Introduction

Team-based care is an essential part of the medical response to a disaster. Numerous human-made and natural disasters highlight the need for an organized system-wide approach to disaster medical care. As the scope of a disaster progresses beyond local capabilities outside assistance is often needed. Many disaster response systems throughout the world are organized to provide scalable levels of response at the local, regional, and national levels. These disaster response systems are often organized into teams of disaster workers. Disaster teams vary by country and in terms of their objectives and specialization. An initial disaster response typically includes local or regional emergency medical service personnel or local medical assistance teams. Specialized teams may also be involved including surgical response teams, search and rescue teams, or mortuary assistance teams. Clinicians should understand the levels of response available in their community and the command structure which helps to guide this response.[1][2][3][4]

Issues of Concern

Local Response

In the United States (US) and Europe, the local responders are the foundation of initial disaster response. Bystanders or community members at the incident scene may act as immediate responders, providing initial lifesaving care such as bleeding control. Emergency medical service (EMS) first responders, including emergency medical technicians (EMT) and paramedics, typically make up the initial formal medical response. Local authorities manage the incident and request additional assistance as needed. Locally organized disaster teams in the United States include the Medical Reserve Corps (MRC) and Community Emergency Response Teams (CERT). There are currently hundreds of MRC teams throughout the United States, typically comprised of both retired and active nurses, nursing assistants, EMTs, paramedics, pharmacists, physicians, and public health workers. CERT members may have various medical and non-medical backgrounds. These volunteer teams provide training to members and can be activated to assist with many roles during a disaster response including medical care, mass vaccinations, first aid at large events, medical monitoring at disaster shelters, and various non-medical tasks.[5][6][7][8]

State and Regional Response

When a disaster overwhelms the local capabilities, the next level of response is typically organized at the state or regional level. In the US all 50 states have emergency management agencies which assist with planning, training, and coordination of local agencies and other state-level agencies. In both the United States and Europe, details of the response structure vary by state or region, but generally, the response is coordinated through a regional and state operations center or agency. State emergency management agencies in the United States organize the state’s response teams. These teams may include the National Guard, EMS districts, public health, and nongovernmental organizations such as the Red Cross. Some states have State Medical Assistance Teams (SMAT) which can respond to disaster situations. The capabilities and structure of the SMATs can vary by state; however, they are often comprised of volunteers and have the ability to rapidly respond to a disaster situation to assist with medical care.[9][10]

Federal Response

Large-scale or regional disasters which overwhelm local and state capabilities typically involve a federal response, at the request of state-level authorities. In the United States, the state governors request a national disaster declaration which must be approved at the presidential level. When declared a national disaster, many medical resources from the federal government become available. The National Response Framework (NRF) organizes public health and medical services under Emergency Support Function No. 8 (ESF-8); part of the overall disaster response framework for the federal government. The National Disaster Medical System (NDMS) is a federal resource organized under the US Department of Health and Human Service (US-DHHS). The NDMS coordinates several disaster response teams including Disaster Medical Assistance Teams (DMAT), Disaster Mortuary Assistance Teams (DMORT), National Veterinary Response Teams (NVRT), and Trauma/Critical Care response teams. DMATs deploy to a disaster area within days of a disaster and have the ability to set up a freestanding medical treatment area. Typically a 35-member DMAT team consists of physicians, physician assistants, nurses, pharmacists, paramedics, EMTs, and non-medical logistics and communications personnel. DMAT members are considered intermittent federal employees when deployed. The DMAT brings various medical and non-medical staff members along with shelter, supplies, and medications making it fully self-sustaining for three days. Outside of the US, similar concepts are used. In Japan, smaller DMAT teams of 5 to 6 personnel deploy and remain self-sufficient for up to 3 days. In Israel, there is cooperation and integration between military and civilian reservists. In Turkey, 5-person National Medical Rescue Teams (NMRT) provide specialized care based on local risks. The federal-level response and resources vary from country to country, but in general, is reserved for larger-scale disasters.

Nongovernmental Organizations (NGOs)

NGOs make up a large portion of the response and recovery workforce after a disaster. The assistance of NGOs is vital. While the management responsibility of a disaster resides with governmental officials, NGOs often work under this framework to provide essential health, shelter, and recovery functions. NGOs are typically independent of the government, consist of mostly volunteer members, and do not exist to make a profit on their activities. Well-known NGOs include the International Federation of Red Cross/Red Crescent Societies (IFRC), the American Red Cross, and Medecins Sans Frontieres/Doctors Without Borders.

Clinical Significance

Disaster care teams assist from the initial response through the final recovery phase of a disaster. The initial response, often local EMS or community members, can typically occur within minutes. The state/regional level of response may take hours. Federal response with DMAT teams can take days. Each level of response in the United States, from local to federal, is guided by an overlying structure called the incident command system (ICS). The ICS integrates management of the emergency under several functional areas: command, operations, logistics, planning, and finance/administration. It is important to understand the idea of ICS and how ICS relates to the management of disaster care teams. Clinicians practicing in a disaster area must be aware of the different levels of response and the chain of command established by the ICS which helps to guide the disaster response. Additionally, clinicians and responders in a disaster area must have the ability to be flexible and expect to work in less than ideal conditions. By understanding the types of disaster care teams available and the idea of ICS, clinicians will be better prepared to respond to a disaster in their hospital or community.