employees and care providers to integrate themselves into the community wide response, while required by federal guidelines, is still reserved for members of the administrative team. Most hospitals have even failed to hold or participate in community-wide Disaster Drills despite a four year old mandate for these drill each year. Although reasons cited by hospitals for their failure are many, they are also largely invalid.  Requirements have existed for such Community-Wide Disaster Drill since 2003 and since 2002, the federal government had paid for or provided free of charge the educational opportunities for hospital employees.  Unfortunately now, most of that federal funding has ended, the five-year grants have expired.

There is however one opportunity for the federal government to use existing assets, augmented by existing state government assets, to provide not only training but disaster drill opportunities to hospitals and other portions of healthcare.  The Natural Disaster Medical System (NDMS) has within its ranks Disaster Medical Assistance Teams (DMAT) who are trained in all aspects of incidents command, disaster vulnerability analysis, disaster planning, disaster response, and disaster recovery.  Individuals who make up DMAT teams are civilian healthcare professionals who, when not deployed by our federal government, function as unpaid reservers, part-time federal employees on stand-by status, receiving no pay while remaining on call and ready to deploy within two hours in the event of national disaster or terrorism.

DMAT teams represents the perfect opportunity for federal government to utilize an asset already in the federal budget to provide not only training to hospitals in the communities surrounding a DMAT team, but community wide, externally designed and graded disaster drills that would include not only the hospitals but fire rescue, law enforcement, local county and even state emergency operations integrated with state and federal disaster response assets in coordinated community-wide drills. In other words, the best possible practice model. 

Expanding the services offered by DMAT teams to their surrounding communities would also serve the objectives of the federal government by providing an opportunity for DMAT teams to hold Field Training Exercises (FTX’s) and to network with healthcare assets in the surrounding communities.  NDMS has sought for years to develop a network of participating hospitals who would accept patients from distant field disaster sites transported by military or other assets and requiring hospitalization outside of the disaster zone. 

The average hospital will spend between $90,000 - 180,000 per year in the coming decade just for disaster drills and training, and this does not include the cost of paying employees to participate in those drills and training opportunities. Participation in federally sponsored federally funded, DMAT based disaster training and exercises would represent a significant inducement to hospitals  to join the NDMS hospital system and a significant benefit to NDMS member hospitals. 

State medical response teams, known under various names in various locations, could provide a similar opportunity for the state to both build relationships between their teams and their communities as well as improve the operational efficiency of teams through exercises and education.

Conceivably, even Medical Reserve Core units (MRC) could participate by providing local leadership and coordination efforts for their hospitals and communities as the MRC provides the earliest possible disaster response, providing for healthcare needs in those initials hours after an event.

Certainly, there will be the challenges of Congressional funding and special interest groups claiming that the federal government is subsidizing programs that benefit for profit hospitals.  More importantly however, a program such as this would ensure that our healthcare infrastructure was maximally prepared for the next Hurricane Katrina, for the next Oakridge earthquake, for the next Americas Georgia tornados, for the next great river flood.  NDMS member hospitals deserve to receive some benefit for becoming an NDMS hospital and assuming the additional responsibilities that come, uncompensated, with agreeing to participate in America’s disaster healthcare response system.  Using DMAT teams to train, drill and evaluate America’s healthcare infrastructure will ensure that the survivors of disaster receive the best healthcare available while the rest of us rest assured that our community’s healthcare is truly prepared if the disaster comes to our doorstep.

The Unsung Heroes

On this second anniversary of Hurricane Katrina, we must not only think of those still in the recovery, those still displaced from New Orleans and Gulfport and homes and businesses all across the Gulf Coast of the United States.  Among those who were the first to provide aid and assistance to the survivors of Hurricane Katrina who were the unsung heroes of the National Disaster Medical System (NDMS).  Few in the United States have heard of the men and women of NDMS.  These healthcare professionals shied away from the public eye and publicity of any kind.  They strive to always observe the first lesson of the disaster field office: “Don’t get in front of the camera!”  Yet those who serve in the various divisions of the National Disaster Medical System are perhaps heroes in the truest sense of the world because it is these men and women who place their lives on hold often on as little as two hours notice and travel to communities not their own to help those in need, to help people whom they do not even know and will likely never see again.

The National Disaster Medical System has existed for over two decades, beginning as a single unit of field responders under the United States Public Health System.  Since its simple beginning NDMS has grown to include units dedicated to providing medical assistance to disaster survivors through Disaster Medical Assistance Teams (DMAT); domestic animals and pets through Veterinary Assistance Medical Teams (VMAT); and the respectful care of those not fortunate enough to survive a disaster through Disaster Mortuary Operational Response Teams (DMORT).

Why are NDMS teams and the people that serve on them unsung heroes?  It is because not only do they shy away from publicity, but they choose to serve rather than to self-promote.

NDMS members exist in a unique place in our federal government and our federal response to disaster.  Although they serve in uniform and operate within a command structure that closely mimics that found both in the fire service and in our esteemed military, NDMS personnel are not technically reservists.  NDMS began at the volunteer program functioning more like AmeriCorp, the Peace Corp or the American Red Cross than like a government agency.  Over time however, the need to provide these intrepid rescuers with the basic protections of workers’ compensation, liability insurance and malpractice insurance spurred the federal government to make them “intermittent part-time employees.”  At times of nationally declared disaster, NDMS personnel respond to deployment request within as little as two hours.  NDMS personnel maintain equipment that they have paid for in deployment ready condition at all times, often carrying that equipment in their automobiles and even on vacation with them.  Three months out of the year NDMS teams place themselves on call, notifying employers that in the event of a national disaster they may have to leave their workplace almost immediately. Yet unlike all other federal assets, in those times between disasters NDMS personnel receive a biweekly federal pay stub for zero dollars. They receive no benefits, no retirement, no reservist pay, none of the other benefits, discounts, or protections afforded those who serve in the United States Military, the National Guard, the Military Reserves, or as federal employees. 

