Surgeons are uniquely qualified to lead the way toward more effective disaster planning and disaster response. They already have the basic skills and training needed to respond quickly.
   "Most sequelae of disaster involve bodily injuries. That is our area of expertise," said Erik Frykberg, MD, chief of general surgery at the University of Florida College of Medicine in Jacksonville. "Providing medical care during a disaster requires rapid decision making under intense pressure. Surgeons do that every day in the OR. We have found that the trauma center is an excellent template for disaster planning."
   "Trauma centers have more day-to-day experience in planning for disasters and managing disaster victims than any other entity outside the military," Dr. Frykberg told the American College of Surgeons Clinical Congress. Like the injuries associated with natural and human-caused disasters, broad patterns of trauma injuries are predictable even though the specific cases brought into the Emergency Department are not.
   Trauma centers are already familiar with basic disaster concepts such as surge capacity, creating extra beds to accept an unexpected surge in patients, and surge capability, and reallocating staff and resources to actually treat the patient surge. Trauma centers already have liaison and communications channels to local police, fire, ambulance, and other first responders. And trauma centers already use triage as standard care.
   But surgeons and other health care personnel are also handicapped by their expertise. Under normal conditions, best care is defined as the care that is best for the individual patient. Under emergency conditions, best care becomes the care that is best for the population as a whole, even if it means allowing individuals to die.
   "That goes against our training and even our morality," Dr. Frykberg said. "The individual loses his or her identity in the need to protect the population before protecting individuals."
   "The twin keys to making the transition are planning and practice," said Jeffrey Hammond, MD, trauma center director at the Robert Wood Johnson University Hospital in New Brunswick, NJ.
   "The purpose of a plan is not to solve all the problems in advance," he explained. "When married to a robust program of training, a plan provides a framework in which you can be adaptable and flexible in responding to any particular disaster situation."
   The Joint Commission on the Accreditation of Healthcare Organizations requires all hospitals to create disaster plans, Dr. Hammond noted. But there are no guidelines as to what should be included, how the plan is to implemented, or even where it is kept.
   Most hospitals forget vital factors such as maintaining communications with police, fire, ambulance, EMT, and other services; security; inventory and resupply of drugs and medical supplies; phone banks and other channels to deal with the flood of public enquiries; and communicating with the media.
   More worrisome, he said, is the tendency to create different plans for different types of disasters.
   "We need to look at this as an all-hazards approach. The only thing worse than having no plan is having two plans. Then nobody knows which plan to follow and what they should be doing next."
   "The biggest problem may be the tendency to rely on outside resources early relief. Surge capacity is a key concept in disaster planning and management, but most U.S. population centers have no surge capacity," warned Paul Carlton, Jr., MD, director for homeland security at Texas A&M University System Health Science Center in College Station, TX.
   "We run 90% to 95% full in our hospitals every day," he said. "And don't forget those living in nursing homes, people who do fine under home care but cannot travel, and other medically dependent populations. If you are going to save lives, it has to be done on the local level because that's where people are."
   "Resources for disaster response must be stockpiled on the local level," said Jay Johannigman, MD, chief of trauma and critical care at University Hospital in Cincinnati. That's because state and federal resources are slow to arrive on the scene of any disaster.
   Federal programs in particular are bound by strict legalities and bureaucracy, he cautioned. Most requests for assistance must begin at the local level and move up through the state to federal authorities through specific channels.
   "It may take 22 steps for a request for assistance to the federal government before anything can move," Dr. Johannigman warned. "You have to have the resources at the local level because that is where the need is. You have to expect to rely on your own resources and self sufficiency for 48, 72, even 96 hours after a disaster hits."