Yes, because of the recent spate of disasters witnessed over the lands.
Absolutely. There should be a dedicated educational module that prepares medical students (and other medical professionals) for the unlikely occurrence of a mass casualty incident (MCI).
First, medical students and other trainees should be aware of the triage criteria and should at least be familiar with changing priorities during MCI...
Second, there should be a simulated MCI done at all major medical centers from time to time; This may involve a simulated scenario across a network of hospitals within a certain geographic area...
Finally, training in emotional intelligence, coping skills, self-control, and resilience should be included as part of the curriculum. This could potentially reduce the emotional shock of dealing with MCIs, as well as the post-MCI traumatic stress
Regards,
Stanislaw Stawicki MD FACS
Trauma & Surgical Critical Care
St. Luke's University Health Network
Bethlehem, Pennsylvania, USA
Why not
Also other topics such as domestic violence, euthanasia, medical ethics, and even short courses of humanities
Medicine has become a vast subject with increasing ties with other sciences
I'm also convinced it should. We surveyed senior medical students in Belgium and the Netherlands. Knowledge on disaster medicine was limited and a huge part of them found that a basic course on DM should be included in their curriculum.
Dear Luc JM Mortelmans
I agreed with you and I think we have to move this topic forward
Dear Ishag
More than 50% of medical schools in the world does not teach this topic.
I agree with you the DM Should be part of Curriculum in Medical Schools.
Of course, this can save lifes and helps the physicians to keep calm in the stress situation. This training is to be established in some university hospitals in Germany as compulsary subject in the post study clinical training.
Dear Hanno Krieger
Yes it will save lifes and helps the physicians to keep calm in the stress situation.
Dear Gamal Abdul Hamid
I think to move it forward and why insert it in the curriculum ?
Hi Dr. Ishag Adam janab, Yes I do feel at least for Indian conditions where disasters are inevitable every year. From me a Big YES. Thanks
Dear Ishag Adam,
i think that any Doctor must have knowledge about Disaster, MCI and any sudden, unexpected and stressed emergency situations. The need is even higher in Emergency Physicians above in countries in which Emergency Doctors work on site in EMS organization or in countries in which Disasters are very common!
Best Regards, GFV
I think it should be included in the curriculum. No given area is immune to mass casualty or medical disaster scenarios. Disaster medicine is a component that medical students need to at least be exposed to in terms of understanding how they fit into the greater preparedness and response picture. If physicians are exposed to the core concepts of mass casualty management, and system planning for disaster operations, they are far more likely to work well in the framework of a disaster response as their careers advance. It would be interesting to poll medical schools to determine how many offer this content and how they measure success.
Any such curriculum should be customized for the local 'dangers' and also include some basic stuff
In Holland in the past 75 years, whe have had some plane crashes, some floodings including a large one, two explosions of a munition factory, one major explosion of a fireworks depot near a community, some very, very very minor earthquakes, some large scale fires of peat / wood and several large industrial fires. Only the flooding of 1953 and the explosion of a fireworks depot should be seen as true disasters, everything else was on a smaller scale.
I know that the Japanese prepare predominantly for tsunami's, earthquakes and larger industrial incidents.
The need for such programs also depends on what is already included in the normal education.
In Holland there are no such things as first aid / basic fire fighting skills / evacuation drills or anything in basic education.
Before 1977 almost every male would have been drafted for military service and would have acquired a lot of those skills trough that system.
In Holland, at least since 1977 every one in medical schools would have to learn basic first aid in the first year and acquire a few additional basic skills early during that education. But as far as I know nowhere in Holland was disaster medicine on the curriculum at least between 1977 and 2013.
I have been to Japan several times in the past 25+ years and have seen a lot and also have spoken to the medical coordinator involved in the Fukuchima evacuation, when he visited the Netherlands in december 2013. What I describe here has been confirmed on several documentaries that could be seen on television in various European countries:
In most larger cities evacuation zones are are well defined in many urban area's. Evacuation drills are common both in schools and in business enterprises. I have seen al of this already in place back in 1989 and as recent as 2013. Most disaster rescue teams are organised there based on their experience with earthquakes: many small teams 5 to 9 persons including one with medical skills, trained to search and rescue earthquake victims. This was also how the rescue work was organised after the tsunami in march 2011.
One weak point at that time was communication. A further weak point is that they depended on a large number of small medical facilities along the coast. During the tsunami a large number of these facilities was basly damaged and/or cut of from power / infrastructure/communication.