While deployed NDMS personnel are protected from employer discrimination and retaliation for their service just as those in the National Guard or the Military Reserves are protected.  During times of deployment, they are full-time federal employee but they receive pay that is seldom more than 25 percent of their usual civilian wage.  For most NDMS members, each week of deployment takes 2-3 months of personal financial recovery.   Informal surveys of NDMS teams responding to the hurricanes of 2004 (Charley, Frances, Ivan, Jeanne) and 2005 (Katrina, Rita and Wilma) found that most team members were still financially recovering as of this writing in 2007. 

Because an employer is required to hold the job open but not for maintaining the employee on the work schedule, upon an NDMS team member’s return it is not unusual for that team member to spend one or even two weeks off the job waiting for the next work schedule to begin. This means that after returning from a two week deployment where they earned 25% of their usual wage, they go without pay at all until their employer can integrate them back into the schedule.  In 2004 and 2005 this meant that individuals deployed to all seven major hurricane, spent on average seven months away from work in only a 14 month period of time.  In that same time period, few made more than the equivalent of three weeks of their regular civilian pay. Despite the fact that in that 14 month period of time, every team in the nation was deployed repeatedly and most deployed for all seven events, the loss of team members across the nation was surprisingly low.

The heroes of the NDMS system are not the typical field responder that most citizens would envision.  These are ordinary doctors and nurses, respiratory therapists, supply personnel, paramedics, EMT’s, physicians’ assistants,    nurse practitioners, administrators and accounting personnel from the whole spectrum of the healthcare workforce.  They are most accustomed to working in nicely appointed offices for well-equipped hospitals.  In their civilian lives -- like most Americans, they sleep in a comfortable bed in an air-conditioned or heated home with pillows and blankets, an alarm clock and a hot shower.  However, in addition to the financial hardships that they gladly endure, they deploy into a field environment where one trip may they sleep on the floor in an airport or on the baggage conveyor belts and the next, they sleep in a tent in a sleeping bag or in the seats of vans and buses.  Although their treatment areas are air-conditioned for patient benefit, seldom if ever do they enjoy air-conditioning in their own billet or bivouac.  A once a week shower is a luxury and since resourcefulness and creativity are the hallmarks of NDMS personnel, it is not unusual to see them washing uniforms in a bucket, in the rain or even in an unmonitored dishwasher, in the first class lounge of the Louis Armstrong International Airport.

Despite the hardships and the lack of personal benefits beyond that satisfaction of having served their fellow American, an increasing number of healthcare professionals from all areas of healthcare, both clinical and nonclinical are seeking to join not just NDMS but the state equivalent medical response teams in all 50 states and US Protectorates.  Those not willing to leave their homes are joining Medical Reserve Corps Teams in order to afford themselves an opportunity to assist their own communities in the event of disaster.

But it is the members of the National Disaster Medical System, those first out the door, first in the field, first on scene, this first line of the nation’s medical and rescue response who are truly the unsung heroes and truly most deserving of our gratitude and praise on this second anniversary of Hurricane Katrina.

When Worlds Collide

John, a veteran of the Fire Department of New York had “retired” to his southeastern home several years ago. Unable to sit and fish all day, John soon joined the county fire service and became a resource for his department and his community. Loved by everyone for his jovial nature John was admired by the rookie firefighters.

One bright summer day, a chemical tanker truck caught fire in front of the regional trauma center. The trauma center was upwind and in no direct danger when fire and hazmat teams arrived. The fire was quickly contained and the hazmat team set about the work of clean-up.

As operations began, John’s first duty was to establish contact and coordination with the hospital. Smiling he turned to the rookie assigned to him for training and said,

“This will be fun, watch their reaction when we ask to speak with their Liaison Officer. They won’t have a clue what I’m talking about.”

John and the rookie walked into the hospital still smiling and asked the security officer at the front door to contact the Liaison Officer. Much to John’s surprise, the security officer immediate called for the Liaison Officer to come to the front lobby. Moments later, a young woman arrived and introduced herself to John.

Unfortunately, John’s experience is still the exception rather than the rule when community response services interact with hospital services. Too often these interactions are seen as either a threat to hospital autonomy or as a public relations exercise. As with most problems of culture and communication, the fault lies on both sides of the relationship.

Hospitals are for the most part private businesses with the duel mission of providing care and delivering a profit. Unfunded mandates and social pressures have created a complex web of regulation and oversight that is largely resented by those in the healthcare professions. Any aspect of the business that is not regulated is seen as an opportunity to distinguish oneself from the competition and is thus jealously protected. Until this year, that included hospital command structure during a disaster.

Fire/Rescue has been steeped in a system of command and control born of the need to ensure that lives and property are not placed at undue risk. Unlike healthcare professionals, Fire/Rescue professionals know that a breakdown in command decision making will cost their life or the life of one of their colleagues. There is no room for individuality or customization of the system in the mind of the Fire/Rescue professional.

