Enoch Choi, MD, an urgent care physician and partner at Palo Alto Medical Foundation in California, found himself in a sweltering Wal-Mart parking lot in St. Bernard Parish, New Orleans, in early October. He was surrounded by National Guards toting M16s, Coast Guard personnel, Federal Emergency Management Agency officials, and lots of dehydrated, sick, and injured area residents. That was when he began to really appreciate the three hours of AMA Category 1 continuing medical education on disaster preparedness he got at a pre-conference activity at the American Academy of Family Physicians annual meeting. As part of a Christian medical relief team sent to help in the post — Hurricane Katrina Gulf Coast efforts, Choi received training from his church in cultural sensitivity, working in a shelter environment, and dealing with social challenges, and of course he was well versed in the clinical aspects of emergency medicine through his usual CME course load. But what he learned from the three Marines who led the AAFP activity about establishing chains of command and communications in an emergency situation proved to be even more valuable, he recalls. “I'm Advanced Trauma Life Support — trained, so I can resuscitate anybody,” he says. “Those marines gave us a broader level of training: How to coordinate the care of a small community, how to establish a command-and-control structure, how to make appropriate triage decisions, and how to work with the various agencies involved in the situation.” In other words, not your usual CME.
Disaster-response training is as different from traditional CME activities as the aftermath of a killer hurricane is from the usual day in the office. These programs teach physicians and other healthcare workers skills that usually lie far outside the realm of CME, such as how to communicate with the various federal, state, regional, and local authorities under chaotic circumstances; in other words, how to work in a multi-specialty, multi-disciplinary environment that extends to fire, police, the military, and beyond. Then there are the other challenges for organizers: funding that comes and goes with the news cycle, a reluctance on the part of physicians and other healthcare workers to spend time learning something they fervently hope they'll never need to know, and the tangle of agencies that must coordinate their training efforts for the activity to be effective.
Disaster-preparation training may not seem to be worth the hassle, but as the past 12 months' worth of tsunamis, earthquakes, hurricanes, terrorist bombings, and other natural and man-made disasters — not to mention the pending threat of an avian flu pandemic — have made all too clear, this type of training is essential for all healthcare workers, not just those usually found on the front lines of emergency care, because disaster can strike anywhere, any time.
Traditional CME activities will only get you so far in terms of truly preparing healthcare workers for a catastrophic situation. Jeffrey P. Gold, MD, senior vice president for medical affairs and Dean of the College of Medicine, Medical University of Ohio, Toledo, says, “While I'm pretty sure the emergency medicine physicians will know how to respond to the emergency in the emergency room, and pediatricians will know how to treat children affected by a mass casualty incident, I'm not sure even the most-prepared two or three specialties are prepared for working with each other and with the public health teams that ultimately manage these responses.” For example, dermatologists not only have to know how the biological and chemical agents present dermatologically and how to treat these conditions as part of their medical responsibilities, but they also need to understand their reporting responsibilities: Under what circumstances do they need to call the Department of Health? Whom do they call? How do they reach them? “These are critical questions when time matters — you don't want to have to go to the Yellow Pages,” Gold says.
James J. James, MD, director of the American Medical Association Center for Disaster Preparedness and Emergency Response, Chicago, adds, “If we teach people how to handle smallpox, from Step 1 to Step 100, and we have all the vaccines and supplies ready to go, we're going to look great if the agent that's used [in a bioterrorist attack] is smallpox. We're not going to look so good if any one of a thousand other agents are used.”
Gold believes it's time to stop focusing efforts on “educating people on what they already know. I'm more concerned about educating people on their role in the system, not their role in patient care. They may not be current on some of the specific medical issues, but if you've taught them where to go, they'll be able to get themselves up to that state of readiness very quickly with just-in-time education.”
He adds, “We need to get them to think like an epidemiologist, to know how to activate the system, and to know what to do if a situation enters into a nonmedical arena.” Docs need to know how to work in the area of a terrorist act without compromising evidence-gathering or other aspects of criminal investigation, for example. “There is a whole host of skills and knowledge beyond what you get in medical school that I think we need to focus on in the CME field.”
