Cover Story - May 2006
Last year's back-to-back natural disasters known as Katrina and
Rita tested emergency preparation and response in Texas like never
before. As areas ravaged by the storms continue to rebuild, a new
hurricane season officially starts June 1, and Texas is right now
in the middle of the spring severe weather season. In fact, some of
the worst tornadoes in the state's history occurred in
May - Lubbock and Waco come to mind - and there
is no guarantee an F5 twister won't come calling on your
Despite the successes in handling last year's largest
hurricanes, Texas physicians must be prepared for future
catastrophes, whether they're natural or man made.
Kenneth Mattox, MD, professor of surgery at Baylor College of
Medicine and chief of staff/chief of surgery at Ben Taub General
Hospital in Houston, sees another very busy hurricane season
encroaching on the state.
"The Gulf of Mexico did not cool down. Texans can anticipate an
equal number or more tropical storms and hurricanes in comparison
to last season," he said. "Every Texas physician must be prepared
to assume a leadership position, which was demonstrated by many
during Katrina and Rita."
The governor's Division of Emergency Management says Texas leads
the nation in tornadoes and flash floods, and is second only to
Florida in hurricanes. Tropical storms can do as much damage as
hurricanes, as Houston discovered in 2001 when Tropical Storm
Allison dumped 37 inches of rain and caused $5 billion in damage to
the Texas Medical Center and other areas of Harris County.
Quick Action Required
History confirms that a disaster's greatest damage occurs within
its first hours. Dr. Mattox says any community facing a disaster is
on its own during the initial 48 hours. As cochair of the medical
effort at Katrina Clinic, he witnessed firsthand the necessity of
structured leadership for disaster management. (See "
Angels of the Storm," November 2005
"If you have your infrastructure, as we did in Houston, you have
lots of options. If you lose that infrastructure, like New Orleans,
it's a totally different story in relation to leadership,
communication, and rallying individuals to make decisions," he
Houston's success, he maintains, was due to the local Joint
Incident Command (JIC) station. All agencies involved with the
city's largest shelters were required to work through the command
station, which had a military management style, and adhere to its
"There must be a collaborative, integrated network of
government, private, and academic resources within a community.
Outside involvement, even by federal agencies, should be
coordinated through the JIC. Local, state, regional, and national
political agendas should be kept out of the JIC. It's important
that operations and logistics be driven only by the specific needs
of the disaster."
Edward M. Racht, MD, medical director of Austin's Emergency
Medical Services, agrees that the hurricanes demonstrated the
importance of collaboration. He says disasters are too large for
any one entity to manage; he credits the City of Austin's Emergency
Operations Center with being the brain behind Austin's disaster
"Physicians may not understand what to do immediately in a
large-scale event, but they should know how to find out that
information quickly," he said. "For example, I can't tell you what
specific actions at a specific time in a specific place we would
take if a tornado ripped through Austin, because every large-scale
event is dynamic. I can tell you how I would find out what to do.
The Emergency Operations Center would be activated, and the Travis
County Medical Society [TCMS] would start coordinating the
physician response. TCMS has a preplanned paging alert system to
notify physicians of what actions to take."
Journal of Family Practice
olunteer physicians are most effective in a
disaster if they understand the importance of reestablishing the
needed infrastructure, they arrive on scene as part of an organized
response, and they have been trained in disaster medicine and
But while volunteers are necessary to treat a large number of
patients, Dr. Mattox stresses that a system must be in place to use
them effectively. He warns against "disaster voyeurs" and explains
that coordinating volunteers, donated supplies, and outside
government agencies is a continuing challenge at all disaster
"Those in charge have to be careful of people who are just
looking. This is especially important when dealing with medical
professionals. If someone arrives and says, 'I'm a doctor,' or 'I'm
a nurse,' there needs to be a mechanism to ascertain they are
licensed and credentialed. In Houston we turned away 200 because we
could not authenticate that they were doctors and nurses. It turned
out a majority of them were not licensed, did not have an MD."