These worlds collide in the modern era of disaster preparation and response. By mandate, hospitals and healthcare facilities are now required to use the same incident command system that Fire/Rescue has used for decades. The relationship is further complicated by the fact that this mandate reverses the traditional lines of authority and knowledge in which Fire/Rescue has always taken instruction and guidance from healthcare as regards Fire/Rescue’s medical operations. Now healthcare must take instruction and guidance from Fire/Rescue.

As with any realignment of a relationship, the integration of hospitals and healthcare institutions with the larger community response will ultimately strengthen the system and the nation’s preparedness. Until then professionals on both sides will do their best when their worlds collide.

Volunteering in Times of Disaster - The Time is Now

Physicians come to their profession with a high sense of personal honor and a high sense of personal duty.  It is these two characteristics that spur physicians to contribute time, energy, talent and resources in times of local, regional or even national disaster. 

Whether hurricane Andrew, hurricane Charlie, hurricane Katrina, hurricane Rita, hurricane Wilma, the terrorist attacks on the Murrah federal building, the World Trade Centers or the Pentagon, whether forest fires or large automobile accidents whenever the healthcare system appears to be overwhelmed physicians and other health care professionals find themselves spurred to action.  Unfortunately they also find themselves spurred. 

It seems senseless whether the time of tremendous need physicians would be turned away from such places as Louisiana, Gulfport Mississippi, Port Charlotte, Florida, Oklahoma City, New York City and Washington D.C.  Yet a small understanding of how disaster response systems work explains this phenomenon. 

The first and most important thing that physicians and other health care providers must know is that if you are not part of a disaster plan, you are not part of a disaster response.  Even though it may seem chaotic when disaster relief professionals are working side by side with volunteers and bystanders to save lives and livelihoods, what you are actually witnessing is a wellchoreographed dance.  Long before the disaster struck plans were established on how best to respond in the event of a disaster.  It is in this planning phase that the use of volunteers whether lay persons or health care professionals is anticipated and integrated. 

Therefore if you wish to be part of a response, if you wish your valuable skills to be used to help stave off disaster and prevent catastrophe the time to volunteer is now. 

What Is The Disaster Life Cycle?

Disasters come in four phases:

• Interphase
• Adverse Event
• Response Phase
• Recovery Phase

With respect to most disasters we hope that interphase, that period between disasters, is the longest period of time.  It is during interphase that plans are reviewed, practiced, refined and practiced again.  It is during this period of time that it is most optimal for health care professionals to join the ranks of volunteers to be called upon when the disaster strikes. 

The Adverse Event is that brief moment in time when the disaster actually occurs.  When the levy actually breaks, the hurricane passes directly overhead or the bomb blasts. This discrete moment is defined by the event itself. There is little that responders can do except survive to lend aid when the event has past. Adverse Events cannot be prevented, but can be mitigated.  They will happen with little regard to what planning has or has not occurred.  Occasionally man made events can be preventive but by and large the event phase is inevitable. 

Immediately following the event begins the response phase.  It is this acute period that determines whether an event becomes a disaster.  Disaster is defined as need exceeding resource.  If during the interphase weaknesses in resource management, procedures or processes are identified such that needs never exceed resources, the event never becomes a disaster. Unfortunately, this occurs in precious few events.

It is in the response phase that defines whether a disaster goes on to be a catastrophe.  While a disaster is when needs exceed resources, a catastrophe is when needs excess all ability to respond.  When the response phase fails or the planning phase is found lacking catastrophe includes. 

Medical Reserve Corps – Your Chance to Serve

The Medical Reserve Corps (MRC) program was launched officially as a national, community-based movement in July 2002. It was formed in response to President Bush’s call for all Americans to offer volunteer service in their communities. The objective of the MRC program is to strengthen communities by establishing a system for medical and public health volunteers to offer their expertise throughout the year and during times of community need. More than just a corps of available healthcare professionals, the MRC is a full partner of the White House’s USA Freedom Corps and the Department of Homeland Security’s Citizen Corps.

Volunteerism for America’s healthcare providers has faced many obstacles in the days before the MRC. Issues of liability insurance, malpractice, worker’s compensation, injury insurance and many other serious concerns have plagued the medial volunteer effort in the United States for the past 2 decades. If insurance issues did not stand in the way of medical volunteers, licensure and accreditation issues stymied efforts to provide much needed disaster medicine services following disasters. 

The adoption of Emergency Medical Assistance Compacts (EMAC) across all 50 states and all United States territories was designed to address the majority of these concerns, but recent legislation introduced in congress shows that the EMAC’s are far from resolving the key insurance issues facing medical volunteers. Legislation is pending before both the U.S. House of Representative and the U.S. Senate to resolve the interstate worker’s compensation issue for healthcare providers who volunteer their services in time of disaster. In the near future, similar legislation will be proposed to resolve malpractice coverage issues for healthcare volunteers in disaster.

Membership in the Medical Reserve Corps resolves all these problems now and without the need for special legislation. Medical Reserve Corps volunteers are credentialed and their membership in the MRC provides Eminent Domain coverage for malpractice as well as volunteer injury coverage in the event of an on duty mishap.

Who Can Volunteer for the Medical Reserve Corps?
MRC volunteers may include medical and public health professionals including:

• Physicians
• Nurses
• Pharmacists
• Emergency medical technicians
• Dentists
• Veterinarians
• Epidemiologists
• Infectious disease specialists.

