The countries pioneer in disaster medical assistance teams, now are inclined to deploy different teams consistent with each kind of disasters or with other effective components on the combination of system. Every disaster has its own condition and would require different combination of relief and medical forces. For example, people’s health needs in flood is different from the earthquake. The characteristics of the affected area and its geographical conditions such as mountainous or desert climate, different seasons of the year and issues like that, have effects on determining the combination of the team. Even in various time periods of a disaster, the deployment of the teams would have a different combination. Medical, health and sanitary needs of the afflicted people in the first days of disaster are different from the next days. According to the experience of Bam earthquake, the disaster can be divided to three phases:
1. Acute phase (the first to the third day after the disaster): in this phase, the main requirement of the field has been trauma management and management of dead people and mental support of injured people.
2. Sub-acute phase (from forth day to two weeks after the disaster): at this time, the major medical requirements of people is controlling chronic diseases such as hypertension, diabetes and giving specialized services for gynecology, otolaryngology(ENT), pediatrics, psychological and infection diseases. In addition, pursuing health problems and prevention of contagious diseases are the priority in this phase.
3. Recovery phase :( after 2 weeks of the disaster): the health and medical services to survivors were closed to the condition of services before earthquake (
Therefore, the necessity of mentioned specialized requirements would be less in the following days comparatively with early days; so maintaining the previous combination of the team is a sort of wasting costs. In other words, by the changing in needs and the expectations from team, the combination of the team is not fixed. After the Los Angeles earthquake, the maximum of injured people presented in the first 48 hours. Most of their complaint in the first 3 days was minor trauma such as lacerations and orthopedic injuries. From the third day, primary care conditions predominated and the main complaints changed to medical profile for gastrointestinal, gynecological and miscellaneous needs. The condition returned to base line after 11 days (
DMAT teams who are deployed to foreign countries for humanitarian aids have different circumstances. Preferably, these teams should be specialized teams and deployment of general teams with low level of specialization should be avoided. On the other hand, deployment of over-specialized teams is not that advantageous. In addition, the conditions of the disaster and the types of requirement and other mentioned criteria should be considered in deployment in order to dispatch a highly efficient and effective team to help the afflicted people. For exemplar, surgical team who sent to Bam by IMSuRT (International Medical/Surgical Response Team) after the 2003 earthquake were including 56 members including one heart surgeon, a pediatrician, a gynecologist, a trauma surgeon, an anesthesiologist, etc. This team visited 727 patients in Bam and performed only 5 surgeries. Other patients who were visited by this team were suffering from general diseases such as anxiety, gynecologic and pediatric diseases (
14). Accordingly, we've concluded that for national deployment, definition of general DMAT teams with a separate combination suit to different situations as type of disaster, afflicted population, time of team deployment to the location, not only is practical, but is economical too.
The combination of the team is divided into medical and non-medical (technical) groups. Non-medical positions are as important as the medical positions. The medical group should include the following 4 groups.
a.Therapy group including physician, nurse, midwife and other therapy personnel.
b.Mental health team including psychologist, psychiatrist, etc.
c.Health group including health experts, health training experts, environmental health engineers and veterinarians, etc.
d.Procurement group and registration including documents specialists and medical register, Stretcher bearers, etc.
Depending on how long after a disaster the team arrives to the scene and on the type of disaster, afflicted population and other conditions, the presence extent of each of four listed groups in the team would be various. The presence of different medical and paramedical specialists in the team is a kind of challenging. One of the most essential and effective specialists who can company the team is emergency medicine specialist. The familiarity with all emergencies and their knowledge about trauma, pediatrics and gynecology, familiarity with different kinds of disasters and methods of response, has made their position to a unique one in the team. Emergency medicine specialists can also be the leader of the team. If an emergency medicine specialist is not in the team, his duties can be delegated to a trained general practitioner or a trained general surgeon. However, these people should attend and pass seriously training courses of disaster and the related skill courses.
