Disaster medicine: the birth of a specialty?
James Matheson interviews some experts on the potential of this exciting new specialty
In May 2006 the American Board of Physician Specialties announced board-certification in Disaster Medicine and, in the United States, a new specialty was born. The Florida hurricanes and a heightened awareness of the terrorist threat in the wake of 9/11 had demonstrated America’s vulnerability to disaster and concerns were high about the ability to respond.
Dr Maurice A. Ramirez, founder-chairman of the American Board of Disaster Medicine (ABODM) explains why: “The most ominous words ever uttered by a disaster preparedness expert were that given the current state of hospital preparedness and the rate at which facilities are becoming disaster ready, there will be no meaningful level of preparedness in this decade unless someone blows up a hospital.
“This may seem extreme but declassified documents show that Al Qaeda seeks to steal an ambulance and blow it up at a major American trauma centre.
“Unfortunately, this scenario is the lesser of threats currently facing healthcare. History has taught us that novel avian pandemic flu occurs every 91 years (plus or minus 3.5 years for antigenic drift). Given that the last major pandemic was the 1917/1918 Spanish flu this means that we can expect a pandemic flu outbreak between 2006 and 2013. It is a mathematical certainty.”
This situation was addressed at the highest level. Homeland Security Presidential Directive (HSPD-21) was issued in October 2007 stating that, “…the Nation must collectively support and facilitate the establishment of a discipline of disaster health. Such a discipline will provide a foundation for doctrine, education, training, and research and will integrate preparedness into the public health and medical communities.” (1)
A curriculum was devised that covered the medical response to natural disasters from floods to volcanic eruptions, mass casualty accidents and deliberate acts of violence including nuclear, biological and chemical attacks. In the official press release (2) Dr David McCann, vice-chairman of the ABODM elaborated on the knowledge required: “You have to be well-versed in the incident command system, the national incident management system and the federal response plan. You have to have knowledge of blast injuries and biochemical and radiological injuries due to terrorism, as well as basic emergency medicine - anything from concussions to broken bones to multi-system trauma, shock and death. You have to be well-versed in how to triage in a mass casualty situation. You may have hundreds, thousands, or even tens of thousands who need your help simultaneously.”
The curriculum is broad. It covers recognition and treatment of anthrax, cholera and plague as well as outbreaks of Venezuelan Equine Encephalitis caused by terrorist release. Clinical skills alone, however, are not enough - disaster physicians are also required to establish the decontamination site and lead the response as a field team commander or at a higher command centre nearby.
“…the criteria for ‘Board Certification’ are high because these are designed for those involved in advanced levels of planning such as community level, regional or national response”, Dr Ramirez clarifies. “The ‘average’ physician involved in disaster response is best served by a knowledge of primary care, the skills built by daily medical practice and skills to ensure their own safety i.e. the AMA’s National Disaster Life Support (NDLS) training.”
The NDLS courses offer four levels of disaster training from the Core Disaster Life Support for allied health professionals, through Basic and Advanced where treatment in all-hazards scenarios is practiced on high fidelity mannequins, to NDLS Instructor. The courses are increasingly available at hospitals and medical colleges across the United States and train participants not just in treatment skills but in the broader disaster response system.
The establishment of a new specialty of medicine on the other side of Atlantic has some considering whether there is a requirement to formally meet the same demands in the UK. US Disaster Medicine evolved from the medical challenges of man-made and natural disasters and the UK has a long history of similar catastrophes, reinforced recently by rail crashes, flooding and the terrorist attacks on Glasgow airport and in London.
There has always been the threat of violence, however, and for as long as there have been natural disasters people have been coping with their consequences. The doctors and surgeons dealing with the casualties on 21 July came from a variety of specialties and worked without the benefit of disaster training. Is there, then, really a justification for founding a new specialty to meet a need already met?
In the US, HSPD-21 emphasised that, “…the establishment of a robust health capability requires us to develop an operational concept for the medical response to catastrophic health events that is substantively distinct from and broader than that which guides day-to-day operations.” (1)
One medical student with an eye on the development of Disaster Medicine as a specialty and its introduction to undergraduate teaching is Rob Stellman, a student representative of the Catastrophes and Conflict Forum at the Royal Society of Medicine.
“It would make both the service and staff more resilient to those unpredictable disasters that lie ahead. That means better care for victims but it also means medics themselves will be in a better position to cope with what can be intensely traumatic experiences.