In addition, volunteer interpreters, chaplains, amateur radio operators, logistics experts, legal advisors, and others may fill key support positions.
Most MRC response and recovery assignments are secured through local and state channels. However, opportunities for MRC volunteers to assist outside their local jurisdiction do arise. During the 2004 hurricane season, MRC volunteers were asked to support the American Red Cross (ARC) response activities in Florida. This was the first deployment of MRC volunteers outside of their local jurisdiction.

During the 2005 hurricane season, the MRC strengthened its partnership with the ARC. Prior to Hurricane Katrina's landfall, the ARC disaster operations staff requested MRC support for their sheltering operations. Policies and processes were developed to identify, assign, and activate MRC members willing, able, and authorized to respond. ARC provided transportation, logistical support, and supervision for the deployed MRC members who supported ARC health services and mental health and shelter operations.
MRC members also participated in response activities outside of their local/state jurisdiction through a mission to support HHS response and recovery efforts.

The first Federal activation of MRC volunteers occurred on September 15, 2005, when HHS needed staffing support for three special needs shelters in Louisiana. Subsequent mission assignments allowed MRC members to fill positions in Community Health Centers and health clinics on cruise ships housing evacuees in Mississippi and to perform health assessments in Texas.

For more information about the Medical Reserve Corps or to become a member, please visit the MRC website at www.medicalreservecorps.gov, or contact the Medical Reserve Corps at:

MRC Program Office
Office of the U.S. Surgeon General U.S. Department of Health and Human Services
5600 Fishers Lane, Room 18C-14
Rockville, MD 20857
Tel: (301) 443-4951
Fax: (301) 480-1163
E-mail: MRCcontact@hhs.gov

The National Disaster Medical System – NDMS the Nation’s Medical Ready Force

The National Disaster Medical System (NDMS) is a federally coordinated system that augments the Nation's medical response capability.  The overall purpose of the NDMS is to establish a single integrated National medical response capability for assisting state and local authorities in dealing with the medical impacts of major peacetime disasters and to provide support to the military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflicts.

The National Response Plan utilizes the National Disaster Medical System (NDMS), as part of the Department of Health and Human Services, Office of Preparedness and Response, under Emergency Support Function #8 (ESF #8), Health and Medical Care, to support Federal agencies in the management and coordination of the federal medical response to major emergencies and federally declared disasters.

Much like Army Reservists, NDMS members are volunteers who become government employees when they are deployed and must commit to two weeks service if called.
NDMS teams are essentially designed to be a rapid-response element that deploys to disaster sites with sufficient supplies and equipment to sustain themselves and care for patients for a period of 72 hours. In mass casualty incidents, their responsibilities include triaging patients, providing austere medical care, and preparing patients for evacuation.

In other types of situations, NDMS teams may provide primary health care and/or may serve to augment local health care staffs. Should disaster victims need to be evacuated to a different locale to receive more definitive medical care, NDMS teams may also be activated to support patient packaging, transport, reception and disposition.

The units are supported by a cadre of administrative, logistical, and communications personnel whose roles are vital to successful deployment. Medical members are required to maintain appropriate certifications and licensure within their discipline. When members are activated as intermittent Federal employees, licensure and certification is recognized by all States.

In contrast to MRC members, as Federal employees, all NDMS team members are paid while serving.

NDMS medical personnel includes many disciplines from physicians to pharmacists, ARNP’s and PA’s. The NDMS teams are also replete with an experienced pool of healthcare talent with diverse medical backgrounds, ranging from RN’s and LPN’s to Nurses Assistants. Paramedics and EMT’s, with years of training and daily emergency experience are also an integral part of the teams. Respiratory therapists bring yet another medical specialty to help round out the deep medical resources of an NDMS team.

Administrative, Logistical and Communications experts round out an NDMS team and ensure that a fully self sufficient group of professionals is ready to deploy at a moment’s notice when requested by federal disaster declaration.

Most NDMS teams are also state disaster medical response teams providing reservist style medical support for their local communities as a supplement to MRC assets in an area.

For more information about the National Disaster Medical System or to become a member, please visit the NDMS website at http://www.oep-ndms.dhhs.gov.

So How Do I Participate?

First, get educated. The sad truth is that few physicians have spent even eight hours learning how to keep themselves, their families and their patients alive in the event of a disaster. Take a Basic Disaster Life Support Course or similar Healthcare First Receiver training. You are of no use to anyone if you fail to go home alive at the end of the day.

Next, get involved. Of the over 5000 hospitals in the United States, only a very small fraction have physicians on the hospital disaster planning committee. Of greater concern is that few if any of those physicians who do participate in hospital disaster planning have any formal training or certification in disaster medicine or disaster management.

Once you are educated and involved, become a resource. The 2006 Institute of Medicine reports on the state of emergency medicine in the United States soundly rebuked hospitals and healthcare in general for poor and ineffective planning, preparedness, training and practice. Throughout the evolution of healthcare disaster preparedness, physicians have been conspicuously absent from the table. It is well past time that those who have the ultimate responsibility for patient care and well being take responsibility for their role in disaster planning and preparation.

Finally once you have become educated, involved and a resource, volunteer. If you are fortunate enough to have a career which allows you the freedom to deploy for weeks at a time to locations far from home, consider becoming a member of an NDMS team. If your career needs and practice responsibilities require that you stay closer to home, join an MRC team in your area. Either way you will serve your community, your nation and your fellow man in a way not possible anywhere else in medicine.