Dr. Racht says although physicians are key in large-scale
disasters, few are trained to function during such
"Most physicians, when they hear their hospital is conducting a
disaster drill, will do everything they can to avoid getting sucked
into the drill that day. It's time we accept our roles in disasters
and know the necessary information to participate efficiently. The
rest of the health care community is looking at us to be prepared
Physicians who are interested in disaster preparation can join
the Texas Medical Rangers (TMR). The rangers, cosponsored by The
University of Texas Health Science Center at San Antonio and other
state-supported health science centers, are chartered by the
governor. They help public health authorities respond to contagious
diseases and other threats to public health, including
bioterrorism. In March 2003, Gov. Rick Perry made TMR part of the
Texas Military Forces under the Texas adjutant general.
To join TMR, go online to
or call (866) 835-8936 for more information.
Additionally, the American Medical Association's National
Disaster Life Support (NDLS) helps health professionals prepare for
large-scale, catastrophic events, including terrorist attacks,
explosions, fires, and natural disasters such as hurricanes,
floods, and infectious disease outbreaks. To view and register for
NDLS courses, visit the NDLS Foundation Web site at
Better Evacuation Planning
Last October, in the wake of Hurricane Rita, Governor Perry
appointed a 14-member Task Force on Evacuation, Transportation, and
Logistics. The task force defines people with special needs as
"those who cannot take care of themselves during an
Although it recommended that local officials identify and
document special-needs populations in their jurisdictions, the task
force acknowledged that those patients and their caregivers must
plan ahead so they have ample medicine and supplies during the
evacuation and after they reach their destination or shelter.
David Persse, MD, Houston's emergency medical services director,
is concerned about the value of a special-needs registry as there
is no proven way to identify all such persons in a community. He
also worries that people may interpret the registry as a guarantee
they will be evacuated.
"An individual might wait to evacuate because his or her name is
on a list. That's dangerous because the volume is too great. There
is no way the government can provide transportation for everyone
during an impending hurricane. In Houston, we're telling listed
individuals that they need to take responsibility and have a
personal evacuation plan. We're providing them with assets and
In late March, Governor Perry issued an executive order
requiring state officials to develop more detailed hurricane
evacuation plans, including a plan for opening major highways to
one-way outbound traffic as storms bear down on the Texas
State officials are trying to prevent a recurrence of the chaos
that ensued during the evacuation of the Houston area as Hurricane
Rita approached in September. Some 60 people, including 23 nursing
home patients, died along jammed highways.
"Our goal is to learn from the lessons that Hurricane Rita
taught us and make Texans safer in future mass evacuations," the
governor said. "These directives focus on saving lives and reducing
the vulnerability of Texans - particularly those least able to
fend for themselves."
Besides directing state officials to devise a plan for one-way
traffic, or contraflow, the order asks the Texas Department of
Transportation to find a way to provide fuel for evacuees.
Additionally, the order directs the state's emergency management
division to create a computer database of people with special needs
so officials will know who needs help evacuating and where they
live. The division also must work with school districts and
universities to find buses to use in evacuations.
A Feb. 14 report by the task force said fuel shortages along
evacuation routes caused hundreds of motorists to be stranded, and
many could not exit roadways for fuel, food, medical care, or
personal hygiene for long periods of time.
Though severe problems occurred during the Rita evacuation, Dr.
Persse maintains that evacuating too many Houstonians was better
than if thousands had hunkered down in their homes to face the
"It's the lesser of two evils. I'd rather people move than stay
and experience something like New Orleans. Tropical storms and
hurricanes are unpredictable. There's no perfect answer."
Harris County Medical Society President Diana L. Fite, MD, says
Houston's emergency departments were hit hard during the Rita
"People were dropping off elders at emergency rooms while trying
to leave the area. They knew travel conditions were difficult.
Other families had members on respirators and were scared the power
would go out at their homes. They came to hospitals asking if the
ventilators could be hooked up there. Emergency rooms became full
and couldn't provide care for everyday emergencies. It was a
dangerous situation," she said.
"Alternative shelters must be considered," Dr. Mattox said.