Orthopedic surgeon can do casting and splinting and other measurements of orthopedic and start the surgeries if the operation room exists. Except for rare cases, orthopedic emergencies are seen rarely in disaster scenes. The rare cases include dislocations and arterial or neural damages. Most of orthopedic emergency measurements are done by an emergency medicine specialist or a trained general practitioner or a general surgeon. There are not good experiences of orthopedic surgeries in disaster field in all over the world. For example, in the 2001 Gujarat earthquake, the trained orthopedists operated in the affected areas by there were high infection after the operation (
3). In the 2003 Bam earthquake, most of the orthopedic surgeries were done outside of Bam. About half of 563 hospitalized patients in Tehran were suffering from lower limb, pelvic or upper limb fracture ( 15). Of 411 admitted patients in Rafsanjani hospital, 60%underwent orthopedic surgeries ( 16). These surgeries lasted days after the admittance of the patients. Accordingly, it’s better to transfer orthopedic patients outside the disaster field for operation, so the presence of an orthopedist is not necessary in the team. Being accessible in emergency conditions, however, some volunteer orthopedists must necessarily attend training courses. Orthopedic can attend in field hospitals or other equipped centers (e.g. hospitals of the city, when they are not involved in the disaster) and in surgery specialized teams such as IMSuRT.
General surgeon's specialized activities in disaster field include triage, management of burn, neck injuries, vascular damages, airway injuries, acute abdomen and abdominal trauma, difficult urinary catheterization, chest tube, wound management, etc. All the above can be done by an emergency medicine specialist or a trained general practitioner except the procedures needing operation room. Abdominal surgery in disaster scene particularly in the first or second days of the disaster is not logical and decision making for such operation requires some equipment such as ultrasound device or DPL set for diagnosis and operation room for treatment. Management of vascular injuries should be done in the golden time but it is impossible in the disaster field. Totally, a few people from saved ones in the first 24 hours need emergency surgery (
17).The presence of a surgeon in the team is not a necessity but specially in case of absence an emergency medicine specialist, the presence of a surgeon is useful. Also, the surgeon should be present in the nearest equipped clinic (e.g. field hospitals being set up around the affected area).
Gynecology& obstetrics are common diseases in disaster. In addition, premature deliveries are possible due to the stress of the event. Menstrual disorders, vaginal infections are exacerbated after the disaster. Unsafe sexual activities and rapes increase after the disaster and family planning is the requirement of any time. All the above actions can be managed by a midwife and a physician (gynecologist, general surgeon, emergency medicine specialist or even general practitioner). Cesarean section is an exception. If a surgeon is in the team, the presence of a gynecologist is not necessary. If a surgeon is not in the team, the women who need surgery can be transported to a field hospital. Also, a gynecologist can be present in specialized DMATs such as specialized DMATs of genecology or UNFPA (United nation Family planning Activity) or in field hospitals.
Most of the experts believe that the most effective people in crisis management are general practitioners and nurses. The position of a general practitioner in the team is imperative. Most of procedures such as immobilizations, wound care, CPR, etc. can be done by a trained general practitioner. Even some procedures such as chest tube, intubation, etc. can be done by a general practitioner who had taken special courses. Controlling chronic diseases such as hypertension, diabetes mellitus and infectious diseases, etc. can be done by an internal medicine physician. Controlling chronic diseases in acute phase of disaster is not a priority but in sub-acute phase (after the third day), should be considered. Although all of these can be done by a general practitioner or emergency medicine specialist, the presence of an internist can be useful after the acute phase of disaster.
Infectious disease specialists can play an important role in coping with bioterrorism and many man-made disasters. In natural disasters, the presence of an Infectious disease specialist can be helpful for observation, planning and management of infectious and parasite diseases being epidemic after acute phase of the disaster. The diagnosis and treatment of common infectious diseases such as respiratory tract infection and gastroenteritis can be done by general practitioners or emergency medicine specialists. In the structure of general DMATs, volunteer Infectious disease specialists should be registered and attend the training courses but their deployment to the event filed is decided based on the type of the event and the deployment time. There is no logical reason for the presence of neurosurgeons in the team. A neurosurgeon should be in an equipped center with a professional operation room and diagnostic devices. This group can attend field hospitals or other equipped centers (e.g. the city hospital, when it is not involved in the disaster) and specially surgery teams such as IMSuRT.