Fortune Cookie Preparedness

Some days you just don't know where the reminder will come from. Today it was a Fortune Cookie! My fortune read:

"Do what you can with what you have, where you are."

While certainly not ancient Chinese wisdom, it is a concise summary of Disaster Response.

The goal of disaster response is to do the most good for the most people with the resources available at that moment. During the planning phase critical processes and pathways are identified. The chock points along those pathways are identified and resources dedicated to those key points. Thus, the capacity of these pathways is expanded and the entire system becomes more robust. Through this process you can do more for more people at that moment in time.

"Do what you can with what you have, where you are."

A basic reality of Disaster Response is that needs cannot be reduced and resources will be limited. Once processes and systems are made as robust as possible, the next technique for expanding the ability to respond is to change the location where less critical processes occur.

The foundation of trauma and disaster medical care is to separate the survivors from the event. This is seen everyday when an ambulance takes the survivors of motor vehicle accidents to the hospital rather than bringing trauma services to the accident scene. In disaster response, this means sending the minimally injured to a more distant treatment site, thus conserving local resources for those unable to evacuate now.

"Do what you can with what you have, where you are."

Not bad for a Fortune Cookie.

Where Should NDMS Reside?

The National Disaster Medical System, the nation’s medical rapid response force has beginnings in the mid 1986 as a small civilian division of the Uniformed Public Health Service in conjunction with the U.S. Department of Health, Washington, D.C. office.  From those humble beginnings, NDMS has expanded to a nationwide program with volunteer reservists in almost all 50 states.  Thirty-five person to 105 person teams exist nation wide.  Sixteen of these teams can be “out the door” in two hours and on the ground providing emergency medical support for devastated communities within hours of an event.  Additional teams can deploy within 24 hours and a support staff of thousands provide resupply and replacement personnel for extended missions such as the hurricane season of 2004 or Katrina, Rita and Wilma in 2005.

NDMS has served in terrorism related disasters as well at the Murrah Federal Building, the World Trade Center, the Pentagon and other events.  NDMS is the nation’s “ready team” deploying on a stand by basis at events of national significance including the Presidential Inauguration, the rededication of the Statue of Liberty, the Republican and Democratic National Conventions and even at the Super Bowl.

So why can nobody find NDMS a permanent home?

Many thought that the Public Health Service was the perfect place for NDMS.  However the Public Health Service is just that a public health service.  Their role is in disease surveillance, vaccination programs, disease prevention and community health.  They are not a response agency.  They do not move with the speed required to mount a disaster response.  They are public health doctors, an epidemiologist more at home in a laboratory or in an office setting than in a field tent or the belly of a rescue helicopter.  Public health as a profession and as individual public health professionals are the best people suited for the work that they do.  They are detail oriented, idealistic and dedicated to doing the most good for everybody.  Unfortunately, these are not the characteristics of a field responder.

NDMS was next moved following the events of September 11, 2001.  With the formation of the Department of Homeland Security and the consolidation of so many government agencies to that new department.  NDMS was inexplicably placed under the auspices of FEMA!

The Federal Emergency Management Agency (FEMA) is a planning and recovery organization.  Staffed primarily by former law enforcement and fire department commanders as well as experienced and highly trained emergency management professionals, FEMA best roles are in community disaster planning and preparedness and in providing for community recovery.  It however must be noted that there is no response role in that definition.  Even those in charge in FEMA admit they have no idea what to do with medical people and NDMS is all medical people.  The excellent response to the hurricane season of 2004 gave tremendous encouragement to those in Congress and in the Department of Homeland Security who placed NDMS under FEMA.  The integrated response and recovery phases exemplified how these two disaster phases can overlap and the ability to integrate services and serve the public well.  2005 was another matter.  The debacle that was the response to Katrina pointed out the need for a true response agency separate and apart from a planning and recovery division.  Discussions began almost immediately of disbanding FEMA or breaking it into two or more agencies.  Fortunately, cool heads prevailed and the understanding that recovery is a nature part of planning ensured that FEMA would continue to exist and do the job for which they are so well suited for the foreseeable future.  It also resulted in another transfer of the NDMS system.

Those of us in NDMS had hoped at this point that after close work with the Coast Guard, a Homeland Security based response oriented organization with limited civilian medical capabilities, would be our new home.  It seemed only natural to put field response medical personnel with field response rescue personnel.  Coast Guard has its own medical corp that cares for its own people.  They understand the needs of medical people of medical response in adverse circumstances.  Coast Guard has its own medical first response rescue personnel in the form of rescue swimmers and even paramedic level trained medics so they understand the unique needs of medical first responders.  It seems like a perfect fit.

Unfortunately, in the vagaries that define Washington decisions, NDMS was effective January 1, 2007 moved back to the Department of Health and Human Services (formerly known as the U.S. Public Health Service).  The reason given to NDMS members was that it was that the Department of Health and Human Services is charged under the National Response Plan with preparation and response to pandemic flu.

Let’s get real!

