Disaster Medicine

Recommended Curriculum Guidelines for Family Practice Residents

Disaster Medicine

This document has been endorsed by the American Academy of Family Physicians and the Society of Teachers of Family medicine and was developed in cooperation with the Association of Departments of Family Medicine and the Association of Family Practice Residency Directors.

Disasters come in many shapes and forms and it is critical that this curriculum encompasses the depth and spectrum of disasters from natural, to accidental, to intentional acts of violence.

Family physicians stand as the front line to help detect, support, direct and participate in all disasters that might strike a community. For this critical role that family physicians will play in the disasters of tomorrow this curriculum is developed.

Attitudes

The attitudes needed by Family Physicians to deal effectively with disasters are:

Understanding the need to be prepared for disasters that strike the community.
Understanding the importance of team work in the planning, preparation and participation of a disaster event.
Understanding the value of excellent communication skills in a time of crisis.
Understanding the necessity of staying calm and keeping ones wits at a time when there is maximal chaos and confusion.
Understanding the need for resourcefulness when the usual supplies, personnel, communication, and transportation are not available.
Understanding the importance of leadership and followership during a time of crisis.

Knowledge

The Family Physician needs to have an understanding of the following:

Definitions of Importance
1. Disasters
2. Mass Casualties
3. Triage
4. Terrorism
Type of Disasters
1. Natural
  1. Earthquake
  2. Flood
  3. Hurricane
  4. Fire
  5. Tornado
  6. Explosion
  7. Volcanic Eruption
  8. Heat Wave
  9. Cold Wave
2. Accidents
  1. Transportation Accidents (e.g. airplane, bus, train)
  2. Agricultural or Industrial Accident (e.g. insecticides, pesticides)
  3. Chemical or Biological Contamination
  4. Nuclear Accident
3. Intentional Acts of Violence
  1. Physical Attack
    1. Bombing
    2. Shooting
  2. Acts of Terrorism
    1. Nuclear/Radiological
    2. Biological
    3. Chemical
Terrorism Agents
1. Nuclear/Radiological Agents
2. Biological Agents
  1. Bacteria
    1. Anthrax
    2. Cholera
    3. Plague
    4. Tularemia
    5. Q Fever
  2. Virus
    1. Smallpox
    2. Venezuelan Equine Encephalitis
    3. Viral Hemorrhagic Fevers
  3. Toxin (e.g. Botulinum, Staphylococcal Enterotoxin B)
3. Chemical Agents
  1. Nerve Agent (e.g. Sarin, Insecticides/Pesticides)
  2. Blister Agent (e.g. Lewisite, mustard)
  3. Precursors (e.g. Chlorosoman, Chlorosarin)
  4. Choking Agents (e.g. Phosgene, Chlorine)
  5. Blood Agents (e.g. Hydrogen Cyanide, Cyanogen Chloride)
  6. Riot Control Agents (e.g. tearing agents, vomiting agents)
Medical Therapies and Supplies
1. Suggested Pharmaceuticals and Related Supplies
  1. Antibiotics
  2. Cyanide Antidote Kits
  3. Nerve Agent Antidotes (e.g. Atropine, Pralidoxime Chloride, Diazepam)
2. Other Equipment and Supplies required will depend on the nature and the scope of the disaster (See reference 10 on Hospital Preparedness for Mass Casualties)
Decontamination
1. Set up site
2. Personnel trained to use
3. Clean and dirty areas
4. Personal equipment
5. Cleaning agents
6. Plenty of water
Personal Protective Equipment
1. Face masks and respirators
2. Personal protective clothing (e.g. MOPP Gear)
External Coordination
1. Develop an understanding of how to coordinate care with the local community emergency resources.
Internal Coordination with Key Hospital Personnel
Incident Command System (Hospital or Clinic)
1. Incident Commander - who is in charge?
2. Command Team - what is the composition and roles of this team
3. Location of Command Center
Evacuation (Hospital or Clinic). Be aware of the policy and procedures of your clinic or hospital regarding evacuation.
Mental Health/Stress Issues: Survivors of mass casualty events and responders to such incidents (fire, police, rescue workers, health care professionals, etc.) will suffer not only physical injury requiring medical care but also will undoubtedly undergo extreme psychological trauma. Thus these disasters produce both acute and chronic psychologic problems. In a disaster, several different groups would require mental health services, both direct and indirect.
1. Individual survivors presenting or brought to the facility
  1. Patients with special needs (e.g. pregnant women, children, elderly, or those who have an underlying mental health problem)
2. Rescue workers
3. Witnesses to the disaster
4. Family and friends of the missing, injured or dead
5. The "worried well"
6. Facility staff working the disaster
7. Physicians and colleagues
Media Issues
1. Location area out of the way
2. Who informs them? How? When?
3. Communication is critical
Crowd and Traffic Control
Guidelines, Regulations, and Policies
1. JCAHO
2. FEMA
3. State, County, and Local Regulations
4. Hospital and/or Clinic Regulations
Triage
1. Location
2. Leadership - who is in charge?
3. Communication
4. Personnel/manpower
5. Supplies
Areas for Medical Care
1. Locations for emergent, immediate, delayed, minimal, expectant, psychological care
2. Policies
3. Personnel
4. Supplies
Ethical Issues
1. Policies/ prior planning
2. Chaplins
3. Communication
Debriefing
1. When, where, whom
2. Lessons learned
Communication Systems
1. Radios
2. Phones (wired and wireless)
3. Computers (internet)
4. Runners

