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Do US Emergency Medicine Residency Programs Provide Adequate Training for Bioterrorism?
Abstract
Currently, there is no standardized curriculum for training of emergency physicians about the health hazards related to weapons of mass destruction. Opportunities for the widespread teaching of this material have remained limited, and the range of knowledge regarding even general disaster medical care is also variable among most residency training programs in the United States. We developed a survey to ascertain whether any formal training in biological weapons is conducted in emergency medicine programs; to determine the overall subjective ability of program directors or residency directors to recognize and clinically manage casualties of biological weapons agents; and to identify which resources might be used by emergency physicians to identify and treat biological warfare casualties. We also document a baseline of current practices regarding biological weapons training in emergency medicine residency programs.
... Rose and Larrimore (2002) explain that the current generation of physicians and nurses feel unprepared in both their knowledge base and confidence levels to deal with potential biological terrorism and its consequence. Previous research has underscored this point by showing that community clinicians often are the first to identify potential bioweapon victims yet remain inadequately prepared clinically to address such events (McFee, 2002;Pesik, Keim, and Sampson, 1999;Sniffen & Nadler, 1999). Consequently, it has become clear that there is a pressing need to rapidly educate and train medical personnel on the signs and symptoms and reporting mechanisms of bioterrorism-related diseases (Gershon et al., 2004). ...
... Yet as previously stated in this literature review (Rose & Larrimore, 2002), the current generation of physicians perceive themselves as unprepared in both their knowledge base and confidence levels to deal with potential biological terrorism and its consequences. Previous research has underscored this point by showing that community clinicians often are the first to identify potential bioweapon victims yet remain inadequately prepared clinically to address such events (McFee, 2002;Pesik et al., 1999;Sniffen & Nadler, 1999;Varkey, Poland, Cockerill, Smith, and Hagen, 2002). Consequently, it has become clear that there is a pressing need to rapidly educate and train medical personnel on the signs and symptoms and reporting mechanisms of bioterrorism-related diseases (Gershon et al., 2004). ...
... Rural healthcare settings have few primary care community physicians and often lack specialty physicians altogether. Several previous studies have shown that primary care community physicians (McFee, 2002;Pesik et al., 1999;Sniffen & Nadler, 1999;Varkey et al., 2002) will most likely be the first to encounter sentinel bioterrorist events. Thus, this study is particularly relevant to rural healthcare settings with primary care community physicians. ...
... 1 Since World War II, the need for improvement in disaster medicine training has been acknowledged by governmental and educational institutions. [2][3][4][5][6][7][8][9] The World Trade Center terrorist attacks and subsequent anthrax threats of 2001 and the severe acute respira-tory syndrome (SARS) epidemic of 2003 provide convincing recent examples of the continued need for such training. Disaster planning has become a core curriculum requirement for emergency medicine (EM) residency programs. ...
... 12,13 The majority of health care centers remain ill prepared to deal with a disaster situation. [1][2][3][4]14,15 The lack of a widespread standardized curriculum to train EM residents in disaster medicine may contribute to this deficiency. 2,4,6,7,9 Disasters are rare events, and few residents, therefore, will directly encounter the critical scenarios that they may eventually face during their practice. ...
... [1][2][3][4]14,15 The lack of a widespread standardized curriculum to train EM residents in disaster medicine may contribute to this deficiency. 2,4,6,7,9 Disasters are rare events, and few residents, therefore, will directly encounter the critical scenarios that they may eventually face during their practice. This creates a challenge, since practical handson experiences are thought to provide the most intense and educationally valid learning opportunities. ...
Disaster planning is a core curriculum requirement for emergency medicine (EM) residency programs. Few comprehensive training opportunities in disaster planning incorporating the appropriate competencies have been reported.
To design, pilot, and evaluate a combination interactive Web-based disaster planning curriculum and real-time multidisciplinary full-scale disaster exercise.
Residents were assigned to groups led by a faculty mentor. Each group used an Internet-based platform to review the literature pertaining to their component of a disaster plan. The groups then used the platform to redesign an existing institutional disaster plan. Finally, they implemented their disaster plan for 80 simulated casualties resulting from a police, fire department, and emergency medical services multiple-casualty rescue exercise. All health professions then participated in a joint debriefing session. All aspects of the program were supervised by specialty EM faculty, and the exercise was evaluated using a five-point Likert scale with specific anchored descriptors.
Sixteen residents and 17 faculty members participated in the exercise. Trained volunteers and high-fidelity simulations represented casualties varying in age from 6 months to 65 years, and in severity from ambulatory to moribund. Residents found the exercise enjoyable (4.9/5), relevant (4.6/5), and educational (4.8/5).
Emergency medicine residency programs can benefit from participating in high-quality medical disaster exercises coordinated with local disaster response agencies. Residents report high satisfaction and learning from realistic simulations of disasters, and from collaboration with other community services.
... The literature suggests that physicians as a group are unprepared for this role, 2-5 due to inadequate training [5][6][7] and limited experience. Most professionals will not have real disaster response experience prior to being called to respond. ...
... [11][12][13][14] A call for expanding disaster medicine training was published in 1995, 11 yet standardization of this training is lacking. 7,10 Paradoxically, one study even suggests that disaster medicine education has decreased since 9/11. 15 The Accreditation Council for Graduate Medical Education's (ACGME) Residency Review Committee (RRC) revised common program requirements for family medicine require that "community medicine…curriculum should include…disaster responsiveness." ...