"Rather than transporting the very sick and frail from Houston to
Dallas, it might be better to erect a shelter 20 or 30 miles away
in an empty hotel or gymnasium. During Rita, ambulances would bring
nursing home elders to emergency rooms instead of making the
24-hour trip to Dallas. The elders weren't sick and didn't need
emergency care, but the drivers didn't want to spend 24 hours going
up, nine hours coming back, and be out of service. It's
understandable, but hospitals need to be protected from becoming
Dr. Mattox also points out that hospitals should prepare for
being isolated and should have redundant communications systems,
including walkie-talkies. He says satellite telephones were
unreliable in New Orleans, which was unfortunate, as many
considered the technology dependable.
Dr. Persse says it's impossible to know what might occur in a
disaster. Although plans should be based on first reports,
physicians must keep in mind that the situation could change in an
instant - sometimes for the worst.
"Until something is actually occurring, it's all rumor. But you
need to make plans, then plan ahead if things take a turn for the
worst. It's a different but necessary mindset in disaster
situations. In Houston we received information, deciphered how it
could be worse, then made contingency plans."
Physicians interviewed by
consider it a blessing that Houston did not take the brunt of
Katrina's or Rita's wrath. Yet each acknowledged it is only a
matter time before Texas has its own hurricane or other natural
Erin Prather is associate editor of Texas Medicine. She can be
reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax
at (512) 370-1629; or by email at
When Rescuers Needed Rescuing
As the magnitude of the Katrina disaster became known, many
Beaumont-area physicians and other health care professionals
volunteered to go to New Orleans and Biloxi to help where they
could. Little did they know another storm was brewing that would
put their own families, homes, and offices in harm's way.
Allergist William A. Fawcett IV, MD, was one of the physicians
impacted by Hurricane Rita. Strong winds ripped the ceiling off his
four-story office building, causing water damage to his practice on
the third floor.
Dr. Fawcett says although his staff members had not drilled
specifically for a mandatory evacuation, they had discussed what
would occur during emergencies and the types of weather that affect
the Beaumont area. He notes that fire could destroy a practice
anywhere and stresses the importance of backing up business
"It's imperative that business records be moved to a safe
place," he said. "Access to that information is going to have a big
impact on when you're up and running. We anticipated the worst and
covered all records in plastic. Other people in the building lost
everything because they didn't take such precautions."
Michael W. Bungo, MD, vice dean for clinical affairs at Baylor
College of Medicine, believes an electronic medical records system
can preserve records during a disaster. He says physicians can
attempt to protect paper records, but they can be lost forever in a
storm surge from a hurricane or tropical storm, a flash flood, a
tornado, or fire.
Besides saving much of their computer and medical equipment by
covering them in plastic and moving everything off the floor, Dr.
Fawcett and his staff had a backup generator to provide power for
icing down perishable medical supplies. But they couldn't save the
office supplies and furniture.
"The most difficult thing we've had to deal with is the
insurance company," he said. "My wife is a lawyer; her specialty is
insurance coverage. We thought the practice had great policies, but
it's been tedious to follow up with the claims. While I recommend
physicians get a business interruption policy, working with my
company has been ridiculously difficult. At this time, I still
haven't received a dime."
The Texas Medical Association's Physicians Benevolent Fund
raised $225,000 to help physicians in Hardin, Tyler, Jasper,
Newton, Jefferson, Liberty, Chambers, and Orange counties rebuild
their practices. Grants were available to physicians whose
practices incurred uninsured or nonreimbursable damages that
interrupted the delivery of medical care and who could not receive
adequate funding from other sources. At press time, grants totaling
$187,500 had been awarded to 67 physicians in 31 practices.
And, the TMA Board of Trustees waived membership dues for
physicians in any of the affected counties.
Dr. Fawcett says his practice attempted to reestablish contact
with patients after reopening. A Beaumont radio station announced
when physician practices resumed operating and when a practice had
to relocate. Dr. Fawcett's building was gutted, and it will be
months before he can return. He emphasizes that after Rita, his
main priority was to have the practice up and running. Now
relocated temporarily to a different Beaumont office building, he
continues to provide care for his patients as they return.