The National Response Plan enumerates 16 possible disasters for which the Department of Homeland Security and the U.S. government has greatest concern.  Only one of these falls within the prevue of the U.S. Public Health Service.  Pandemic flues occur once every 91 years and while we are at the beginning of the “window of opportunity” for this next pandemic.  There will be little that a field response service can do.  The pandemic when it strikes will strike simultaneously across the nation.  Local professionals such as those who make up the volunteer reservists of the NDMS system will be needed in their local communities.  The Centers for Disease Control and the Secretary for the Department of Health and Human Services have already said that those individuals will remain in their local communities to ensure that local health care is not compromised to any greater degree than necessary anywhere in the country in order to provide services to some other portion of the country.  In other words, NDMS has no role in the current pandemic flu response plan.

Even accepting on face value the reasoning for the most recent transfer of the National Disaster Medical System from the Department of Homeland Security to the Department of Health and Human Services as valid, by 2013 the pandemic will have struck.  This is a mathematical certainty based on several centuries of experience with this type of pandemic disease. 

Will that mean that NDMS will be moved again? 

Will NDMS find a permanent home more suited to its unique role in disaster response and recovery? 

Again, NDMS will fall victim to the vagaries of Washington decision making.  Unfortunately for the National Disaster Medical System and the vulnerable citizens whom these fine professionals have dedicated their lives to serving, NDMS itself has stayed so far out of the limelight that few if any people will even notice the next time that their services are hampered by poor management or supervisors who do not even know what to do with medical people.

What Is Wrong with Continuing Medical Education?

A good friend in college in the National Speakers Association emailed me yesterday.  In the back and forth of emails told me two things about the conference that she was attending:

1. She was beginning to see the frustrations of being in the continuing education (CME) market, and
2. She could not understand how such intelligent people (experts) could be so business stupid. 

Now my friend has been in the speaking industry as a talent agent, a book agent, and as a professional speaker and trainer for more years than she will tell me.  Her frustration arises from the fact that in the speaking industry we look at four benchmarks of proficiency:

1. Expertise – knowing your subject better than anyone in your audience.
2. Eloquence – having the skills and the preparation to relay that expertise from the platform.
3. Enterprise – having the business knowledge to convey expertise and eloquence without losing your shirt.
4. Ethics – having the professional selfrespect to do business in a morally correct fashion and not feel, coop, or plagiarize other people’s materials. 

My friend’s email betrayed that she could not understand why all four benchmarks were missed in the CME arena. 

I explained to her that it was not that the speakers she watched lacked expertise.  It was that they lacked the eloquence to portray it.  They used the same old jokes that they heard at the last four or five seminars very often, jokes that are not even relevant tangentially to the subject at hand.  Alternatively, they will use a story whether it is heart wrenching, heart warming, scary, or reassuring even if it does not apply to the topic at hand.  They will stretch and then over stretch to make a connection and in the process lose the audience and the entire point of their speech. 

I explained to her that I am a devotee of AudioDigest (TM).  AudioDigest (TM) is a recording service for medical seminars.  Their editors listen to literally hundreds of speakers recorded at major CME programs around the world.  They then have no trouble editing this down to the few that are worthy of audio reproduction.  Even with that editorial review and relying on the grading of medical audiences, significant amounts of editing are required to produce useable audio seminars.  An audioDigest program runs 55 to 60 minutes and very often has two speakers.  I always have to remind my own speech students that each of these speakers were recorded at a 55 to 60 minute speech and yet very often it requires three of them edited to 20 minutes of useable information to create one 60minute audioDigest program.  That means that each speaker wasted twothirds of their time and the audience’s time.

Speakers in the CME market are selected based on a written abstract.  Almost never is a demonstration DVD required nor testimonials or prior review scores from previous appearances.  When a CME committee selects a speaker, it is either political or based on their knowledge (expertise in the field).  That committee has no idea of whether or not the speaker possesses any eloquence. 

When it comes to enterprise, the old adage,

“Doctors do not know business”

rings truer than in any other endeavor.  Medical speakers are very much like retired federal employees, they believe that a $500.00 speak use fee is a “homerun.”  Beginning speakers charge greater than $1,500.00 with no expertise and little or no eloquence.  In CME programs, all of the speakers have “terminal degrees.”  They are doctors.  They possess eight years or more of formal education and another three years or more of postgraduate training.  Why are they charging the same amount as a college student or a construction worker turned speaker? 

The reason is their expectation.  They expect to get $500.00.  I call this the “doughnut money” because most of these medical speakers got their first speaking engagement from a local drug rep that paid them out of the same budget that the drug rep uses to bring doughnuts to the doctor’s staff in the morning.  These “doughnut money” speakers destroy the opportunity for enterprise in the CME market for more eloquent experts.  This is why those of us who are professional speakers for a living simply do not speak in the CME arena.  We ply our trade in more fervent pastures such as the corporate board room or high tech industry. 

So if doctors have expertise but lack eloquence and enterprise, what about ethics?  Aren’t doctors supposed to be the most ethical people?  Don’t we trust them with decisions of life or death?

Physicians are on ethics committees in hospitals and make decisions regarding the appropriateness of each other’s care as well as weighing the risks and benefits of various treatments for various diseases.  In these arenas, doctors are tremendously ethical. 

Unfortunately when it comes to plagiarizing each other’s materials, “borrowing” comic strips, cartoons, and other artwork, even photographs, from copyrighted print material, playing music and even videos without royalty, even playing a recording of another speaker without their knowledge, doctors lack any form of professional speakers’ ethics.  The speaking industry has a strict code of ethics regarding these activities and many others just as the medical profession has a code of ethics within their scope of practice.  Those physicians that choose to live in both worlds choose to live by both codes of ethics and they must learn it. 

