Disaster Education in Emergency Medicine Residencies Steven J. Parrillo DO, FACOEP- D, FACEP Introduction No one is likely to dispute the need for disaster related education in emergency medicine. After all, who is better at handling a CBRNE / undifferentiated emergency patient than an emergency physician? We could say the same about education that would allow a residency graduate to care for a patient with an acute MI, stroke, DKA etc. The questions, then, is this. Does the residency curriculum include sufficient training in disaster- related issues? The Residency Review Committee and the AOA / ACOEP have requirements, but you might be surprised to know how little that requirement is. For example, RRC accredited residencies must have a minimum of five hours of didactic education per week. That adds up to about 250 hours per year. The combined EMS / Disaster Medicine (the two are traditionally linked) requirement is just 5 hours. Take a look at the AOBEM Table of Specificity (appendix below) to get a sense of how the Board views the importance (H, M, L) of some issues. By the way, the corresponding ACGME document doesn t list anything related to disaster medicine, though several infectious diseases, blast injuries etc are covered in relevant sections. There is just no section specific to disaster medicine. The problem actually begins in medical school. A 2012 Prehospital and Disaster Medicine article described the results of a Johns Hopkins survey that looked at disaster- related education in allopathic medical schools. The results showed that most included little if any, and that medical students wanted more. A group of us are in the process of doing a survey in osteopathic schools. It is almost a given that our results will be similar. I would like to briefly describe the components of disaster education that I believe should be part of every EM residency. ICS/NIMS/HICS Every civilized nation uses some variation of an incident command system. In the US, the standard is ICS under the national umbrella of the National Incident Management System (NIMS). The hospital version is HICS the hospital incident command system. Without going into a great deal of detail about incident command, the importance to our EM residents is that they will someday face multiple or mass casualty incidents. When that happens, they will need a system that is flexible, expandable, assigns specific roles with duties. If there is a single disaster- related educational need in EM residencies, to my mind, this is it.
Phases of Disaster Management Now that emergency management has matured, authorities recognize four (or five) phases. In the old days, the emphasis was on what to do when the unthinkable happens response. While response is still a large part probably a majority for most emergency physicians of disaster management, there are also the phases of preparation, mitigation and recovery. Some residencies include such education, but many do not. Mass Casualty Management Whether the situation is small event (such as a three car pile- up on the highway) for pre- hospital providers or a true MCI like a building collapse with dozens (or hundreds) of casualties, the bottom line is that the need exceeds the available resources. Triage becomes utilitarian (greatest good for the greatest number) and a good triage officer must be able to tag someone as deceased or expectant. Primary treatment is kept to a minimum. CBRNE Incidents While our faculty and residents tend to take pride in their ability to treat whatever comes through the door, a CBRNE incident is unique. Not only are the causative agents out of the ordinary, but the number of victims may very well qualify the incident as an MCI. Emergency Management The relatively new discipline of emergency management has helped people to understand that the old days of asking the Safety Director also serve as the disaster person are over. People now take graduate and post graduate courses in this very diverse and wide- ranging field. Mass Gathering Medicine The preparations for a mass gathering event could take weeks or even months. The variables (location, type of event, age and number of participants etc) all play a role in how the event will play out. Residents rarely have the opportunity to be involved in the planning and management of such an event, though many will play a role once they graduate. Natural Disasters When you think about the typical ED patient or even the ones our residents treat in non- ED rotations you usually don t think about the effects of a tornado, hurricane, flood etc. Unless such an event happens to occur during a resident s time in his program, that resident may not give much thought to natural disasters. Most post graduate programs require that emergency management students take a course in natural disasters.