It means more reassurance for the public and, likely, lower costs too but, perhaps most importantly, the teaching of Disaster Medicine should reflect the wider move to health promotion, with a focus on the role of doctors in incident-planning - preventing catastrophes is better than cure.”
A major incident will stretch any hospital’s manpower and resources and here, Mr Stellman believes, students have a role: “Number one, we’re liable to be involved in the field whether we know it or not. Many trust major incident plans make reference to student involvement, as does recent planning from the Department of Health but, unfortunately, this expectation is often not communicated to students. Disasters by their nature are difficult to predict in location and timing so there’s the potential to find oneself in the thick of things for all of us - even when not at the hospital.
“Secondly, factors like global politics, technological advance and events like London 2012 are presenting new or increased disaster threats, which as both students and doctors we will need to be aware of. It’s not just terrorism - British doctors are likely to be playing an increasing role in the aftermath of disasters overseas like the Boxing Day Tsunami or the Pakistan Earthquake.
“Finally, the specialty itself is a new and exciting one to be involved in, with lots of scope for academic involvement (and even some clinical work) while at medical school.”
Rob Stellman’s international perspective is well-founded. Doctors trained in the UK have responded to many of the major acute natural disasters or more chronic health emergencies around the world. The skills they require to meet patients’ needs in these environments are often very different to those required for work in the UK’s National Health Service (NHS). To provide the best care possible in such circumstances, training in Disaster Medicine needs to be part of the undergraduate and postgraduate education and training curriculum. With resources in the NHS tight, justification must be made for any diversion of funds within education. Training which meets a high-profile domestic requirement as well as a potentially much larger (but more distant from the tax-payer) need abroad may be an effective means to find funding.
Of course, for Disaster Medicine to be effective globally, it needs to become not just the specialty of those countries rich enough to indulge, but a basic element of the medical education of doctors everywhere, especially in those countries with populations most vulnerable to disasters’ effects.
Dr Ramirez agrees. He will be visiting the UK for a conference on Disaster Medicine in the summer and his views on its global importance are clear:
“There is a place for the specialty of Disaster Medicine in every medical community, including the United Kingdom. The Disaster Medicine community internationally must move beyond national boundaries, professional politics and territorialism to work cooperatively and collaboratively to serve those most in need.”
James Matheson
3rd year medical Student
St George’s, University of London
London
m0501997@sgul.ac.uk
To find out more about Disaster Medicine and becoming involved, visit:
-Catastrophes and Conflict Forum, Royal Society of Medicine at www.rsm.ac.uk
-Faculty of Conflict and Catastrophe Medicine, Society of Apothecaries of London at www.apothecaries.org
(1) United States of America. Homeland Security Presidential Directive 21. [Presidential Directive online]. Washington: George W. Bush; 2007. [cited 2007 Nov 25]. Available at http://www.whitehouse.gov/news/releases/2007/10/20071018-10.html
(2) Guadagnino C. Board certification offered in disaster medicine. Physician’s News Digest [serial online]. May 2006. [cited 2007 Nov 25]. Available at http://www.physiciansnews.com/spotlight/506.html
Bookmark on delicious | Digg
February 18th, 2008 at 5:34 am
I would like to commend the author on his thorough survey of disaster medicine. However, the statement that “a new specialty was born” does not accurately convey the controversy surrounding this move. The American Board of Physician Specialties, which sponsors the disaster medicine board, is by far the smallest certifying body in the U.S. (By far the largest and most widely recognized is the American Board of Medical Specialties.) The ABPS is not recognized by the American Medical Association, the largest multi-specialty organization in the U.S., nor by by the American College of Emergency Physicians, the founding organization of emergency physicians in the U.S.
This is not to say that these organizations or American physicians as whole do not recognize the value of disaster medicine. On the contrary, ACEP has an active disaster medicine section, and there are a number of fellowships in disaster medicine in the U.S. ACEP and other groups are working together to develop a disaster subspecialty board that would be recognized by ABMS.
I agree with Dr. Ramirez that “the disaster medicine community internationally must move beyond national boundaries, professional politics and territorialism [sic] to work cooperatively.” However, without the support of the house of medicine in the U.S., it is premature to hail a new specialty.
Marlow Macht
Candidate for MD-MPH in 2008
Tulane University
New Orleans, Louisiana, USA