When disasters strike, local physicians are at the front lines of the response in their community. Curriculum guidelines have been developed to aid in preparation of family medicine residents to fulfill this role. Disaster responsiveness has recently been added to the Residency Review Committee Program Requirements in Community Medicine with little family medicine literature support. In this article, the evidence in support of disaster training in a variety of settings is reviewed. Published evidence of improved educational or patient-oriented outcomes as a result of disaster training in general, or of specific educational modalities, is weak. As disaster preparedness and disaster training continue to be implemented, the authors call for increased outcome-based research in disaster response training.
... If respondents do not answer the first question, then the invesfigator can use a reminder notice to encourage compliance. This follow-up reminder can be delivered at 10-14 days after the initial quesfionnaire is provided, and then again four weeks after that (Lopopolo, 1999;Pesik, Keim, & Sampson, 1999;Vaughan-Williams, Taylor, & Whittle, 1999). ...
... The most traditional measure for distribufion is using the conventional mail service (Klessig et al., 2000;Millholland, Wheeler, & Heieck, 1973;Vaughan-Williams et al., 1999). Other investigators have used facsimile (Robert & Milne, 1999) and Email (Pesik et al., 1999) -Tapping et al., 1990;Millholland et al., 1973). Although this pracfice appears to defy the original model, it demonstrates that variations can be exercised in the delivery of the Delphi instrument, which apparently can be custom-tailored to the needs of the respondents and the invesfigators, Sfill other combinafions can be exercised. ...
Thesis (Ph. D.)--Texas Tech University, 2002. Includes bibliographical references (leaves 179-203).
... Most family physicians as a group don't have an adequate training preprepared them for their role in disaster management, so they have limited experiences [4][5][6]. Additionally, most of them didn't have a proper disaster response experience before they are called to respond due to limited disaster training [7]. It was reported that the responsibilities and duties of family physicians in disaster management should be a definite part of their special training [2]. ...
Background: Family physicians have a pivotal role in responding to the medical community's needs and have a crucial role in disaster health management. Family physicians have several tasks and duties during and after the disaster, such as event detection, critical information’ collection and distribution, and rehabilitative activities. It is important to identify the level of awareness of the family physicians regarding their role in the management of disasters. Aim: To assess the awareness of family physician residents of their roles in disaster health management, Saudi Arabia. Methods: This study was cross-sectional; it was performed on Saudi family physician residents in family practice clinics and centers in Saudi Arabia. A self-administrated questionnaire has been sent electronically to the participants to investigate their awareness. IMB SPSS version 22 was used to analyze the collected data. Results: This study included 400 family physicians; more than one-half 52.75%were in the age of 28-30 years old. There were 61.5% worked previously at hospital emergency services. A few percentages reported receiving training on disaster medicine management in the clinic, 38.5%. 47.75% reported willingness to train on disaster management. There was 71% of physicians had high knowledge regarding their role in disaster management. Conclusion: There was high awareness among the family physicians regarding their role in the management of disaster with an acceptable attitude toward receiving training.
... In a 2007 study, Moye et al., 2 found that bioterrorism preparedness had increased from the level reported in a 1999 report. 3 Education and training occurred predominantly through lectures. 2,3 Both 1999 and2007 surveys addressed only bioterrorism training not "allhazards" training. ...
Objective:
Disasters, both natural and man-made, have become commonplace and emergency physicians serve on the front line. Residency may be the only time that emergency physicians are exposed to a disaster, through training, until one happens in their department; therefore, it is critical to provide residents with appropriate and timely disaster education. The goal of this study was to assess the current status of disaster education in emergency medicine (EM) residencies in the United States.
Methods:
A list of disaster topics was generated by reviewing disaster literature and validated by subject matter experts. Between May and December 2016, the authors conducted a national computerized survey of the 229 US EM residencies listed by the American Osteopathic Association and the American Medical Association. It focused on the methods of instruction and amount of time devoted to each topic.
Results:
Of the 229 eligible residency programs, 183 (79.9 percent) completed the survey. Of those, 98.9 percent report teaching disaster management topics. Nine of 18 disaster medicine topics were taught at >60 percent of responding programs. The most common topics were emergency management principles and mass casualty triage, while the least common was hazard vulnerability analysis. The most common method of instruction was lecture (68.5 percent) and the least common methods were journal club and field exercises.
Conclusions:
Broad education in disaster medicine is provided in most US EM residencies. Standardization of topics is still lacking and would be beneficial to encourage comprehensive education. Addressing the educational gaps and curriculum methodology changes identified in this survey would increase curriculum standardization.
... Positive attitudes of FPss on the need for good preparation in case of mass incidents are identical to the attitude of Khorram-Manesh et al., [21] who displayed in the New Global Program study. The current study corroborates international studies indicating that primary care physicians globally are not prepared to deal with the disasters or public health emergencies [10,11,12,22], mainly due to the lack of training and experience [23,24]. Disasters usually come up rather unexpectedly and tend to become more intense as the years go on, but as they are unpredictable, it is very hard to organize proper type of education on preparedness. ...
... Positive attitudes of FPss on the need for good preparation in case of mass incidents are identical to the attitude of Khorram-Manesh et al., [21] who displayed in the New Global Program study. The current study corroborates international studies indicating that primary care physicians globally are not prepared to deal with the disasters or public health emergencies [10,11,12,22], mainly due to the lack of training and experience [23,24]. Disasters usually come up rather unexpectedly and tend to become more intense as the years go on, but as they are unpredictable, it is very hard to organize proper type of education on preparedness. ...