But preparing for disaster can be overwhelming. “[Some physicians] want to learn more about smallpox, or they feel they don't know enough about chemical agents, but overall disaster-preparedness training seems kind of nebulous. There's a lot of confusion about what it entails, and what has to happen before someone is actually prepared.” says Andrew Crim, executive director, professional and continuing education, University of North Texas Health Science Center at Fort Worth.
AMA's James says his office is currently conducting research on which educational format — an exercise, a didactic lecture, or a Web-based program — is most effective for disaster-preparation training. While the data is not yet in, most would agree that a live exercise where healthcare workers practice decontamination, do mass triage, run an emergency operation center, and work with the other disciplines, is effective in increasing long-term knowledge. But while that's the ideal, you don't have to put on a full-blown simulation to contribute to effective disaster training.
Since the state of California already offers annual statewide simulations of various emergency situations, the California Medical Association several years ago began providing CME credit for taking part in the three-day-long disaster-preparedness conferences that are held in different parts of the state each fall in preparation for the state's disaster drill. The Emergency Medical Services Authority puts together a program on how to prepare for whatever disaster scenario the state simulation will be based upon, and there's a day-long boot camp that's more hands-on for first responders the day before the conference, according to CMA spokesperson Karen Nikos. “They talk about how to turn a cafeteria into a morgue, or what to do in the case of an earthquake, when the next shift can't make it into the hospital to relieve the staff.”
“You need to have a combination of traditional CME activities and simulations,” says Crim, whose office provided preliminary CME on radiological and chemical preparedness and response in preparation for a radiological mass-casualty simulation in North Texas, in which it also participated. “We laid groundwork before the activity for hospital-based healthcare providers who would be receiving the patients, but they didn't know that would be the subject of the simulation,” he says. The simulation itself then put that knowledge to the test.
Gold, who has taught crisis management extensively and is working with the AMA and Department of Homeland Security on developing a Web-based primary-responder course, believes that interactivity is key. During a course for thoracic surgeons, he employed a simulated mass-casualty disaster, then screened disaster scenes and used an audience-response system to allow participants to select their course of action. “We dimmed the lights and set off a powder-keg bomb, and we had arranged for the local fire and rescue people to arrive as they would for a real event. When a bomb goes off and covers everyone with talcum powder, it gets people to focus on some of the serious questions,” he says.
Tabletop exercises — where firefighters, paramedics, physicians, public health officials, law enforcement, and representatives of all the other agencies involved in crisis management sit down at a table and prepare a response to a specific scenario — also can be very effective for disaster preparation, says Elizabeth Kachur, PhD, medical education development, Psychosocial Aspects of Bioterrorism and Disaster Medicine, New York University School of Medicine, New York. “The isolation of the two New Orleans hospitals after Hurricane Katrina, where communication wasn't possible and the hospitals themselves became dysfunctional, that would have come up in a credible tabletop exercise,” she says.
Leonard J. Marcus, PhD, co-director, National Preparedness Leadership Initiative, Harvard School of Public Health, Boston, says a tabletop exercise his preparedness center held this fall in Boston pinpointed some important areas that need attention.
The exercise, which included the area's major hospitals and focused on a flu pandemic with fatalities, showed that it wasn't just a matter of being able to rally the respirators, face masks, and medicines. One thing that came out of it was “that there's a need for redundancy when it comes to knowledge and expertise leaders. For example, the experts themselves could be taken out of action by the flu. We have to be sure we have a number of people who have the knowledge and capacity to make decisions in the moment of crisis.
The challenge is for the healthcare community to really understand what would be involved in a crisis situation by drilling and exercising to see if the planned response works in reality as well as theory. The effectiveness of our preparedness will be measured in mortality and morbidity statistics during and after the event.”
NEXT STEP: STANDARDS
The AMA's model for disaster-preparedness CME is one James would like to see become the standard for other CME efforts in this area (see box on page 32 for details). And while the Joint Council on Accreditation of Healthcare Organizations requires disaster training in a hospital setting, how and when they drill varies widely from state to state.