Nonetheless: by dutch standards, Japan was pretty good prepared, throughout the entire population and a wel distributed, trained and disciplined force was in place. All of this was at least partially due to the fact that that society does take disaster-preparedness seriously and did so consistently long before the 2011 tsunami.
with regard to the Fukuchima component of the tsunami disaster: Japan was wel prepared, but the disaster was of a somewhat different nature than anticipated. Japan had a system of 3 layers of medical care in case of major radiation incidents. There were 2 top-level tertiary centres [one in Hiroshima and one in Tokyo] and spread over the country a number of secundary centres of which one was situated in the town of Fukuchima itself [a considerable distance from the coast line] . The basic level of medical care had to be delivered from many small medical facilities along the coast line. Many of these facilities were themselves heavily damaged as a result of the tsunami.
The actual evacuation was done in an orderly fashion, but was organized and controlled by people with next to zero medical education. During the second evacuation wave at least 60 persons died during the [more than] 24 h duration of the actual transports, as a result of failing to arrange proper medical support and adequate facilities away from the coast line.
No one died of radiation.
In fact within walking distance of the damaged reactor buildings a new temporary first aid department was arranged [in existing buildings] for the entire area, it was in place within days after the disaster.
So, while some lessons must be learnt from the Japanese experience, grosso modo their society is fairly wel prepared and trained. Preparation for disasters is integrated in the communities, in the educational system and in the medical system. The society has in general a positive attitude towards disaster preparedness.
In The Netherlands the government has attempted to introduce mandatory solutions, such as that every factory / office must have qualified first aid personell, that a certain proportion of the staff should receive basic fire-fighting and evacuation training. What is lacking is the deep engrainment into society. Nothing is taught about it in the basic educational system. Over 90% of doctors do not learn any relevant skills beyond first aid.
It was only after my 52th birthdate that my employer offered me training for fire-fighting and evacuation.
I think from these two countries, Japan is clearly the better example.
Holland over-emphasizes the need to have special units for just about anything, while keeping the masses ignorant. In Japan the masses get considerable basic training and the effort is fairly distributed over the entire population.
Therefore I think Japan as a society is far more resilient.
Dear Judocus Borm
Thank you very much for comprehensive report
Interestingly I have got my PhD from Holland (Maastricht ) and I know the situation in this lovely friendly land and I am in dept to you
Please, let you know that the situation is critical here in Sudan and in Africa as general as we are facing disaster every now and then e.g Ebola
as well as many infectious diseases
So I agree with you that the community ( setting) flavor should be added in this essential topic
Warm Regards
Dear Judocus,
I´ve read your statements with interest and got a lot of new infos. But at one phrase I try to contradict. If you tell us that "No one died of radiation" you just take into account the deterministic impact. What you cannot assess, is the possible and probable stochastic long time insult by causing cancer.
Dear Ishag,
Disaster Medicine is an entity of its own in medicine, and should be part, in my eyes, of every medical school curriculum. At least in Israel it is. I guess only those who had to face mass casualty situations can really appreciate it.
You cannot handle it successfully unless you are well prepared, in terms of organizing your medical and non-medical teams, logistics (medical and non-medical), infra-structure (water supply, electricity etc.), media, and international collaboration.
There are some basic rules, kind of a generic check list, for basic response. On top of it, you should have different and specific response plans for different disaster scenarios that add to the basic generic plan, enabling you maximal flexibility when facing an un-expected disaster.
You must also be familiar with other relevant first response organizations. If the police don't know what to expect from the fire brigades or from the emergency medical teams, the situation may become chaotic even more.
This is only a brief overview of the subject. It is being taught in Israel both in Medical Schools and in the hospitals, as part of our home-front preparedness.
So disaster medicine is not only about medicine, but also about every other relevant organization that has a role in disaster response.
Once you are prepared, you will be able to improvise well. I know this sounds weird, but the truth is that you are never fully prepared to an event, there are always surprises, and only if you plan and train/exercise, and have the right equipment, you will be able to tackle well with an event.
Arik Eisenkraft
Jerusalem, Israel
I have added a course in emergency management to our undergraduate degree program. I believe that in todays environment a minimum of general emergency management and the basics of the NIMS and ICS methodology should be taught at every medical and first responder degree program.
Additionally I have included in service training in multiple emergency situations for the faculty with excellent results.