Objective:
To explore family physicians' attitudes, previous experience and self-assessed preparedness to respond or to assist in mass casualty incidents in Croatia.
Methods:
The cross-sectional survey was carried out during January 2017. Study participants were recruited through a Facebook group that brings together family physicians from Croatia. They were asked to complete the questionnaire, which was distributed via google.docs. Knowledge and attitudes toward disaster preparedness were evaluated by 18 questions. Analysis of variance, Student t test and Kruskal-Wallis test t were used for statistical analysis.
Results:
Risk awareness of disasters was high among respondents (M = 4.89, SD=0.450). Only 16.4 of respondents have participated in the management of disaster at the scene. The majority (73.8%) of physicians have not been participating in any educational activity dealing with disaster over the past two years. Family physicians believed they are not well prepared to participate in national (M = 3.02, SD=0.856) and local community emergency response system for disaster (M = 3.16, SD=1.119). Male physicians scored higher preparedness to participate in national emergency response system for disaster (p=0.012), to carry out accepted triage principles used in the disaster situation (p=0.003) and recognize differences in health assessments indicating potential exposure to specific agents (p=0,001) compared to their female colleagues.
Conclusion:
Croatian primary healthcare system attracts many young physicians, who can be an important part of disaster and emergency management. However, the lack of experience despite a high motivation indicates a need for inclusion of disaster medicine training during undergraduate studies and annual educational activities.
... The range of knowledge regarding even general disaster medical care is also variable among most medical professionals. Pesik et aI (1999) had developed a survey to ascertain whether any formal training in biological weapons was conducted in emergency medicine programs, to determine the overall subjective ability or to recognize and clinically manage casualties of biological weapons agents and to identify which resources might be used by emergency physicians to identify and treat biological warfare casualties [18]. The existing lacunae necessitates the urgent introduction of specific syllabi aimed at inculcating knowledge in medical students about bioterrorism. ...
... 24 Two consecutive follow-up reminders were delivered at 10 and 20 days after the initial invitation was sent. 25,26 Demographics/background information was also captured during Round II. The Cherries 27 guideline for confidentiality of subjects was followed and the identification of each Delphi participant remained confidential throughout the study. ...
Background:
The utility of a dedicated clinical test is dependent on the diagnostic accuracy values and the quality of the study in which the test was examined. Scales allow a summative scoring of bias within a study. At present, there are no scales advocated to measure the bias of diagnostic accuracy studies.
Objective:
The objective of this study was to create a new diagnostic accuracy quality scale (DAQS) that provides a quantitative summary of the methodological quality of studies evaluating clinical tests and measures.
Design:
The study used a four-round Delphi survey designed to create, revise, and develop consensus for a quality scale.
Methods:
The four-round Delphi involved a work team and a respondent group of experts. An initial round among the work team created a working document, which was then modified and revised, with opportunities to create new items threaded in the second round. Rounds III and IV involved voting on the importance of each of the proposed items and consensus development from the respondent group. Consensus for the selection of an item required a 75% approval for the importance of that item.
Results:
Sixteen individuals with a variety of research/professional backgrounds made up the respondent group. Modification and revision of the initial work team instrument created a scale with 21 items that reflected potential areas of methodological bias.
Limitations:
The new scale needs validation through weighted assessment. In addition, there was a large proportion of physical therapist/researchers on the work team and the respondent group.
Conclusions:
Systematic reviews allow summation of evidence for clinical tests and scales are essential to critique the quality of the articles included in the review. The DAQS may serve this role for diagnostic accuracy studies.
... The essential resources in providing support to first responders, law enforcement agencies, and the medical community to incidents involving biological weapons include microbiologists, biosafety professionals with a strong foundation in microbiology, and a designated clinical microbiology laboratory (72). The continuing education of medical responders is also an important component of this response network (14,16,56). ...
Biological weapons are not new. Biological agents have been used as instruments of warfare and terror for thousands of years to produce fear and harm in humans, animals, and plants. Because they are invisible, silent, odorless, and tasteless, biological agents may be used as an ultimate weapon-easy to disperse and inexpensive to produce. Individuals in a laboratory or research environment can be protected against potentially hazardous biological agents by using engineering controls, good laboratory and microbiological techniques, personal protective equipment, decontamination procedures, and common sense. In the field or during a response to an incident, only personal protective measures, equipment, and decontamination procedures may be available. In either scenario, an immediate evaluation of the situation is foremost, applying risk management procedures to control the risks affecting health, safety, and the environment. The microbiologist and biological safety professional can provide a practical assessment of the biological weapons incident to responsible officials in order to help address microbiological and safety issues, minimize fear and concerns of those responding to the incident, and help manage individuals potentially exposed to a threat agent.
... Besides , their knowledge, attitude and behavior about health emergencies and the response capacity are directly related to the control and prevention of public health emergencies. However, research have indicated that primary care medical staffs of many countries are not ready to deal with the public health emergencies [8,9,14,15], which mainly due to the lack of training and experience about public health emergencies161718. The public health emergencies are usually sudden, unpredictable and with considerable severity. ...