“Right now, you have medical schools, public health departments, states, different grants under different federal programs, all increasing the educational base for potential responders. That's all well and good, but the next big thing will be to get standardization across these courses, not just so people will have a common base of knowledge, but also so they will know how to interact in a given system and what to expect from their co-responders,” says James. “It's a huge issue, and it's magnified by the fact that medical care is under the purview of the state governments. Because of that, you tend to have 50 systems with different licensing, credentialing, and CME requirements. Our job is to try to integrate that to the degree possible. We are making progress, albeit slowly.”
The important thing in any of these programs, he stresses, is that the education address all hazards, cut across specialties and disciplines, and eventually be standardized across the states so that a person from Florida will have the same educational base as a person from North Dakota. “I believe response is a system. If we don't teach the system, what we have is a bunch of well-intentioned, well-trained individuals who don't integrate very well. We want to go across disciplines and specialties.”
All agree that it's not enough to provide a training course and then think the participants are prepared. “To really make a difference, it has to become part of the culture, as it is in Israel where training and drills are quite common,” says Kachur. Adds Gold: “We have learned that these types of events, be they natural or terrorism-based, are not going to magically disappear. Our level of preparedness and ability to respond needs to be continually refined and heightened.”
But going across disciplines and specialties also means that you can expect to find yourself working with all sorts of people and agencies you normally wouldn't be dealing with. Crim's office has been working closely with its county health department in its efforts to further the National Association of County and City Health Officials' goal of setting up advanced practice centers that will develop information, tools, materials, and evaluation methods for disaster preparedness. “Our county health department was one of the first to receive a NACCHO grant, they have been among the most active participants, and they partnered with us every step of the way,” he says.
Pamela M. McFadden, who works with Crim as associate vice president of the professional and continuing education office of the University of North Texas Health Science Center at Fort Worth, calls it “one of the most successful collaborations we've had in the past several years. There is discussion now on expanding our role to avoid their duplication of our efforts, since our goals and audience are often the same.”
McFadden and Crim's office also learned a lot about cooperation during the simulation mentioned earlier, for which it recruited, registered, and managed 2,500victims. The simulation — of an airplane with a dirty bomb exploding over the Texas Motor Speedway in Fort Worth — included the volunteers, plus the police department, fire department, state and local emergency management offices, 22 area hospitals, FEMA, the Environmental Protection Agency, and even the Federal Aviation Administration and the FBI.
“One of the big things we learned was the importance of building the cooperation between the different municipalities,” says McFadden. “How do you break down those barriers and get people to move out of their silos and into a network before something happens? We're offering our input and capabilities to enhance that [cooperation] through continuing medical education for the organizations that are working toward that goal.
“It's a good avenue for us to pursue to build up that public-health-agency relationship, on a city, county, state, and federal level,” she says. In addition to public health departments, the university also is working with the local Council of Governments, which has a regional approach to disaster preparation that could have far-reaching impact on the state as a whole, she says.
“You try to build the network of organizations you're working with because in the case of a disaster, the more people you get involved on the front end, the more education everyone will have, and the more everyone will have the ability to handle a disaster situation,” McFadden says.
Because the vast majority of disaster-preparation training is underwritten by the federal government — generally through the Centers for Disease Control, the Department of Homeland Security, the National Institutes of Health, and other federal agencies — which then trickles down to the state, regional, and local agency level, there's a business-related reason to partner with public health organizations as well.
“Working with local, regional, and statewide public health agencies has also provided a great source of revenue for our office,” says Crim. “We are building relationships that will help them keep us in mind when they're submitting other proposals in other areas that are hard for us to find funding for.” However, Kachur cautions, government disaster-CME funding, while plentiful immediately after a crisis, can dry up once the situation is no longer in the news. “It's all so political: One moment the funding is there and in another it's gone. You can't depend on it to develop a training program,” especially for her topic, the psychosocial aspects of bioterrorism. “That's more difficult to sell than the physical well-being of people during the immediate aftermath, even though it affects many more people than the physical aspects.”
Another important alliance is with the media, says the AMA's James. “I think we do the media a great disservice by not involving them in some of the pre-planning activities we go through, which would enable them to tell the appropriate story.” Without that cooperation, he points out, the media tend to inflame public fears, as was the case with SARS and the anthrax scare after the 9/11 terrorist attacks.