What should you do to prepare for a disaster?
The January/February 2002 issue of the Texas Medical Liability
, says the fist step in preventing disasters and minimizing risks
"Physicians are owners and operators of small businesses and, as
such, need a plan to deal with disasters that may disrupt or shut
down business. It has been estimated that approximately 25 percent
of small businesses that shut down due to a disaster never reopen.
Even though you may be a solo practitioner, a simple disaster plan
is important," it said.
The article also says emergency plans for any practice are
unique because of the certain needs of practices.
Disaster experts recommend 10 ways to ready yourself and your
practice to deal with an emergency before an emergency strikes.
According to the Jan. 1
Southern California Physician,
- Conduct a risk assessment of all potential hazards or
emergencies for your practice and develop a disaster plan based
on that information. Include emergency escape procedures,
procedures to account for all employees and visitors, and
procedures for reporting emergencies to local authorities.
Practice the plan with your office staff.
- Back up medical records or critical data frequently
throughout the day. Keep copies of data at a remote site or
online. Use Internet-based services such as
www.EZbackup.com, which can back up files from a computer every 24 hours.
- Keep a current phone list for all office staff members and
provide a copy to key staff. If you have a voice-mail system at
your office, designate one remote number on which you can record
messages for employees and give all employees the number.
- Buy three days worth of food and water supplies for yourself
and your staff. Choose nonperishable food items such as canned
meals, fruits, and vegetables, and granola or energy bars. A
small water purifier is recommended as well, in case of water
- Put together a disaster workplace kit of essential items your
practice will need in an emergency, such as a flashlight with
extra batteries, a battery-powered radio, nonprescription
medications, blankets, plastic garbage bags, and a manual can
- Be on the alert for any diseases reportable to the local
health department, such as West Nile virus or avian flu. If you
see a patient with an unusual symptom or disease, report those
cases as well to prevent the spread of a potential communicable
- Review information on biological agents, such as anthrax and
smallpox. Know about symptoms and treatment. Identify resources
for reliable and up-to-date information on biological agents,
such as Web sites of local health departments and the U.S.
Centers for Disease Control and Prevention. TMA has placed a
on the TMA Web site. It includes physician protocols on the
diagnosis, reporting, etiology, and management of anthrax,
botulism, smallpox, and plague, and one-page reproducible patient
handouts on each disease. You can find it under Physician
Resources on the Public Health and Science page.
- In case of an epidemic or communicable disease outbreak, you
should have plenty of personal protective equipment, such as
masks, gloves, and goggles. Initiate purchasing plans with supply
vendors and distributors for protective equipment and other
medical supplies to avoid running out.
- Have first-aid kits and wound care supplies available. During
a disaster, patients who don't require immediate care may be
triaged to your practice. These patients typically suffer from
orthopedic and soft-tissue injuries that are handled easily by
first-aid kits and wound care supplies such as casts and
- Adopt a family disaster plan. The American Red Cross has
developed an online family disaster plan (
) that you can use to maintain communication with your family
during an emergency. Discuss possible hazards, and practice your
plan with your family to ensure your individual
Disaster and emergency experts say physicians shouldn't stop
with these 10 items. Physicians should stay educated on disaster
and emergency procedures by taking courses offered by the state and
various medical organizations.
Preparing for the Next One
The response to the September 2005 hurricanes showed that
emergency management plans were fairly effective. But the TMA
Council on Public Health has identified numerous problems the state
needs to address before the next natural or man-made disaster hits
The importance of preparedness is particularly acute because of
looming threats of pandemic influenza, the spread of avian
influenza to this country, and bioterrorism threats, the Council on
Public Health says in a report to be delivered to the TMA House of
Delegates during TexMed 2006 this month in Houston.
The council recommended TMA take these actions to prepare for
- Ask the American Medical Association to work with experts at
the national level to produce a provider manual on medical
liability and coverage during disasters.
- Ask AMA to work with the American Red Cross to improve plans,
protocols, and policies regarding the provision of health care in
mass casualty shelters.
- Ask AMA to develop templates for private practice/office
continuity plans in CD-ROM or Web-based format with backups to be
stored at state medical association offices.