Abstract Background Primary care medical staffs’ knowledge, attitude and behavior about health emergency and the response capacity are directly related to the control and prevention of public health emergencies. Therefore, it is of great significance for improving primary care to gain in-depth knowledge about knowledge, attitude and behavior and the response capacity of primary care medical staffs. The main objective of this study is to explore knowledge, attitude and behavior, and the response capacity of primary care medical staffs of Guangdong Province, China. Methods Stratified clustered sample method was used in the anonymous questionnaire investigation about knowledge, attitude and behavior, and the response capacity of 3410 primary care medical staffs in 15 cities of Guangdong Province, China from July, 2010 to October 2010. The emergency response capacity was evaluated by 33 questions. The highest score of the response capacity was 100 points (full score), score of 70 was a standard. Results 62.4% primary care medical staffs believed that public health emergencies would happen. Influenza (3.86 ± 0.88), food poisoning (3.35 ± 0.75), and environmental pollution events (3.23 ± 0.80) (the total score was 5) were considered most likely to occur. Among the 7 public health emergency skills, the highest self-assessment score is “public health emergency prevention skills” (2.90 ± 0.68), the lowest is “public health emergency risk management (the total score was 5)” (1.81 ± 0.40). Attitude evaluation showed 66.1% of the medical staffs believed that the community awareness of risk management were ordinary. Evaluation of response capacity of health emergency showed that the score of primary care medical staffs was 67.23 ± 10.61, and the response capacity of senior physicians, public health physicians and physicians with relatively long-term practice were significantly better (P
... Terrorist states and organizations attempting to perpetrate attacks using botulinum toxin to date have been, to our good fortune, unsuccessful (Arnon et al., 2001; Stewart, 2001 ). Clinicians, and the healthcare infrastructure as a whole, have limited awareness and even more limited experience in the recognition and management of casualties of botulism (Pesik et al., 1999; Richards et al., 1999; Rebmann & Mohr, 2008). Also, the lay public has an immediate need for clear, concise, and actionable information that it can process and act upon (Glik et al., 2004; ). ...
A botulism-induced mass casualty incident has the potential to severely compromise a community's health-care infrastructure, based upon its lethality, rare occurrence, and duration of symptoms, which require extensive support and care. Although early recognition and treatment with antitoxin or botulism immunoglobulin are essential to the effective management of this type of an incident, the two major challenges in recognition and treatment are the hundreds, if not thousands, of casualties or potential casualties requiring rapid screening and the fact that most clinicians remain ignorant of the management of botulism. The purpose of this article is to present the Botulism Questionnaire, which will assist with the screening of casualties, provide educational and diagnostic cues for clinicians and the lay public, and create a layer of protection for the health-care infrastructure. The applications of this questionnaire in various formats, the numerous points of distribution, and the variety of platforms from which it can be launched will be explored.
... The essential resources in providing support to first responders, law enforcement agencies, and the medical community to incidents involving biological weapons include microbiologists, biosafety professionals with a strong foundation in microbiology, and a designated clinical microbiology laboratory (72). The continuing education of medical responders is also an important component of this response network (14,16,56). ...
Biological weapons are not new. Biological agents have been used as instruments of warfare and terror for thousands of years to produce fear and harm in humans, animals, and plants. Because they are invisible, silent, odorless, and tasteless, biological agents may be used as an ultimate weapon-easy to disperse and inexpensive to produce. Individuals in a laboratory or research environment can be protected against potentially hazardous biological agents by using engineering controls, good laboratory and microbiological techniques, personal protective equipment, decontamination procedures, and common sense. In the field or during a response to an incident, only personal protective measures, equipment, and decontamination procedures may be available. In either scenario, an immediate evaluation of the situation is foremost, applying risk management procedures to control the risks affecting health, safety, and the environment. The microbiologist and biological safety professional can provide a practical assessment of the biological weapons incident to responsible officials in order to help address microbiological and safety issues, minimize fear and concerns of those responding to the incident, and help manage individuals potentially exposed to a threat agent.
... Recently, less than 40% of emergency medicine residency programs responded positively to reporting all cases of suspected food-borne illness to the proper officials. 19 Regular surveillance and communication may also aid in the mitigation and response to bioterrorism. If ED surveillance is performed on a continuous basis, advanced time-series algorithms can be used to account for the monthly to seasonal periodicity of infectious disease presentation to the ED found in our study. ...
To determine the effectiveness of a simulated emergency department (ED)-based surveillance system to detect infectious disease (ID) occurrences in the community.
Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD-9 codes related to ID symptomatology. ICD-9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross-correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 +/- 0.074; thus CCFs > 0.074 were considered significant for trend correlation. Further cross-correlation analysis was performed after chronic and non-community-acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance.
Fifteen thousand five hundred sixty-nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120).
Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real-time ID surveillance.
... Respondents that did not answer the request for participation were emailed a reminder notice to encourage compliance using a method suggested by Dillman (2000). Two consecutive follow-up reminders were delivered at 10 and 20 days after the initial questionnaire was provided, respectively (Lopopolo, 1999;Pesik et al., 1999;Vaughan-Williams et al., 1999). ...
Accurate ability to diagnose lumbar spine clinical instability is controversial for numerous reasons, including inaccuracy and limitations in capabilities of radiographic findings, poor reliability and validity of clinical special tests, and poor correlation between spinal motion and severity of symptoms. It has been suggested that common subjective and objective identifiers are specific to lumbar spine clinical instability. The purpose of this study was to determine if consensual, specific identifiers for subjective and objective lumbar spine clinical instability exist as determined by a Delphi survey instrument. One hundred and sixty eight physical therapists identified as Orthopaedic Clinical Specialists (OCS) or Fellows of the American Academy of Orthopaedic Manual Physical Therapists participated in three Delphi rounds designed to select specific identifiers for lumbar spine clinical instability. Round I consisted of open-ended questions designed to provide any relevant issues. Round II allowed the participants to rank the organized findings of Round I. Round III provided an opportunity to rescore the ranked variables after viewing other participant's results. The results suggest that those identifiers selected by the Delphi experts are synonymous with those represented in related spine instability literature and may be beneficial for use during clinical differential diagnosis.
