Public Health Feature - July 2008
Tex Med. 2008;104(7):25-28.
By Crystal Conde
Scared, bewildered children and their mothers filed into the San Angelo Coliseum in April, thrust into an unfamiliar environment in a makeshift medical clinic and forced to contend with a culture foreign to them. They looked to physicians there to accomplish one mission: protect their health and well-being.
More than 460 children and their mothers ended up in San Angelo after authorities removed them from the Yearning for Zion Ranch of the Fundamentalist Church of Jesus Christ of Latter-Day Saints in Eldorado. To attend to their medical needs, the Texas Medical Association responded to a request by the Texas Department of State Health Services (DSHS) to gather physician volunteers.
Then-TMA President William W. Hinchey, MD, sent an e-mail asking pediatricians and family physicians to volunteer to screen the women and children. By April 9, approximately 10 physician volunteers, along with nurses and other clinicians, were on site, donating their time and expertise.
Practice Makes Perfect
Sandra Guerra-Cantu, MD, MPH, who was the medical director in San Angelo, says the events leading to a mass-sheltering setting were unique, but thanks to well-rehearsed disaster response plans, the state knew what to do.
Dr. Guerra-Cantu is the DSHS regional medical director and residency program director for the DSHS Preventive Medicine/Public Health Residency Training Program in San Antonio. No stranger to disaster relief, she helped care for evacuees during hurricanes Katrina and Rita. She was on the scene in San Angelo for 15 days.
"We [DSHS] weren't planning on ever sheltering a population made up of a vast majority of children. We did not have that in our plans, but many concepts we have planned for on a regular basis definitely apply to any disaster setting," Dr. Guerra-Cantu said.
Using disaster protocol allows everyone involved to move quickly, set up a command-and-control structure, and mobilize necessary resources. Operating from an emergency response plan allows medical care to be provided in one place and keeps pressure off the local health care community.
DSHS has plans for a number of possible public health disasters and emergencies. Health care professionals and patients can access information about preparedness on the DSHS Web site . DSHS also is working on developing an online system for health care professionals to volunteer in future emergencies.
Once a structure was in place to make sure volunteers functioned uniformly, officials brought in personnel to set up a medical clinic, including an on-site pharmacy to fill prescriptions.
The clinic completed health screenings of more than 450 children in three days. The assessments weren't complete histories and physicals, but gave health professionals an idea of the acute medical needs and chronic medical conditions that could be exacerbated in the shelter.
An urgent care clinic had to be set up in the coliseum, as well. Stephen Seifert, MD, an emergency medicine physician and the health authority at the San Angelo Health Department, received a contract through DSHS to staff the clinic. He worked at the site for eight days.
His team's primary concern was stopping the spread of communicable diseases. A small number of children with chicken pox had to be isolated. Gastroenteritis and upper respiratory infections were also common among the closely quartered patients.
Overall, Dr. Guerra-Cantu says, the patients were in good health.
"The clinicians said it was an amazingly healthy population in comparison to what we're all used to dealing with in terms of obesity and other factors," she said. "That was surprising to most of the clinicians coming in."
With a large number of children requiring medical attention, pediatricians were in high demand. TMA contacted Robert Douglas Schultz, MD, a San Angelo pediatrician at Shannon Medical Center, who was happy to help. He volunteered for four days.
He says TMA's assistance in arranging for physicians to volunteer was invaluable and that the association kept in constant contact with him to answer his questions.
Among the questions on doctors' minds, according to Dr. Schultz, was an uncertainty about the medical liability protections afforded to volunteers. Physicians who volunteer for a government agency may be protected under a state law that safeguards physicians who assist at the request of an authorized representative of a local, state, or federal agency, and also may be protected by the federal Volunteer Protection Act of 1997. (See " Legal Protections for Health Care Volunteers .")
Despite any hesitations volunteers may have had over legal concerns, Dr. Schultz says no one's dedication waivered.
"I feel like we have an obligation to help in those situations," Dr. Schultz said. "You do get a good feeling in the end. Who could turn down helping little kids? They were innocent."
Saundra Seifert, MD, also a pediatrician at Shannon Medical Center, spent three days helping out. She says working around the cultural gap was challenging. For instance, the mothers objected to their children's clothing being removed during examinations.