- Work closely with the Texas Department of State Health
Services (DSHS) in statewide disaster planning efforts and
advocate for stronger roles for county medical societies in local
disaster planning efforts, drills, and other activities.
- Establish a liaison to both the commissioner of health and
the state's emergency coordinator to explore medical needs during
terrorism and natural disasters.
- Work closely with DSHS to establish state-level
communications through the Health Alert Network and help local
health departments or other appropriate agencies expand the
mechanism for informing physicians of essential information on
newly recognized outbreaks.
- Work with DSHS to improve physician reporting and
consultation systems at the state and local levels.
- Work with DSHS to establish standards for local public health
departments to ensure that reporting physicians have immediate or
rapid access to a public health authority who can provide
additional guidance on confirmation and treatment of patients,
especially during natural and biological disasters.
- Work closely with DSHS, in the event of a pandemic or other
infectious disease disaster, to ensure that disaster plans
minimize the negative impact on the health care community.
- Maintain a database of volunteer physicians, coordinating
with state ESAR-VHP (Emergency Systems for Advance Registration
of Volunteer Health Professionals) efforts and including tracking
of member participation in other disaster response organizations
(e.g., local health facility response, the Texas Medical Rangers,
the Medical Reserve Corps, Disaster Medical Assistance teams, and
the Texas National Guard).
- Work with DSHS to define when it will be appropriate to
contact area physicians and ensure that potential volunteers
understand the commitment they are making, including information
on liability, travel expenses, job protection, and personal and
- Examine state laws governing practice and liability under
these various disaster declarations and advocate for any needed
legislative changes to address these issues.
- Work with DSHS to identify specific needs and to deploy
physicians and special services to assist with the medical needs
of shelter evacuees during a disaster.
- Recruit physicians in advance of a disaster with particular
emphasis on assuring sufficient pediatric and other specialists,
including mental health counselors with special efforts to
address the specific needs of patients with mental illness,
Alzheimer's disease, and infectious diseases; long-term care
residents; and pregnant women.
- Encourage local communities to identify, before an event, a
designated infection control practitioner to provide basic
infection control guidance to prevent exposure to or transmission
of infectious diseases in temporary community evacuation
- Educate its members on the essential aspects of terrorism and
disaster medicine through continuing medical education (CME)
programs at TMA meetings and by articles in TMA journals and
newsletters, with special focus given to training on Incident
Command Structure, Basic and Advanced Disaster Life Support, and
triage for health care providers.
- Ensure that physicians understand the circumstances in which
quarantine is appropriate and utilized and how to carry out
complementary, previously determined roles in their practices
regarding surveillance, health care, and public information.
- Promote the Texas Medical Rangers and the Medical Reserve
Corps to physician members.
- Encourage medical educators at all levels to participate in
training physicians in the essentials of disaster and terrorism
medicine relevant to their practice and specialty.
- Encourage each county medical society to appoint a staff
member or member physician to coordinate the society's
participation in disaster preparedness and to participate in
community disaster drills that test these plans.
- Encourage county medical societies to maintain an ongoing
relationship with their local or regional public health
departments and to consider appointing the local or regional
public health director to the board of the county medical society
as a consultant.
- Encourage the county medical societies to work with their
local health departments to compile and maintain a contact list
of physicians (both members and nonmembers) in the community and
to ensure that physician-friendly reporting mechanisms are in
place and that a two-way flow of information exists to provide
incentives for physician collaboration.
- Encourage the county societies to provide a venue for
physician education, work with sponsors of local CME efforts, and
identify members who are particularly interested and may become
peer leaders and educators.
- Encourage the county societies to participate in practice
drills and exercises that involve local health departments and
local emergency response units.
- Encourage physicians and their staff organizations to
advocate for these disaster planning measures in their health
- Encourage individual physicians to have a strategic plan for
covering such eventualities as evacuating their office building,
protecting employees during a communicable disease outbreak,
maintaining continuity of their practice, and maintaining
communication with their families. TMA should provide templates
and guidelines for these types of plans to physicians.