The presence of a pediatrician in the combination of the deployed team in acute phase is not logical, either. In the following phases as children were 1/3 of the patients, the presence of a pediatrician can be useful, but in the absence of a pediatrician, a general practitioner or emergency medicine specialist can play their role. Registering pediatricians and training them and keeping them in reservation for DMAT teams are sensible in special cases. The presence of anesthesiologists is more vital than other specialists due to their ability in CPR, stabilizing the unstable patients and their knowledge about sedative and analgesic drugs. The presence of anesthesiologists for all the specialized DMATs such IMSuRT is necessary. Generally, DMAT team is not a specialized team. Its duty is mostly the initial resuscitation, triage, helping to transport patients and also treatment of some injuries and diseases. DMAT team should not waste its time on time-consuming procedures on patients or their CPR. Its duty is giving the maximum services to maximum people. Because of this, the presence of specialists in the team when they occupy the general positions is not logical. Regarding the teams being sent to abroad, it is better to send a specialized team with adequate facilities. In addition when we are far from acute phase of disaster, deployment of specialized teams is more logical.
The role of a midwife in the team can be useful in all the phases. The midwives can manage most of gynecology & obstetrics diseases and can work as a substitute for a gynecologist and even they can work as a nurse. About half or all positions of female-nurses in the team can be given to midwives. Menstrual disorders, family planning, pregnant women health care, delivery during disaster, prevention of sexually transmitted diseases, treatment of gynecological inflammations and infections and many other diseases are in specialized field of midwives. If the patients need to visit by a gynecologist, midwives should refer them to the hospitals of the region that their address is given to the commander. In case of the presence of gynecologist in the team, the patients refer to her. It is obvious that this group should participate in special disaster training courses.
A nurse has a key role in the team and can appear as the team commander. Doing triage, treatment, medical records, patients transport, etc. can be done by a trained nurse. The presence of a physiotherapist in the team during acute phase is not efficient. If according to climatic and seasonal conditions and the past history of vaccination in the region, vaccination is required, a person should be sent as a vaccinator with adequate equipment. In the previous investigations, 80-90% of the mortality rate in homeless population in emergency conditions is due to one of the following 5 diseases: malnutrition, measles, acute respiratory diseases, diarrhea and malaria. In disasters, the probabilities to be affected by these diseases are high. Measles is one of the main killers of children under 5 years after all disasters and if the children suffer from malnutrition, this urgency is increased (
18). Vaccination against rabies and tetanus also should be considered.
The mental health services should be started from the earliest moments after the event and even before the relief forces arrive, by all the people who are already trained for this case. Regarding all the events we are informed before their occurrence such as flood and hurricane mental health teams should take the required actions before the event and train the people. Specialized teams of mental health should visit the injured people for a long time after the event. After the 2003 Bam earthquake, the initial interventions of mental health was started by local and international teams in the second day after the event and within 8 months, about 72000 people underwent psychological and psychiatric interventions (
19). One month after the event, 100% of Bam children (7-11 year) were suffering from behavioral disorders, of which 75% were suffering from neurotic disorders, 10% anti-social and 10% were not separable ( 20). But mental health group has another important duty and it is mental support of team members. Using narcotics, alcohol, drugs and sexual intercourse to reduce the stress of team members are forbidden. It seems that in a DMAT general team, the presence of a psychiatrist is not necessary in acute phase of disaster. Its duty such as drug prescription can be done by general practitioner or emergency medicine specialist.
Supervising of water and food safety and sanitation, proper disposal of excreta, garbage and wastage; supervising of burial of corpse and obliterating the animal carcasses, combating against insects, rodents and other disease vectors, disinfection of water wells, surface water management, sanitary wastes disposal and supervision of resettlement of homeless are some of sanitary and health unit activities namely environmental sanitation. Health unit has some duties in the team, too. Food health control and their maintenance conditions, disinfection of patient’s discharges and keeping DMAT location and the patient care place clean, disinfection of ambulance and kitchen and supervision of hospital waste disposal are the duties of this unit. Also, we can add a health training expert for teaching health education to afflicted people and non-professional volunteers. The commander of the event can be one of the medical or non-medical members of team but he shouldn’t have another responsibility at the same time in medical or non-medical group. The main crisis is always consisted of many small crises including crisis of water supply network, crisis of electricity and telecommunication network, security and food, etc. Thus, the deployed team to the field should be a self-sufficient team for a practical time period which shows the high importance of non-medical group of the team.