My physician colleagues who speak for a hobby are not bad people.  They are simply not educated in the speaking profession.

So what is the solution?

Just as physicians attend continuing medical education (CME), professional speakers attend continuing education dealing with the skills required to advance their Expertise, Eloquence, Enterprise and Ethics. My physician colleagues who choose to “dabble” in professional speaking should go to their local community college and take a speech course as well as creative writing course.  If they took one in college, they need to take it again.  Refreshers are always good.  If they do not want to go to the community college, then they should join Toastmasters International.  This is an excellent opportunity for a new and burgeoning speakers to have their work critiqued (doctors fear critique) and a tremendous venue to try out new material.  They do not have to be afraid of not knowing all the answers because their audience does not care what the message is, they do not care about the expertise.  At Toastmasters International they care about the technique, it is the eloquence that matters. 

If my physician colleagues do not want to join Toastmasters or go to a community college, then they should take an improv course at a local comedy club.  Here they will learn stage presence, timing, pauses, joke writing, and finding the comedy in everyday life. 

Through any one or all of these opportunities, the physician who “dabbles” in speaking can be as good on the platform as the family practitioner who “dabbles” in office surgery.  They will be competent.  They will be selfassured.  They will have great outcome and they will know when they are getting in over their head. . . .  When to ask for help. 

The Race to a Paperless Society

It is amazing how once you notice something, you begin to pay attention and in paying attention you discover a whole new world.

Several weeks ago I wrote an article on portable medical records and the possible uses of technology to bring part of the medical records from novelty status to a mainstream medical device.  A few weeks later I was introduced to a new generation of portable medical records that were capable of synchronizing with the electronic medical records at a physician's office or at a hospital.

For those of you who are not familiar with portable medical records allow me a moment to give some definitions.  A portable medical record is a USB drive device such as a Thumb Drive, a USB wristband, a USB flash drive wristwatch, pendant, or other portable mass storage that can be worn on the body attached to a belt or keys and holds basic medical information in a database form.  Almost all these devices now are password protected and offer varying levels of functionality.

A personal health record is the online equivalent of the portable medical record.  This software exists on the Internet with storage maintained at a third-party site.  The information is again password protected and in an emergency can be accessed by the healthcare provider with an Internet connection and that password.

An electronic medical record is a software package utilized by hospital healthcare facility physicians that replaces the paper patient chart.  This is an official document and subject to significant government regulation.  By 2008 every healthcare provider in the United States must be executing concrete plans to transition from paper to electronic records and by 2014 all paper must be gone.

With that in mind let's turn now back to the portable medical records.  This is a market that is exploding.  A few short weeks ago I wrote an article, my second in this arena, that described nine products of this type.  Two days ago I did a new Google search on this topic (okay, I was desperate for an article topic) and I found no fewer than 24 companies now offering these devices in the United States, Canada and England.  Many of these devices are now being made in Taiwan and China and installed directly on the flash drives.  They are coming in every shape, size and form but unfortunately with little or no functionality.

Yes, they all have some form of password protection and an emergency screen where basic information can be seen without the use of the password.  They hold information such as living wills, organ donor cards, healthcare surrogate contracts, past medical histories, allergies, medications and a few hold greater levels of data.  Two of them integrate with online personal health records but only one can import and export to electronic medical records.

None of these systems however have one basic piece that is required for credibility in the medical world.  It is called change tracking and it is the ability for the healthcare professional reading the portable medical record to look at what changes have been made in the portable medical record and what existed in the record before the change was made.  Change tracking is an internal audit of the system and ensures that there has been no tampering that could threaten a patient's life.

At least there was not such a system until this week.  This week www.theoriginalmymedicalrecords.com announced the prototype release of Version 1.2, a portable medical record with change tracking, high-level encryption and password protection.

This is truly something new and represents a second generation of portable medical record.

Where will this new medical device find a home? 

As the water resistant or splash resistant USB devices these units are already finding a home on the wrists of scuba divers, sky divers, mountain bikers and others who enjoy high fun/ high risk sports.
      
But I envision a larger market.  I envision a day when rather than receiving a flimsy paper wristband at the hospital or nursing home a patient has a portable medical record in a waterproof band around their wrist.  When the nurse comes by with their wireless Tablet computer to chart she simply plugs the patient record band in and the records are immediately synchronized.  The patient goes nowhere without their chart on their wrist.
      
When they go home the patient takes the band with them carrying the entire chart in miniature form.  The hospital has its copy.  The patient has their copy and their copy goes back to the doctor's office.
      
In the event of an emergency the patient's band is on their wrist and it does not matter what emergency room they go into, what EMS service picks them up all the important information is at the fingertips of those there to save their life.
      
I envision a day when my disaster medical assistance team (MDMS/DMAT-FL3) provides care in a Katrina like event after a natural disaster with subsequent flooding and places a USB flash drive wristband around the wrist of every evacuee.  Information on federal assistance, registration for finding lost family members, their own personal information as well as a health record will travel with them from the moment of rescue until their final destination.  If they already had a personal medical record on their wrist or in their pocket or around their neck as an independent we in the MDMS/DMAT-FL3 would be able to plug their device into our computers and upload the important information to help them recover their lives and help us treat their injuries.
      
This second generation of flash drive device holds tremendous promise not only for the transfer of information but even the prevention of medical errors by ensuring that the most basic information is in the hands of those who are making the most important decisions.