The bottom line, says Marcus, is that any particular physician doesn't have to know everything, but they do need to understand what they need to know, whom they need to contact in the event of a major emergency, who might be contacting them, the decisions they're going to have to make, the situations they might have to manage, and what they're going to do.
The time to get the continuing medical education isn't after an emergency is under way, Marcus stresses. “We don't know when it will happen, or what form it might take. But looking at the risk, we all should know that it will happen. The time to prepare is now.”
AMA's All-Hazards Approach
Developed by a group of academic, state, and federal centers called the National Disaster Life Support Education Consortium, the American Medical Association has designated for CME credit the Basic Disaster Life Support and Advanced Disaster Life Support course models. The eight-hour BDLS is a didactic activity aimed at physicians, nurses, paramedics, veterinarians, dentists — any healthcare practitioner who could benefit by having a common baseline of disaster-preparedness knowledge. It offers an all-hazards approach based on the DISASTER Paradigm (DISASTER stands for Detect, Incident Command, Scene Safety and Security, Assess Hazards, Support Required, Triage and Treatment, Evacuation, Recovery). The three-day ADLS is a hands-on, in-depth training that further imbeds the knowledge gained in the BDLS, which is a prerequisite. AMA also has a four-hour core program known as CDLS, which is aimed at the general responder community, and it is working on a two-hour version for citizen groups. (For more, visit the AMA's Web site, ama-assn.org.)
Back to Basics: The Need for Traditional Disaster CME
Anyone in the U.S. who watches television or reads the newspapers has a pretty good grasp on the gaps that still need to be addressed in disaster-preparation training. As Andrew Crim, executive director, professional and continuing education, University of North Texas Health Science Center at Fort Worth, says, “The need is obvious. FEMA [Federal Emergency Management Agency] and the Department of Homeland Security have models that establish what works in disaster preparation. There also are sets of data that show these models aren't being followed and that there are huge gaps in knowledge.” The question is: What more should CME providers do? After all, providers are already offering CME activities on clinical-care areas relevant to medical emergencies.
Jeffrey P. Gold, MD, senior vice president for medical affairs and Dean of the College of Medicine, Medical University of Ohio, Toledo, says that while medical societies have done a lot of specialty-specific work in disaster preparation, it's not enough. “I think it's still a long stretch between having a reasonable number of specialists within a specialty prepared, to having a critical number prepared, to having most of the specialists prepared so that geographically, we're covered.”
And there are still many more traditional types of training gaps that need to be addressed, says Crim. One example became glaringly clear during a simulation in which his office participated. The simulation involved a dirty bomb explosion over the Texas Motor Speedway in Fort Worth. While hospitals had received grants to purchase up-to-date equipment for dealing with radiological and chemical emergencies, very few people had been trained to use them.
“If the simulation had been real, they would have contaminated an entire emergency room by their handling of just one patient,” he says.
Israel's Army of Baby Sitters
In the case of a major disaster in Israel, one of the first things the hospitals do is round up the baby sitters and bring them in to the facility, says Leonard J. Marcus, PhD, co-director, National Preparedness Leadership Initiative, Harvard School of Public Health, Boston. Marcus has studied Israel's emergency-response initiatives extensively, and has found much to learn from that country's highly regarded system.
“The first call is to get an army of baby sitters, because the first thing the doctors and nurses want to know is that their families are OK. Once the childcare centers are set up, they can get to work without worrying.”
Marcus relates a story of a doctor at the Hadassah Hospital in Jerusalem, who has timed how long it takes to get from his office to the emergency room, and has honed his speed-dialing skills to be able to contact his wife and two kids in that minute and a half. “That fear is real and must be addressed because if the healthcare workers are afraid, they won't be able to work at their best.” he says.
Your Resource List
The following Web sites have helpful information on disaster preparedness:
- Alliance for CME, acme-assn.org
- American Medical Association, ama-assn.org
- Association of Schools for Public Health, asph.org
- Department of Homeland Security, dhs.gov
- National Association of County and City Health Officials, naccho.org
- National Disaster Life Support Foundation, ndlsf.org
- New York University School of Medicine, chip.med.nyu.edu
- Pan American Health Organization, panho.org
- World Health Organization, who.int/en
- World Association for Disaster and Emergency Medicine, wadem.medicine.wisc.edu/home.htm