... 41 Two consecutive follow-up reminders were delivered at 10 and 20 days after the initial invitation was sent. [42][43][44] Invitations to rounds 2 and 3 of the instrument were automatically distributed through e-mail to all respondents from round 1, providing the respondents with a Web link to the appropriate survey. ...
Clinical cervical spine instability (CCSI) is controversial and difficult to diagnose. Within the literature, no clinical or diagnostic tests that yield valid and reliable results have been described to differentially diagnose this condition. The purpose of this study was to attempt to obtain consensus on symptoms and physical examination findings that are associated with CCSI.
One hundred seventy-two physical therapists who were Orthopaedic Certified Specialists (OCS) or Fellows of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT) participated in the survey.
This study was a 3-round Delphi survey designed to obtain consensual symptoms and physical examination findings for CCSI.
The symptoms that reached the highest consensus among respondents were "intolerance to prolonged static postures," "fatigue and inability to hold head up," "better with external support, including hands or collar," "frequent need for self-manipulation," "feeling of instability, shaking, or lack of control," "frequent episodes of acute attacks," and "sharp pain, possibly with sudden movements." The physical examination findings related to cervical instability that reached the highest consensus among respondents included "poor coordination/neuromuscular control, including poor recruitment and dissociation of cervical segments with movement," "abnormal joint play," "motion that is not smooth throughout range (of motion), including segmental hinging, pivoting, or fulcruming," and "aberrant movement."
The Delphi method is useful in situations where clinical judgments are encountered but empirical evidence to provide evidence-based decision making does not exist. Findings of this study may provide beneficial clinical information, specifically when the identifiers are clustered together, because no set of clinical examination and symptom standards for CCSI currently exists. Diagnosis of CCSI is challenging; therefore, appropriate clinical reasoning is required for distinctive physical therapy assessment using pertinent symptoms and physical examination findings.
Recent worldwide terrorist acts and hoaxes have heightened awareness that incidents involving weapons of mass destruction (WMD) may occur in the United States. With federal funding assistance, local domestic preparedness programs have been initiated to train and equip emergency services and emergency department personnel in the management of large numbers of casualties exposed to nuclear, biological, or chemical (NBC) agents. Hospital pharmacies will be required to provide antidotes, antibiotics, antitoxins, and other pharmaceuticals in large amounts and have the capability for prompt procurement. Pharmacists should become knowledgeable in drug therapy of NBC threats with respect to nerve agents, cyanide, pulmonary irritants, radionucleotides, anthrax, botulism, and other possible WMD.
Background
The increase in natural and man-made disasters occurring worldwide places Emergency Medicine (EM) physicians at the forefront of responding to these crises. Despite the growing interest in Disaster Medicine, it is unclear if resident training has been able to include these educational goals.
Hypothesis
This study surveys EM residencies in the United States to assess the level of education in Disaster Medicine, to identify competencies least and most addressed, and to highlight effective educational models already in place.
Methods
The authors distributed an online survey of multiple-choice and free-response questions to EM residency Program Directors in the United States between February 7 and September 24, 2014. Questions assessed residency background and details on specific Disaster Medicine competencies addressed during training.
Results
Out of 183 programs, 75 (41%) responded to the survey and completed all required questions. Almost all programs reported having some level of Disaster Medicine training in their residency. The most common Disaster Medicine educational competencies taught were patient triage and decontamination. The least commonly taught competencies were volunteer management, working with response teams, and special needs populations. The most commonly identified methods to teach Disaster Medicine were drills and lectures/seminars.
Conclusion
There are a variety of educational tools used to teach Disaster Medicine in EM residencies today, with a larger focus on the use of lectures and hospital drills. There is no indication of a uniform educational approach across all residencies. The results of this survey demonstrate an opportunity for the creation of a standardized model for resident education in Disaster Medicine.
SarinRR , CattamanchiS , AlqahtaniA , AljohaniM , KeimM , CiottoneGR . Disaster education: a survey study to analyze disaster medicine training in emergency medicine residency programs in the United States . Prehosp Disaster Med . 2017 ; 32 ( 4 ): 368 – 373 .
Recent worldwide terrorist acts and hoaxes have heightened awareness that incidents involving weapons of mass destruction (WMD) may occur in the United States. With federal funding assistance, local domestic preparedness programs have been initiated to train and equip emergency services and emergency department personnel in the management of large numbers of casualties exposed to nuclear, biological, or chemical (NBC) agents. Hospital pharmacies will be required to provide antidotes, antibiotics, antitoxins, and other pharmaceuticals in large amounts and/or have the capability for prompt procurement. Pharmacists should become knowledgeable in drug therapy of NBC threats with respect to nerve agents, cyanide, pulmonary irritants, radionucleotides, anthrax, botulism, and other possible WMD.
