Printed in the USA. All rights reserved0736-4679/$–see front matter
doi:10.1016/j.jemermed.2009.08.064
Education
DISASTER 101: A NOVEL APPROACH TO DISASTER MEDICINE TRAINING FORHEALTH PROFESSIONALS
Lancer A. Scott, MD (PI),* Deborah S. Carson, PHARMD, FCCP,† and I. Brian Greenwell, BS‡
*Division of Emergency Medicine, Medical University of South Carolina (MUSC), Charleston, South Carolina, †Disaster Preparednessand Response Training Network, South Carolina Area Health Education Consortium, Charleston, South Carolina, and ‡College of
Medicine, Medical University of South Carolina, Charleston, South CarolinaReprint Address: Lancer Alan Scott, MD, Division of Emergency Medicine, Medical University of South Carolina (MUSC), 169 Ashley
Avenue, PO Box 250300, Charleston, SC 29425
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Abstract—Background: Despite efforts to improve pre-aredness training for health professionals, disaster medi-ine remains a peripheral component of traditional medicalducation in the United States (US) and is a rarely studiedopic in the medical literature. Objectives: Using a pre-/ost-test design, we measured the extent to which 4th-yearedical students perceive, rapidly learn, and apply basic
ECEIVED: 14 February 2009; FINAL SUBMISSION RECEIVED:
CCEPTED: 15 August 2009
220
Keywords—disaster; disaster medicine; emergency pre-aredness; training; medical students; health professional;isaster medicine training; emergency preparedness train-
ng; mass casualty incident (MCI); education; curriculumevelopment; simulation
INTRODUCTION
eviews of health care operations during Hurricane Katrinamphasized the lack of basic training in disaster preparationnd response by physicians as a contributing factor to thedverse patient outcomes (1–6). Other research underscoreshe need for resident subspecialty training, in particular, inmergency Medicine, Anesthesiology, Family Medicine,ediatrics, and Surgery as critical to the future success of
ocal emergency preparedness plans (7–10).In 2003, the Centers for Disease Control and Preven-
ion reported that whereas more than 90% of hospitalsrained nurses and staff physicians for terrorism-relatedonditions, less than half trained residents for the same11). A 2008 survey of Emergency, Family, and Pediatricesidency programs supports the notion that physician
rainees are not being properly trained in disaster medi-ine. Of the respondents in this survey, only 20% ofediatric and Family Medicine Resident training pro-rams in the United States (US) reported adequate trainingor responding to terrorist events, whereas � 50% of Emer-ency Medicine Residency training programs reported ad-
y 2009;
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A Novel Approach to Disaster Medicine Training 221
quate training for events affecting children (10). A 1999urvey of residency programs regarding bioterrorism train-ng capabilities revealed similar findings (12).
Calls for medical students to develop skill-based com-etencies for emergency preparedness predate the terror-st attacks of September 11, 2001. In June 2001, anmerican College of Emergency Physicians task force
ecommended that both residents and medical studentschieve proficiency in the medical response to bioterror-sm and weapons of mass destruction (13). Unfortu-ately, in the years after the 9/11 terrorist attacks, emer-ency preparedness education assessment largely focusedn practicing physicians and not trainees (14–17).
In 2003, the Association of American Medical Col-eges (AAMC) and the Institute of Medicine publishedeports encouraging the early introduction of bioterror-sm topics in medical school. The AAMC report, “Train-ng Future Physicians about Weapons of Mass Destruc-ion,” was the first to detail a vertical integration ofioterrorism curricula into all 4 years of medical educa-ion (18). In response to these reports, medical schoolsncreased the attention paid to bioterrorism topics. In004, 104 of 125 US medical schools reported thatBiological/Chemical Terrorism” was included in one orore required medical school courses (19).Yet, US medical schools have been slow to develop
tand-alone curricula that capture the academic breadthf disaster medicine. For example, a search of theAMC Course Details Database using the terms “disas-
er,” or “preparedness,” or “casualty,” or “bioterrorism,”r “triage” revealed only two courses with any of the aboveerms in their titles (20). And, with the exception of theotable work of some of our public health educators—forxample, those at Columbia University—few medicalchools have defined and implemented core competenciesor all health professionals in Emergency Preparedness suchs those recently advocated by the American Medical As-ociation’s Expert Working Group (21).
