CORRESPONDENCE

that we are doing what is right for our patients. •

John C Johnson, MD, FACEP Immediate Past President

Disaster Relief Efforts To the Editor: As two emergency physicians with recent experiences in two different disaster relief/disaster assessment efforts, we comment on the article by Roth et al, "The St Croix Disaster and the National Disaster Medical System" [April 1991 ;20:391-395].

My experience was as part of a US Public Health Service Disaster Medical Assistance Team (DMAT}, which followed the New Mexico DMAT into St Croix. Our team pro- vided care to similar number of patients and similar types of illness- es and injuries as the New Mexico DMAT. The USPHS team consisted of 36 members, of whom 24 were directly involved in patient care [five physicians, ten nurses, four pharma- cists, four EMTs, and one respiratory technician). The remainder were assigned to administration or com- munications. Of the communication group, most were engineers who provided a wide variety of services. These members assisted in repair of medical equipment, the hospital's water chlorination system, and the electrical generating system. They also aided in the planning and construction of additions to the deployable medical systems, which served as the temporary medical facility.

Dr Cloonan's experience was as the medical officer on the Joint Military Task Force Disaster Assessment Team dispatched from Hawaii to Western Samoa in February 1990 after Cyclone Of a struck the island. The cyclone caused extensive wind, rain, and sea surge damage. Dr Cleonan's job was to assess the extent of damage to the health care infrastructure and to provide medicat support to the team.

Dr Cloonan and I have several common observations that deserve comment in light of our different

experiences. Despite our initial pre- conceived ideas, there was, in fact, little need for "emergency" care on our arrival. As is most often the case, for a variety of reasons, medi- cal response teams from outside the disaster area rarely arrive early enough to make a significant contri- bution to "emergency" care. Further- more, cyclones and hurricanes, despite occasionally being very destructive to the health care system in an area, are rarely associated with large numbers of casualties, especially casualties with major injuries. As pointed out by Roth et al, the bulk of the work for medical personnel after a hurricane involves preventive medicine in the form of water purification and sewage dis- posal.

Crucial to performance of these tasks are mechanical, electrical, and biomedical engineers. In St Croix, our engineers performed a wide variety of functions that ultimately resulted in restoration of essential services to the relief effort and to the population in general.

One aspect that Dr Roth neglected to mention is an essential compo- nent to disaster relief: returning the responsibility of health care back to the local health care providers. This transition period is often difficult because of diminished assets, altered or unfamiliar facilities and equipment, and the personal losses of health care providers. One of our first missions in St Croix was to gradually integrate the local providers into the deployable medical system. Providers gradually worked into the call schedule and progressively assumed control of the day-to-day operations. By two weeks, they were fully functional in this temporary facility.

It is clear that disaster relief efforts must encompass a wide variety of missions. The composition of the reIief team is equally impor- tant as team size. It is our opinion that relief teams should include mechanical, electrical, and biomedical engineers. In addition, all disaster response preplanning must include mechanism for early coordination with local health care officials to

integrate the local health care providers into the relief effort, with the ultimate goai of returning the medical operations to the local providers.

Kevin Yeskey, MD, FACEP Clifford Cloonan, MD Department of Military and Emergency Medicine

Uniformed Services University of the Health Sciences

Bethesda, Maryland

The opinions expressed h) the authors

are their own and are nol to be construed

as those <f the Dept~rtment of Dej~nse, the US Public He(dth Ser~,ice, or the

USUHS.

In Reply. We appreciate the comments made by Drs Yeskey and Cloonan regarding our article. It is very true that the main mission of our team was to establish at least a sheraton health care system on a temporary basis until the islanders were able to resume their medical duties after the shock of Hugo. One of the specific goals of the New Mexico DMAT on arrival in St Croix was to avoid taking responsib@y for medical services away from Iocat systems and providers. Thus, from the very beginning, every effort was made to work with and supplement existing health services and personnel The nursing and medical staff had resumed their duties and had been working in the deployable medical system field hospital for 48 hours by the time the Public Health Service DMAT arrived.

From the very beginning, we successfully involved St Croix Hospital doctors, nurses, pharma- cists, administrators, and others in the operation of the deployable medical system hospital and in plan- ning for the provision of health care in the future. We wished to avoid the independent development of DMAT and deployable medical sys- tem hospital operations to later avoid a requirement to integrate St Croix Hospital staff into an estab- lished operation. This was already "their" hospital. Planning the opera- tion, setting up, stocking and staffing the deployable medical system hos- pital to provide patient care were,

from the very beginning, joint efforts by the US Virgin Islands Territorial Health Department, the St Croix Hospital, the New Mexico DMAT, St Croix Emergency Medical Services, and the Alabama Air National Guard 109th Evacuation Hospital.

I also agree with both Drs Yeskey and Cloonan regarding the need for expert technicians- especially biomedical engineers. Clearly, relief efforts for all segments of public utilities must be provided, preferably with advanced planning. As to whether these experts should routinely be incorporated in a DMAT is debatable, as a DMAT is self- contained and has a very limited and quite specific role in immediate provision of health care for a limited time. •

Paul Rot& MD AI Vogel, MD george Key, MO Department of Family, Community and Emergency Medicine

Division of Emergency Medicine University of New Mexico Albuquerque

Sample Size & Selection Criteria To the Editor. We read with interest the article "Emergency Department Treatment of Alcohol Withdrawal Seizures with Phenytoin" [May 199t;20:520-522]. We commend the author for his efforts in addressing this topic, which is of particular relevance for those of us associated with inner- city emergency departments. However, we feel compelled to comment on several issues. These concern primarily sample size and selection criteria.

We question the small sample size used to draw the conclusion to accept the null hypothesis, ie, there is no difference between the pheny- toin and control groups. The author based his sample size calculations on the assumption that alcohol with- drawal seizures have a natural recur- rence rate of 40%, and he wished to detect a difference between this rate and the complete elimination •

1 6 0 / 3 4 4 ANNALS OF EMERGENCY MEDICINE 21:3 MARCH 1992