"We wanted to make sure there weren't any acute illnesses to address. Every once in a while, if we thought we needed to look at skin, we did it and explained why it was necessary," she said.
Dr. Guerra-Cantu also notes that the medical volunteers had to respect the patients' cultural differences.
"They [physicians] had to face an acute need to understand the culture. This was a pretty segregated culture in our society that most clinicians hadn't come in contact with before," she said.
Another difference was the mothers' preference of homeopathic, holistic remedies. Dr. Guerra-Cantu says the mothers understood that prescription drugs were necessary in some circumstances, however.
The mothers also made daily journal entries to document what was occurring, according to Dr. Guerra-Cantu.
"That practice can be viewed by an unsuspecting clinician as antagonistic but had to be understood," she said.
The TMA Web site features a Patient Safety Resource Center that focuses on cultural competency. The Web page provides tools, links, literature, and research for physicians who want to learn more.
A Positive Experience
Watching the medical community pitch in to care for the women and children in San Angelo is an experience Dr. Saundra Seifert will never forget.
"We all have this skill to give. It was nice to know we were contributing in some way," she said. "For the most part, there was a trusting relationship between the doctors and mothers. We were a positive experience for them. We didn't push things they were uncomfortable with. We were there to help. We didn't make any judgments."
During a TexMed 2008 presentation on emergency preparation in Texas, David Lakey, MD, DSHS commissioner, encouraged physicians to take an active leadership role in a crisis. Dr. Lakey says that by working with TMA, physicians can step up to oversee shelter operations, provide disease surveillance and infection control, and attend to the patient populations' mental health needs.
He outlined the following lessons learned from the San Angelo response effort:
- A significant response effort may emerge from a completely unexpected event;
- Sometimes you may be in a lead role and other times a support role;
- Preparations, training, exercises, and skills are transferable; and
- Be flexible.
Indeed, Dr. Guerra-Cantu says her experience in San Angelo was enlightening and illustrated for her the rare opportunity physicians have to serve those who are most vulnerable.
"People trusted us because we're doctors. That inherent trust people have for physicians is universal. To me, that's amazing, and I'm thankful for it every day," she said. "I think a lot of us who responded took to heart our mission: to do everything in our power to protect the health and well-being of the children. We were committed to making sure that happened."
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Legal Protections for Volunteers
Texas law gives certain legal protections to physicians volunteering their services at any time and during emergencies. The Texas Civil Practice & Remedies Code establishes charitable immunity, a doctrine that reduces the liability exposure and insurance costs of charitable organizations, their employees, and volunteers, and maximizes the resources devoted to delivering these services.
The Good Samaritan Law limits the civil liability of those administering emergency care in good faith at the scene of an emergency or in a health care facility.
Physicians providing emergency care are immune from civil liability unless:
- Their actions are willfully and wantonly negligent;
- They expect payment for the care;
- They regularly administer care in a hospital emergency room (unless they are at the scene of the emergency for reasons unrelated to their work);
- Their actions caused the emergency; or
- They are a patient's admitting physician or an associated treating physician.
Overall, physicians generally are immune from civil liability in providing uncompensated emergency care when the need arises, according to Lee Spangler, JD, associate general counsel for TMA.
Physician volunteers have civil liability limits for providing nonemergency care for certain charitable organizations, as well. As a general rule, charitable organizations are those that are exempt from federal income tax by being listed as an exempt organization in Section 501(c)(3) or 501(c)(4) of the Internal Revenue Code.
A physician may qualify as a volunteer health care professional for a charitable organization by voluntarily providing health care services without compensation or expectation of compensation and being licensed to practice medicine or retired and eligible to provide health care services.
A volunteer health care professional for a charitable organization is immune from civil liability for any act or omission resulting in death, damage, or injury to a patient if he or she meets the following criteria:
- The physician acted in good faith in the scope of volunteer duties within the organization;
- The act or omission was committed in the scope of providing health care services;
- The services are provided within the scope of the volunteer's license; and
- The volunteer obtains a written statement signed by the patient or the patient's legal guardian that includes limitations on the recovery of damages from the volunteer and stipulates that the volunteer doesn't expect compensation for the service.
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