Research suggests that health care worker trainingrograms lack clarity, objectivity, competency-drivenoals, scientific rigor, prospective validation, and consis-ency across medical specialties (21,22). This is particu-arly true regarding disaster training for medical students.n our review of the literature, we found only twoublished articles focusing on the feasibility and effi-acy of implementing disaster training to medical stu-ents (23,24). Both focus solely on preclinical medicalducation (i.e., the first and second medical schoolears), only one study implemented performance-basedraining in the study design, and neither study included aretest or post-test to gauge efficacy.
To address this research and training gap, we devel-ped a novel 3-h educational demonstration project and
valuated its effectiveness in teaching medical students a 3
ew key concepts of disaster medicine, including aspectsf incident command, self-preservation, and medical re-ponse. The project was conceived by the Division ofmergency Medicine after it was observed in September007 that most of the graduating medical students had notarticipated in a mass casualty drill nor had they receivedignificant emergency preparedness training. Using a pre-est/post-test design combined with performance-basedraining exercises, we measured the extent to whichth-year medical students perceive, rapidly learn, andpply basic concepts of disaster medicine and emergencyreparedness.
METHODS
n an effort to introduce concepts of disaster medicineithout the necessity of seeking university approval fornew course or changing an existing curriculum, an
pplication was submitted to the Office of Medical Ed-cation to offer a disaster medicine course as part ofInternship 101.” Internship 101 is designed to prepareth-year medical students for their first days as practicinghysician interns. It is composed of dozens of 3-h elec-ive courses that students select based on availability andersonal preference. Our application for “Disaster 101”as accepted in October 2007 with a maximum capacityf 50 students and first scheduled during the 2008 Springemester.
Between January and March 2008, a novel curriculumas developed via a multistage process. First, we part-ered with the South Carolina Area Health Educationonsortium (SC AHEC), who assisted with grant fund-
ng, materials, and training expertise. An expert panel inisaster medicine and curriculum design was convened,onsisting of four Emergency Medicine faculty physi-ians, emergency medical technicians, law enforcement,ducation, and preparedness training experts from the SCHEC. The primary goal of the expert panel was to
ondense dozens of hours of existing didactic materialnd drills into 3 h. The group met three times before thecheduled class date. The primary questions asked of thexpert panel were “What concepts do 4th-year medicaltudents need to know about disaster medicine?” andWhat can be effectively taught to medical students inne class period?”
Utilizing lessons learned from the SC AHEC, thexpert panel decided: 1) the didactic component shoulde case-based so students could recognize the relevancef disaster medicine knowledge and clinical skills noatter where they went into practice; 2) course content
hould be directed toward a general medical trainee so itould develop into an interdisciplinary experience; and
) one-half of the time allotment should be dedicated to
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erformance-based training. Via a modified Delphi tech-ique, the panel pared down numerous disaster medicinend emergency response competencies and competencyomains to eight (Table 1).
Once the competency domains were established, thexpert panel developed the didactic and performance-ased curriculum objectives, a fictional disaster scenario,slide set, and a pre-/post-test. Performance componentsf the hazardous materials (HAZMAT) and mass casu-lty incident (MCI) exercises had been vetted by theC AHEC during similar educational exercises withommunity-based physicians. Competencies and objec-ives were arranged to accommodate the course’s 3-hcheduled time limit (Table 2).
Running concurrent with the curriculum developmentrocess was logistical planning. The MCI exercise re-uired meetings and facility tours to establish a safe siteor trainees, HAZMAT equipment, and mannequins.niversity officials, including those from the Office of
he President, the Board of Trustees, the Office of theean, Medical University Hospital Disaster Prepared-ess Committee, and Parking, were made aware of ourlans to reduce logistical and public relations problems.ublic Safety assisted in cordoning off the area, andublic Affairs actively participated to ensure appropriateedia coverage of the event.
able 1. Disaster 101 Competency Domains
isaster Definition/Incident Command (ICS)ersonal Safetyisaster Communications/Role of PublicSpokesperson/Community Wellness
ersonal Protective Equipment (PPE)riagextrication and Patient Transportationass Decontaminationecognition and Treatment of Toxic Syndromes
able 2. Disaster 101: Final Course Curriculum
0-minute lecture: case scenarioConsent and PretestDisaster Definition/Incident Command (ICS)Personal Safety and Personal Protective Equipment (PPE)START TriageRecognition and Treatment of Toxic SyndromesPost-test
0-minute Hazardous-material ExercisePersonal Safety and Personal Protective Equipment (PPE)Mass DecontaminationRecognition and Treatment of Toxic Syndromes
0-minute Mass Casualty Incident (MCI) Exercise: 100Mannequins
Competency Assessment of START Triage
TART � Simple Triage and Rapid Treatment.ts
The fictional case and a brief overview of appropriateesponses, both at the scene and at the receiving hospital,ere presented by content experts in a traditional lecture
ormat. The case involved an overturned truck on a rural,wo-lane highway with a possible chemical exposure andultiple victims. After the 90-min lecture component,
tudents went outside to be greeted by five tactical emer-ency medical services professionals who divided themnto two groups: one group dressed in HAZMAT suitsnd participated in a simulated chemical spill victimecontamination (Figure 1), whereas the other grouparticipated in the MCI drill that required them to rapidlyriage 100 life-sized inflatable mannequins tagged withhysical parameters indicating respiratory, circulatory,nd mental status parameters (Figures 2, 3). After about0 min, the student groups switched exercises.