In the aftermath of September 11(th) and autumn 2001, tremendous efforts have been expended to enhance national preparedness to protect against terrorism and weapons of mass destruction (WMD). However there remain significant vulnerabilities across domains, including communications, health care facility preparedness, professional training. interagency collaborations, public health infrastructure, surveillance capabilities, the food supply the environment and resource allocation. It is a significant challenge to prepare for an unknown event, without a clear-cut indicator of who to protect and from whom. The daunting tasks of preparing a nation, remedying years of under-investment in public health, and promoting cooperative endeavors among agencies unaccustomed to working together cannot be solved merely by money, brief overview training programs, and Quick fixes. None the less, much progress has been made and hope is on the horizon, Although it would seem obvious to include toxicologists in WMD planning, often this is not the case. What role should the poison control and toxicology communities play? What follows is the first of a two-part discussion of our current state of WMD preparedness and the vulnerabilities we must address. Part 2 will examine possible solutions and discuss the critical leadership role toxicology can play in this important arena.
Medical inteligence can be defined as "that category of intdligc:ncc resulting from collection, evaluation, analysis, and interpretation of foreign medical, bio-scientific, and environmental information which is of interest to strategk: planning and to military medical planning and operations for the conservation of the fighting strength of friendly forces and the formation of assessments of foreign medical capabilities in both military and civilian sectors."1
Medical inteIHgence related specifically to the threat of terrorism has obvious applicability to civilian sectors as well. It involves information as applied to the identification, characterization, and management of the risk as applied to both military and civilian c0tu1tcrmcasures against terrorism.
Collection of medical intelligence may include both classified and open sources. Evaluation may involve preexisting publications < >r ongoing publications or ongoing public health surveillance, and it may also include analysis and/or interpretation of well-established or newly gained data. Characterizations may include situational awareness of current events, as well as descriptions of both foreign and domestic medical and public health capabilities and capacity.
The sequence of major events that occurred after entering the twenty-first century have all pointed to an effective emergency response as one of the most complex challenges many countries now face. Social Computing in Homeland Security: Disaster Promulgation and Response presents a theoretical framework addressing how to enhance national response capabilities and ready the public in the presence of human-made or natural disasters. A practical reference for those involved in disaster response and management, this book explores fascinating topics including designing effective threat warning advisories, quantifying public reactions to and confidence in warning advisories, and assessing how anxiety and fear translate into impacts on effective response and social productivity.
Objectives: To determine the effectiveness of a simulated emergency department (ED)-based surveillance system to detect infectious disease (ID) occurrences in the community. Methods: Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD-9 codes related to ID symptomatology. ICD-9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross-correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 ± 0.074; thus CCFs > 0.074 were considered significant for trend correlation. Further cross-correlation analysis was performed after chronic and non-community-acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance. Results: Fifteen thousand five hundred sixty-nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120). Conclusions: Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real-time ID surveillance.
With the recent anthrax attacks, bioterrorism has become a reality in the United States. These attacks have changed our understanding of anthrax and the use of bioweapons (BWs). Emergency department staff will be the first line of defense against probable future attacks. It is therefore critical that medical personnel are trained to recognize, respond to, and manage BW attacks. Recognizing a BW attack requires an understanding of the specific signals indicating a possible outbreak, as well as knowledge of the agents that constitute the most likely threat. Responding to an attack involves the proper notification of public health and law enforcement officials, surveillance tools to alert the medical community, and appropriate communication with the public to prevent panic. Managing an attack, in addition to direct treatment of victims, involves hospital defensive actions and effective utilization of resources and staff. Fundamental to the entire process is appropriate education and training of medical staff. Current data indicates a need for more BWs training to ensure preparedness.
Recent worldwide terrorist attacks and hoaxes have heightened awareness that more incidents involving weapons of mass destruction (WMD) may occur in the United States. With federal funding assistance, local domestic preparedness programs have been initiated to train and equip emergency services and emergency department personnel in the management of large numbers of casualties exposed to nuclear, biological, or chemical (NBC) agents. Hospital pharmacies will be required to provide antidotes, antibiotics, antitoxins, and other pharmaceuticals in large amounts and/or have the capability for prompt procurement. Pharmacists should become knowledgeable in drug therapy of NBC threats with respect to nerve agents, cyanide, pulmonary irritants, radio-nucleotides, anthrax, botulism, and other possible WMD.
Disaster preparedness training is a critical component of medical student education. Despite recent natural and man-made disasters, there is no national consensus on a disaster preparedness curriculum. The authors designed a survey to assess prior disaster preparedness training among incoming interns at an academic teaching hospital. In 2010, the authors surveyed incoming interns (n = 130) regarding the number of hours of training in disaster preparedness received during medical school, including formal didactic sessions and simulation, and their level of self-perceived proficiency in disaster management. Survey respondents represented 42 medical schools located in 20 states. Results demonstrated that 47% of interns received formal training in disaster preparedness in medical school; 64% of these training programs included some type of simulation. There is a need to improve the level of disaster preparedness training in medical school. A national curriculum should be developed with aspects that promote knowledge retention.