Skills

Family Physicians should be able to perform:

Triage Skills
1. ABC's
2. Categorization of patients (e.g. emergent, immediate, delayed, minimal, expectant)
Medical/Surgical Skills
1. ATLS Procedures
2. ACLS Procedures
3. PALS Procedures
Wearing of Appropriate Personal Protective Equipment
1. Gas masks, face masks, respirators
2. Protective clothing
Set up and Use of Decontamination Systems
Being An Effective Team Member
1. Leadership
2. Followership
3. Effective communication
4. Staying calm and focused under pressure
5. Using the rest of the team effectively
Development and Utilization of Checklists
1. Supplies and equipment
2. Jobs/responsibilities
Being Part of Planning, Preparation, and Practice of Emergency Response System
Utilization Different Communication Systems
Speaking To The Media or Community About The Event
Conducting Drills
1. Participation
2. Evaluation and feedback
3. Lessons learned
Development of an On-going Trusting Relationships With The Community Organizations
1. Local Health Department
2. Police and Fire Officials
3. EMS

Implementation

The disaster medicine curriculum can be implemented into Family Practice Residency programs both in block format and longitudinally over the entire three years of residency training. In fact it is encouraged to be implemented in both of these fashions.

The block-training phase can be a part of the community medicine rotation. During this phase it is suggested that scenario education occur (both on paper, in person and with computer simulations) as well as visiting different key agencies and discussions with key individuals and planners. It is critical that the residents get to meet with key leaders and discuss issues of how a community will mobilize during a disaster. This knowledge and these skills of working with these different individuals will help them in their future locations for planning, development, training and participation.

The longitudinal training over the three-year residency will primarily consist of lectures, workshops, scenario discussions and most importantly as part of drills that the hospital or clinic should do twice yearly. It is important that the residents be part of performing or evaluating the hospital or community emergency management drills. The experience gained and lessons learned will be important for potential later use in being part of the future development and participation in these programs in their new communities.

Resources

Literature

Arnon S, Schechter R, et al. Botulinum toxin as a biological weapon. JAMA 2001; 285 (8): 1059-1070.
Dennis D, Inglesby T, et al. Tularemia as a biological weapon. JAMA 2001; 285 (21): 2763-2773.
Henderson D, Inglesby T, et al. Smallpox as a biological weapon. JAMA 1999; 281 (22):2127-2137
Inglesby T, Dennis D, et al. Plague as a biological weapon. JAMA 2000; 283 (17):2281-2290
Inglesby T, Henderson D, et al. Anthrax as a biological weapon. JAMA 1999; 281(17):1735-1745
Kortepeter M, Christopher G, Cieslak T, et al. USAMRIID's Medical Management of Biological Casualties Handbook. 4th ed. Fort Dietrick, Maryland: USAMRIID, 2001.
Update: Investigation of bioterrorism - related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep 2001; 50(42):909-919.
Macintyre, Anthony G et al. Weapons of Mass Destruction with Contaminated Casualties: Effective Planning for Health Care Facilities. JAMA 2000; 283:2.
Waeckerle, Joseph F. Domestic Preparedness for Events Involving Weapons of Mass Destruction. JAMA 2000; 283:2.
Hospital Preparedness for Mass Casualties By the American Hospiral Association (March 8-9, 2000) Final report of the "Invitational Forum on Hospital Preparedness for Mass Casualties" held by AHA with support from the Office of Emergency Preparedness of the U.S. Department of Health and Human Services in Chicago, Illinois. The report includes recommendations on community-wide preparedness, staffing, staff training, staff support, internal and external communications, and public policy.
AAFP Home Study Self-Assessment (HSSA), Home Study Audio 276, Bioterrorism, May 2002
AAFP Home Study Self-Assessment (HSSA), Home Study Monograph 276, Biological and Chemical Terrorism, May 2002