igure 1. Students participating in the HAZMAT scene train-ng scenario.
igure 2. Students transporting an inflatable mannequin,
agged with vital signs and clinical information, to a triagetation during the MCI training scenario.
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A Novel Approach to Disaster Medicine Training 223
Due to time constraints, “Disaster Communications” andExtrication and Patient Transportation” were eliminatedrom the exercise, and “Personal Safety” and “Personalrotective Equipment” (PPE) were combined. In addition,
he START (Simple Triage and Rapid Treatment) systemas the only triage paradigm discussed and demonstrated.The pretest/post-test and course evaluations assessed
tudent attitudes, appreciation, and knowledge of the disas-er curriculum. The test developed by the expert panel wasimited to seven multiple-choice questions that assessednowledge of basic disaster medicine concepts. The coursevaluation was a standard College of Medicine course ques-ionnaire. The percentage of correctly tagged mannequinsuring the MCI drill was used to assess learning of theractical aspects of the START system.
All students signed a “Consent and Waiver” prior theourse. To enhance the learning experience, it was decidedhat the students would not be informed about the hazardousaterial or MCI scenarios before the lecture, but that theyould be given an opportunity to decline participation if
hey did not feel comfortable with the exercise. The projectas approved by the University Institutional Review Board.
RESULTS
he course was offered in the spring semesters of 2008
igure 3. MCI triage station for “delayed” patients.
nd 2009. Thirty-five 4th-year medical students were in t
he first class offering and 33 participated in the secondffering. All students consented to full participation be-ore the course. Students in the 2008 class took theretest to survey basic knowledge and assess learning ofhe didactic material immediately before the 90-minase-based lecture, and the post-test immediately afterhe lectures. The 2009 class could take the pretest via an-learning tool up to several days before the class, andhe post-test was available online for 3 weeks after com-letion of the course. Thirty (86%) students completedhe post-test in 2008 and 31 (94%) completed the post-est in 2009.
In 2008, the average of the students’ post-test scoresmproved by 48%, with 39% correct on the pretest and8% on the post-test. In 2009, post-test scores improvedy 21%, with an average of 47% correct on the pretestnd 57% correct on the post-test. In 2008, students par-icipating in the MCI drill correctly tagged 94% of vic-ims in approximately 10 min time. In 2009, studentsarticipating in the MCI drill correctly tagged 90% ofictims in the same time period. In a post-course evalu-tion, students were asked to rate their knowledge ofisaster medicine both before and after the course. In008, before the didactic program, the students ratedheir overall knowledge as 3.76/10 (below average toverage) compared to 7.64/10 (average to above average)fter the didactic program. In 2009, the students ratedheir overall knowledge as 2.52/5 (average) before and.76/5 (above average) after the didactic program. In008, the average overall rating for the experience was.85/5, and 100% of the respondents recommended thelass for next year’s students. In 2009, the course eval-ation did not have an average overall rating. Whensked if they would recommend Disaster 101 to nextear’s students, three students responded neutrally, 14tudents agreed, and 16 students strongly agreed that thelass should be recommended to next year’s students.
DISCUSSION
errorist attacks, weapons of mass destruction, the threatf pandemic influenza, and the recent devastating impactf natural disasters have fostered growth in emergencynd disaster preparedness training for US health careorkers. The Joint Commission now requires all hospi-
als that provide “emergency services” to perform annualommunity-wide disaster drills (25,26). In October of007, President Bush signed Homeland Security Presi-ential Directive 21 calling for the dissemination ofisaster medicine education and training in public healthelds (27). In 2008, Health and Human Services an-ounced they would provide $398 million to states
hrough the Hospital Preparedness Program to help hos-
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224 L. A. Scott et al.
itals improve “surge capacity” and train workers forass casualty events (28).Although some progress has been made, disaster med-
cine and emergency preparedness remain peripheralomponents of traditional medical education in thenited States. Of the many common obstacles encoun-
ered by educators when attempting to implement orhange medical school curricula, the availability of timend the allocation of money are often cited (10).