Introduction: Events such as September 11, 2001, the 2005 tsunami in southeast Asia, and hurricane Katrina in the United States have emphasized the necessity for disaster medicine education in medical schools internationally. Society expects that physicians will be capable of planning for and managing the consequences to mankind of natural and man‐made disasters. Objective: The purpose of this systematic review was to examine articles related to disaster medicine in indexed peer‐reviewed journals, describing courses for medical students, physicians and medical military, before and after September 11, 2001. Method: This was a systematic review, from 1985 to 2006, in the English language, of four bibliographic databases (ERIC, MEDLINE, Embase, and Healthstar). Methodological quality assessment of courses described in the included articles was completed using the Learning Outcomes Inventory (LOI), which was developed to assess four key components for managing medical education: course objectives, course content, evaluation process, and target audience. Results: The initial search yielded 7595 research titles. With increasing specificity in inclusion and exclusion criteria, 54 articles (34 qualitative/20 quantitative) were retained, with 26 published before September 11, 2001 and 28 after. All articles were evaluated against the criteria from the LOI, resulting in 25 articles graded as weak, 25 as moderate, and 4 as strong. Conclusion: The body of knowledge in indexed peer‐reviewed journals concerning disaster medicine curriculum was limited in quantity and quality before September 11, 2001, but has improved dramatically since. This increase in quality and quantity of published articles is promising in view of the plethora of web‐based reports describing disaster medicine courses that have not been indexed or peer‐reviewed.
Despite efforts to improve preparedness training for health professionals, disaster medicine remains a peripheral component of traditional medical education in the United States (US) and is a rarely studied topic in the medical literature.
Using a pre-/post-test design, we measured the extent to which 4(th)-year medical students perceive, rapidly learn, and apply basic concepts of disaster medicine via a novel curriculum.
Via a modified Delphi technique, an expert curriculum panel developed a 90-min didactic training scenario and two 40-min training exercises for medical students: a hazardous material scene and a surprise mass casualty incident (MCI) scenario with 100 life-sized mannequins. Medical students were quizzed before and after the didactic training scenario about their perceptions and their disaster medicine knowledge.
Students rated their overall knowledge as 3.76/10 pretest compared to 7.64/10 after the didactic program. Students' post-test scores improved by 54% and students participating in the MCI drill correctly tagged 94% of the victims in approximately 10 min. The average overall rating for the experience was 4.85/5.
The results of this educational demonstration project reveal that students will value and can rapidly learn some core elements of disaster medicine via a novel addition to a medical school's curriculum. We believe the principle of a highly effective and well-received medical student course that can be easily added to a university curriculum has been demonstrated. Further research is needed to validate core competencies and performance-based education goals for US health professional trainees.
[Houry DE, Pons PT. The value of the out-of-hospital experience for emergency medicine residents. Ann Emerg Med. October 2000;36:391-393.]
The threat of domestic and international terrorism involving weapons of mass destruction-terrorism (WMD-T) has become an increasing public health concern for US citizens. WMD-T events may have a major effect on many societal sectors but particularly on the health care delivery system. Anticipated medical problems might include the need for large quantities of medical equipment and supplies, as well as capable and unaffected health care providers. In the setting of WMD-T, triage may bear little resemblance to the standard approach to civilian triage. To address these issues to the maximum benefit of our patients, we must first develop collective forethought and a broad-based consensus that these decisions must reach beyond the hospital emergency department. Critical decisions like these should not be made on an individual case-by-case basis. Physicians should never be placed in a position of individually deciding to deny treatment to patients without the guidance of a policy or protocol. Emergency physicians, however, may easily find themselves in a situation in which the demand for resources clearly exceeds supply. It is for this reason that emergency care providers, personnel, hospital administrators, religious leaders, and medical ethics committees need to engage in bioethical decision making before an acute bioterrorist event.
ICD-9-coded chief complaints and diagnoses are a routinely collected source of data with potential for use in public health surveillance. We constructed two detectors of acute respiratory illness: one based on ICD-9-coded chief complaints and one based on ICD-9-coded diagnoses. We measured the classification performance of these detectors against the human classification of cases based on review of emergency department reports. Using ICD-9-coded chief complaints, the sensitivity of detection of acute respiratory illness was 0.44 and its specificity was 0.97. The sensitivity and specificity using ICD-9-coded diagnoses were no different. These properties of excellent specificity and moderate sensitivity, coupled with the earliness and electronic availability of such data, support the use of detectors based on ICD-9 coding of emergency department chief complaints in public health surveillance.
An overview of the special needs of the pediatric population during a mass casualty emergency.
The Connecticut Department of Public Health (DPH) entered into a cooperative agreement with the Centers for Disease Control and Prevention (CDC) to establish public health preparedness and a response plan for bioterrorism. With funds from the CDC and an additional grant from the Health Resources and Services Administration (HRSA), the DPH designated Hartford Hospital as one of two Centers of Excellence that will coordinate and manage a statewide system for bioterrorism preparedness. This paper reviews the progress that Hartford Hospital has made in meeting this challenge. Highlighted are the development of a Web application to use for statewide preparedness and response, and the preparation for a smallpox vaccination program at Hartford Hospital.
While awareness of bioterrorism threats and emerging infectious diseases has resulted in an increased sense of urgency to improve the knowledge base and response capability of physicians, few medical schools and residency programs have curricula in place to teach these concepts. Public health agencies are an essential component of a response to these types of emergencies. Public health education during medical school is usually limited to the non-clinical years. With collaboration from our local public health agency, the Emory University School of Medicine developed a curriculum in bioterrorism and emerging infections. By implementing this curriculum in the clinical years of medical school and residency programs, we seek to foster improved interactions between clinicians and their local public health agencies.
Early recognition of a terrorist attack with biologic agents will rely on physician diagnosis. Physicians' ability to diagnose and care for patients presenting after a bioterror event is unknown. The role of online case-based didactics to measure and improve knowledge in the diagnosis and treatment of these patients is unknown.