Key Disaster Legislature There are several that come to mind, but the Stafford Act is clearly the foundation. Others include the various Presidential Directives that mandated such entities as NIMS and the National Response Framework as well as laws that created the 14 Emergency Support Functions. Public Health Implications of Disasters While there are portions of a curriculum that deal with the types of infections or injuries that may happen in a disaster, there is so much more that a good program should teach in the area of public health. Think of the photos from the NOLA Superdome after Katrina to get an idea of what happens when shelter is poor, water isn t clean, bathrooms are inadequate and people can t get there medicines. Hospital Emergency Management All hospital accrediting agencies (TJC etc) have very clear expectations in terms of emergency management. The Joint Commission actually has an entire set of guidelines under the heading EM. Emergency management had formerly been part of the Environment of Care. Many hospitals especially larger ones have full time planners. Most have someone who keeps tabs on regulatory requirements. In the old days, all a disaster committee Chair needed to do was show proof that there were regularly committee meetings and drills. Now the EMC Chair must show the EOP, after action reviews for all drills and show community involvement, surge exercises etc. While all agree that this is a good thing for hospitals, most EM residents have very little contact with the planner or manager unless someone in the department gets them involved in this area. At our residency, for example, the resident who is doing his EMS rotation is invited to sit in on EMC meetings. Residents on their administrative rotations (ours is a four year program with such a month built in for PGIVs) are also invited. Our residents know that their departments and hospitals must be prepared to surge, but don t hear all that goes into making surge possible. Overview of key governmental agencies and teams (FEMA, DMAT, USAR etc) Sometime during the residency there should be education into the role agencies such as FEMA and state counterparts play in disaster response. Most residents know what a USAR team does, but have very little if any idea of how such teams are put together, trained and deployed. Similarly, many have little education regarding use of DMATs, DMORTs etc. The Table of Specificity only mentions DMAT.
Use of Drills and Exercises I think it s safe to say that EM programs do a reasonable job of incorporating their residents into the yearly mandated hospital exercises. Very few residents, however, have any idea that there are tabletops, functional and full scales. Most have not taken part in developing one or doing a hotwash or an after action report. In years past, graduates often found themselves being appointed to a position on a hospital disaster or emergency preparedness committee, so learned via on the job training. Now that many hospitals have full time emergency managers, the EM physician may never learn these skills. There are now several excellent textbooks to consider Ciottone Koenig and Schultz Hogan and Burstein Conclusion By and large, emergency medicine residents leave their programs well prepared to deal with whatever comes through the door. The problem is that most are not prepared to deal with a true disaster. Part of that lies with a curriculum that has to allot educational hours to many important areas areas deemed much more vital for the daily practice of life in the ED. A trusted colleague once told me that WMD should stand for weapons of mass distraction since disaster training takes time from education about things that are much more common. The thinking is often that such an education will be enough to prepare the resident to deal with a disaster or MCI. It isn t. Our challenge is to get medical schools and residencies to recognize that all of us in the discipline must be prepared for the next 9-11 or Katrina or building collapse etc.
AOBEM Table of Specificity for Disaster Medicine (BTW, there is nothing like this in the equivalent ACGME document) 19. Disaster Medicine Definition of disaster Disaster assessment... L Epidemiology of disasters... L Philosophy of disaster management and the incident command system... M Types of disaster/nomenclature Explosions and fires... M Mass crowd gathering events... M Medical response to terrorist incidents (conflict related)... M Natural... M Transportation disasters... M Technologic industrial/hazmat... M Phases of disaster response Notification..L Search and rescue... L Triage.M Medical care of disaster victims... M Disaster communications... L Record keeping... L Transportation and evacuation... L Debriefing/critical incident stress debriefing (CISD)(SEE 18.13.2.3)... L Recovery...L Disaster medical care Rapid assessment of emergency health care needs... M Medical care at mass casualties... M Disaster specific medical problems (SEE 17.0) Mental health and behavioral consequences... L Shock and its treatment in field situations... M Toxic-chemical casualties... M Radiation exposure casualties... M Blast injuries... M Medical supply/equipment management Essential drugs for disasters... L Pharmaceutical distribution/control... L Role of immunizations... L Public health issues after disasters... L Nonmedical emergency responders... L
Disaster information services Local/national/international disaster information... L Public relations... L Media coordination... L Legal aspects.l Disaster education Hospital disaster planning... M Disaster drills M Post-disaster injury prevention and surveillance... M Disaster medical assistance teams (DMATs)... L International relief assistance... L Research Assessment of new methods and procedures... L Testing of new equipment and technologic advances... L Data collection/analysis... L