Mechanisms of Injury and The All Hazards Approach

The “all hazards” approach to disaster preparedness is based on the concept that while adverse events can not be predicted in their timing, location or type there are limited ways in which they can impact a community, business, or individual. In disaster medicine we call these limited “mechanisms of injury.”  In individuals the mechanisms of injury that may arise regardless of the type of adverse event are:

• Asphyxiation
• Burns
• Crush injury
• Drowning
• Environmental exposure
• Fractures
• Group infections
• Historically poor health
• Impale
• Jolts
• Knucklehead
• Laceration
• Mental health
• Nutrition

Asphyxiation covers everything from smoke inhalation to oxygen-poor environments to noxious gasses to chemical weapons.

Burns may be thermal burns, such as those found in fires and explosions; chemical burns, as found in chemical weapons and inadvertant chemical releases; as well as radiation burns from criticality and non-criticality events alike. 

Crush injuries include everything from motor vehicle accident related injury to entrapment under a fallen building and cave collapses. 

Drowning is quite obvious. 

Exposure includes exposures to hot, cold environments as well as radiation in both the criticality and non-criticality type event.

Fractures are not limited only to bones, but to any body tissue or shock sensitive organ system.

Group infections deal with the events of the sanitation that impact evacuees, refugees and even the rescuers (everybody has heard of the “FEMA flu”). Group infections also include epidemics, pandemics and biological weapons.

Historically poor health deals with that 97% of all medical care rendered after the disaster.  It is the exacerbation of pre-existing medical conditions that is inherent when chronically ill people are exposed to austere medical environments. 

Impalement is again as obvious as drowning.  It includes not only falling upon an object, but being thrown against a penetrating object or having a penetrating object thrown through you.  Thus, it includes bullets as well as shrapnel. 

Jolts are simply electrical injuries. 

Knuckleheads represents all of the group events that culminate in the social anarchy like that which surrounded Hurricane Katrina.  It was the knuckleheads who threw there fellow evacuees from the tops of parking structures and shot at the rescuers and rescue helicopters that attempted to come to the aid of survivors.

Lacerations are again obvious.

Mental health issues are often difficult to differentiate and are only now being recognized as the largest portion of healthcare surge after and event. 

Finally, nutritional issues are perhaps the most difficult to deal with.  A poorly prepared citizenry who themselves have not yet stocked sufficient amounts of food and water for even three days begin the problems while amassing large numbers of refugees and evacuees are a challenge for even the most organized of government agencies.

The predominant theme in “all hazards” preparedness is to develop resilience around the mechanisms of injury and ensure that there are sufficient resources to mitigate any stress along any mechanism.

An Angel Blowin' By

My service at the Louis Armstrong International Airport in New Orleans in the first days and weeks following Hurricane Katrina are the highlight of my career both a disaster responder and a medical professional. Surprisingly, it is not the fact that I reorganized triage along Integrated Triage guidelines, nor the lives saved in the critical care tent, but the life that reached out and touched me that is my most cherished and humbling memory.

It was the third day of operations in the airport. The flight line was still unbelievably busy with 80 to 90 evacuees arriving every 10 minutes. Thanks to the triage process, those requiring medical care were quickly separated from the fortunate majority who only needed transportation to a safer city.

One of those not so fortunate was “Mattie.” “Mattie” was 90 years old, or better, 90 years young. She had been rescued from the attic of her home in the flooded Ninth Ward. “Mattie” had not been able to evacuate despite the fact that she was in excellent health. Prior to the storm she cared for the home where she had raised her children and grandchildren. This spunky dynamo even cut her lawn with a push mower.

“Mattie” had seen the storm devastate her neighborhood and her home. Just when she thought the worst had past, the levee gave way and her home quickly flooded past the safety of the second floor. “Mattie” sought refuge in her attic where she waited for help for three days.

When the Coast Guard rescue swimmer repelled onto her roof with a chain saw and cut a hole, “Mattie” scrambled into the light and the waiting arms of her winged angel. “Matte” arrived at the airport dehydrated and looking terribly ill. Despite this, she had a glowing smile that grew larger as the intravenous fluids and Gatorade began to take effect. Soon “Mattie” was sitting up on her litter and thanking us for coming to help her city.

“Doc, would you pray with me?”

“Mattie’s” request left me a little uncomfortable. I am a devote Catholic, but I am not disposed to public displays of devotion. “Mattie’s” smile was however irresistible.

“Of course I will ‘Mattie’!”

“Mattie” began: “Dear Lord, please bless Dr. Ramirez…”

I was shocked and embarrassed. Here was someone who had lost her home, her community and for all she knew her family yet she was praying for me! Most people would be cursing God for their misfortune. Even those whose faith was strong would pray for their own needs. Here was this incredible woman praying for me.

“Mattie” continued: “… and the heroic men and women who have come here to help us in our hour of need. Surely they are here doing your will. They are your angels here on Earth. Amen”

“Angels” I had never been thought of as an “angel.” I knew I was far from an “angel.” I found myself staring at the floor in shame. I had come here to fulfill my need to serve, to be a part of something important for me as much as for those I served. Now this woman reminded me that my purpose for being was far greater.

“Mattie” soon felt strong enough to stand and walk. Soon she left us to travel to a safer city, but before she left she changed my life. My memory of Katrina is of an angel who visited me in those dark days. An angel I call “Mattie.”

(excepted from my book, Blowin’ Through the Big Easy: Memories of Katrina)