A multicenter online educational intervention was completed by 631 physicians at 30 internal medicine residency programs in 16 states and Washington, DC, between July 1, 2003, and June 10, 2004. Participants completed a pretest, assessing ability to diagnose and manage potential cases of smallpox, anthrax, botulism, and plague. A didactic module reviewing diagnosis and management of these diseases was then completed, followed by a posttest. Pretest performance measured baseline knowledge. Posttest performance compared with pretest performance measured effectiveness of the educational intervention. Results were compared based on year of training and geographic location of the residency program.
Correct diagnoses of diseases due to bioterrorism agents were as follows: smallpox, 50.7%; anthrax, 70.5%; botulism, 49.6%; and plague, 16.3% (average, 46.8%). Correct diagnosis averaged 79.0% after completing the didactic module (P<.001). Correct management of smallpox was 14.6%; anthrax, 17.0%; botulism, 60.2%; and plague, 9.7% (average, 25.4%). Correct management averaged 79.1% after completing the didactic module (P<.001). Performance did not differ based on year of training (P = .54) or geographic location (P = .64). Attending physicians performed better than residents (P<.001).
Physician diagnosis and management of diseases caused by bioterrorism agents is poor. An online didactic module may improve diagnosis and management of diseases caused by these agents.
Understanding and quantifying the impact of a bioterrorist attack are essential in developing public health preparedness for such an attack. We constructed a model that compares the impact of three classic agents of biologic warfare (Bacillus anthracis, Brucella melitensis, and Francisella tularensis) when released as aerosols in the suburb of a major city. The model shows that the economic impact of a bioterrorist attack can range from an estimated $477.7 million per 100,000 persons exposed (brucellosis scenario) to $26.2 billion per 100,000 persons exposed (anthrax scenario). Rapid implementation of a postattack prophylaxis program is the single most important means of reducing these losses. By using an insurance analogy, our model provides economic justification for preparedness measures.
Context.
—This large outbreak of foodborne disease highlights the challenge of investigating outbreaks caused by intentional contamination and demonstrates the vulnerability of self-service foods to intentional contamination.Objective.
—To investigate a large community outbreak of Salmonella Typhimurium infections.Design.
—Epidemiologic investigation of patients with Salmonella gastroenteritis and possible exposures in The Dalles, Oregon. Cohort and case-control investigations were conducted among groups of restaurant patrons and employees to identify exposures associated with illness.Setting.
—A community in Oregon. Outbreak period was September and October 1984.Patients.
—A total of 751 persons with Salmonella gastroenteritis associated with eating or working at area restaurants. Most patients were identified through passive surveillance; active surveillance was conducted for selected groups. A case was defined either by clinical criteria or by a stool culture yielding S Typhimurium.Results.
—The outbreak occurred in 2 waves, September 9 through 18 and September 19 through October 10. Most cases were associated with 10 restaurants, and epidemiologic studies of customers at 4 restaurants and of employees at all 10 restaurants implicated eating from salad bars as the major risk factor for infection. Eight (80%) of 10 affected restaurants compared with only 3 (11%) of the 28 other restaurants in The Dalles operated salad bars (relative risk, 7.5; 95% confidence interval, 2.4-22.7; P<.001). The implicated food items on the salad bars differed from one restaurant to another. The investigation did not identify any water supply, food item, supplier, or distributor common to all affected restaurants, nor were employees exposed to any single common source. In some instances, infected employees may have contributed to the spread of illness by inadvertently contaminating foods. However, no evidence was found linking ill employees to initiation of the outbreak. Errors in food rotation and inadequate refrigeration on icechilled salad bars may have facilitated growth of the S Typhimurium but could not have caused the outbreak. A subsequent criminal investigation revealed that members of a religious commune had deliberately contaminated the salad bars. An S Typhimurium strain found in a laboratory at the commune was indistinguishable from the outbreak strain.Conclusions.
—This outbreak of salmonellosis was caused by intentional contamination of restaurant salad bars by members of a religious commune.
"The role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all." This 1981 resolution of the World Health Assembly (resolution WHA 34.38) recognizes that the greatest threats to the health of the people of the world lie not in specific forms of acute or chronic disease, not even in poverty, hunger, or homelessness, but rather in the consequences of war. Any war, and even preparation for war,1 can of course lead to poverty, hunger, homelessness, and disease. Indeed, these consequences make even "victory," or the quest for "national security" through massive arms expenditures, seem hollow. Among the dangers of war, the greatest single threat lies in weapons of indiscriminate mass destruction, which The Journal recognizes annually with its Hiroshima anniversary issue.Nuclear Weapons
Nuclear weapons remain the most potentially destructive of all these
[Okumura T, Takasu N, Ishimatsu S, Miyanoki S, Mitsuhashi A, Kumada K, Tanaka K, Hinohara S: Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med August 1996;28:129-135.]See related editorial, Chemical Agent Terrorism.
Disaster education in US emergency medicine residency programs
- Kallus L J Burstein
- Richman
Kallus L, Burstein J, Richman P: Disaster education in US emergency medicine residency programs [abstract]. Disaster '97 Conference, Orlando, FL, 1997.
Recommendations for OEP/CDC Surveillance, Laboratory and Informational Support Initiative
- Keim Me
- Af Kaufmann
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Keim ME, Kaufmann AF, Rodgers GC: Recommendations for OEP/CDC Surveillance, Laboratory and Informational Support Initiative. Atlanta, GA: US Centers for Disease Control, National Center for Environmental Health, May 4, 1998.
Fairfax man accused of anthrax threat
- Bates
Bates S: Fairfax man accused of anthrax threat. Washington Post March 3, 1992;C-3.