We believe the principle of a highly effective andell-received medical student course that can be easily
dded to a university curriculum has been demonstratedere. The three major indicators for success of our courseere the pretest vs. post-test grades, course evaluations,
nd MCI exercise performance. Increases of 48% and1%, in 2008 and 2009, respectively, were seen in thecores between the pretest and post-test.
The second indicator was the course evaluation. Inhis evaluation, the students rated the course as a 4.85/5n 2008. Unfortunately, due to a new computerized eval-ation system used in 2009, no overall rating was usedy the students to rate the course. However, in bothears, students were enthusiastic about recommendinghe course to the next year’s 4th-year medical students, aseen by the 100% of 2008 students recommending theourse, and 91% in 2009 saying that they agree ortrongly agree that the course should be recommended toext year’s students, with no students saying that theyisagree with recommending the class to students theollowing year.
Finally, the results of the MCI exercises indicate thatfter the didactic portion of the course, students are ableo apply the material learned to a training scenario.ecognizing that a full-scale MCI drill or actual massasualty incident requires more training in the aspects ofncident management, advanced triage, and medical re-ponse, this brief hands-on experience demonstrated thathe students applied the basics of a simple triage systemith some precision.
imitations
he number of students observed in this educationalemonstration project was small and, as a result, thetudy’s conclusions are not easily generalized. Measur-ng competency is inherently difficult, but even moreifficult when well-validated standards for disaster med-cine are not available. Our pretest/post-test was short toccommodate time constraints and its brevity may haveimited our study’s ability to measure students’ knowl-dge accurately. We were not able to assess long-termecall of the data largely because we had difficulty con-
acting students after they graduated. We also recognize
hat providing the same questions to students before andfter the didactics can confound the knowledge of theaterial with knowledge of the test. Although statisti-
ally sophisticated testing would have been preferable, itas not practicable, nor do we feel it necessary to dem-nstrate the efficacy of our novel curriculum in thisnique academic setting.
We recognize that student answers to our questionegarding self-knowledge may reflect the student’s com-ort with the topic as opposed to knowledge, but theelf-rated assessments were in agreement with the find-ngs of the pretest/post-test scores. Also, we attempted toeasure performance using the percentage of accurate
atient triage during the MCI drill. Our evaluation ofriage skills was not an accurate measure of the compre-ension and retention of the didactic training material, ashere was no “pre” evaluation of the students’ triagekills. Although this was the most accessible methodol-gy available, it is a relatively simplistic measure that inuture studies could be replaced by video reproduction oromputer simulation for competency review.
When using the course evaluations to measure valuef the course as perceived by the students, comparisongainst the other “Internship 101” courses would beeneficial. Unfortunately, we did not have access to thesevaluations.
CONCLUSION
his project revealed that senior medical studentsalue and can rapidly apply core concepts of disasteresponse. We believe the principle of a highly effec-ive and well-received medical student course that cane easily added to a university curriculum has beenemonstrated. To validate core competencies and per-ormance-based education goals for US health profes-ional trainees, medical schools should consider novelpproaches to incorporating disaster medicine intoxisting curriculum.
cknowledgment—Kristin Caldwell Cochran, BBA, is acknowl-dged for her assistance with the administration and planningf the 2008 and 2009 Disaster 101 courses.
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The project outlines a significant research and traininggap in disaster medicine, namely, emergency prepared-ness competencies for health professional trainees. Al-though some progress has been made, disaster medicineremains a peripheral component of traditional medicaleducation in the United States and is a rarely publishedresearch topic in the medical literature.2. What does this study attempt to show?
Using a pretest/post-test design combined with perfor-mance components, we measured the extent to which4th-year medical students perceive, rapidly learn, andapply basic concepts of disaster medicine and emergencypreparedness.3. What are the key findings?
The results of this educational demonstration projectreveal that students will value and can rapidly learn somecore elements of disaster medicine and emergency pre-paredness via a novel addition to a medical school’scurriculum.4. How is patient care impacted?
Patient care is not directly impacted by the results ofthis study. However, we believe that the principle of ahighly effective and well-received medical student coursethat can be easily added to a university curriculum hasbeen demonstrated. To validate core competencies andperformance-based education goals for US health profes-sional trainees, medical schools should consider novelapproaches to incorporating disaster medicine into theirexisting curriculum.