Dear Ishag Adam,
I agree that Disaster Medicine should be part of the medical school curriculum. In my place it is part of Emergency Medicine posting. The reason be, almost everyday there are some major incidents or disaster happening. And when this happened doctors together with paramedic and nurse are one of the people being call to go to the field (I'm not sure in other country but mine its definitely is). To makes matter worst some of these doctor are being put in-charge of the response effort before their seniors come. Therefore I strongly agreed that Disaster Medicine should be given the respect and put into the medical curriculum.
I did a survey of 34 medical school in my country, only 4 have included disaster medicine in their curriculum.
Dear Ismail Mohd Saiboon
Thank very much for your comments
I think you are to move to include the rest of the medical schools
@Hanno Krieger
I agree with you that stochastic causes were not addressed by me.
It is too soon for any significant stochastic effects.
There was another reason for this provocative statement: At least 60 people died in the second wave of evacuation. If one looks carefully at the root causes and then translates that knowledge to one's own country, I strongly believe that current mass evacuation plans are probably equally lethal[!] all around the western world.
Making a decision as difficult as this one: to evacuate or not, using incomplete and at least partially grossly unreliable data should be seen as a very major and difficult one, with a large impact on the population.
Knowing that those evacuated during the second wave in Fukuchima were initially screened for contamination, but rarely were found contaminated, one knows that the combination of contemporary building codes and the advise to keep windows and doors closed is a very effective one to protect the public from harmfull intern contamination. During the second wave the rescuers later resorted to screening the evacuated patients after these were allowed to enter the buses, to limit the delays, because of the very low yields [= few people contaminated & low levels of contamination]. So there was far less urgency [with respect to radiation] than the authorities believed. Therefore we can now judge that the preparation for that evacuation was certainly not good enough.
Witth the two WHO reports out for the public we can now state with confidence that the vast majority of the evacuated residents would never have accumulated an addition dose beyond 10 mSv.
If one would judge this to be a level worthy of starting an evacuation procedure, we should do so consistently. [Everybody on earth has a similar right to be protected against harm]
And as worldwide millions upon millions of people live in areas with similar background levels for all of their life [in Japan the levels are falling], we must publicly question the ethics.
Applying this limit consistently all around the world would start a stampede of millions, having to leave there homes and homelands. Is the world prepared for this.
For the Dutch: large parts of the south of France become NO ENTRY zones == no holiday zones EVER . Millions in India and probably Iran too, must move ....
A one-time dose of 10 mSv and a lifetime dose of 50 mSv is epidemiological noise, all other factors included.
Untill the early nineties in Holland an exposed worker was permitted to be exposed to this level EVERY year of his/(her) working career.
In the eighties of past century, workers in nuclear medicine in holland and very probably world wide were exposed to higher levels every year of their working life.
We already have had extensive discussions [while discussing the scientific status of the LNT-model in another question in research gate] about how to deal with low-dose-rate low-exposures. The LNT-model is fine for regulation & administration [because of lack of any better], but is scientifically not validated for assessing or prognostication of mortality and morbidity...
Especially the low end of the dose range is highly uncertain.
We do know [i.e. from radiation therapy] that dose rate [and in case of 'pulse doses' the interval between pulses = treatments] strongly affects the outcome [in case of deterministic effects] and that therefore the cumulative dose alone is NOT suitable for the purpose of predicting radiation therapy response. This is in direct violation of the LNT theory. However this is about deterministic effects.
For stochastic effects, data is insufficient aspecially at the lower end of the dose range.
For low doses / low dose rate versus single 'high' 'pulse'exposure literature for stochastic effects are chaotic at best, especially if one [mentally] compensates for the publication bias [hormesis-like findings have been suppressed in literature].
Effects suggesting hormesis in humans have been reported as early as 1958.
But now back to march 2011:
In Japan somewhere between 17000 and 24000 people have died as a result of the tsunami and quite a few may have reduced life-spans because of the long term secundary effects of having to live under conditions with less medical facilities / medication / support as part of the aftermath of the tsunami.
Statistically / epidemiologically this is near impossible to analyse. A very large proportion of the medical facilities along that coast line were damaged.
Three disasters took place involving overlapping populations: 1- Tsunami -2- Mass-psychological effects -3- radiation. [in order of decreasing number of severity, to my opinion].
The psychological over-response [mass-psychological effect] has a somatic effect as wel. Such responses are known to affect various immunological responses. Immuniological effects may alter responses to low dose radiation.
Who or what is to blame? Radiation / mass-psychology ??
No one knows. No authorative studies dealth with both simultaneously.
In previous answers I refered to a plane crash in Amsterdam, where NO radiation was involved, but in the aftermath of a large turmoil where authorities were publicly challenged by ignorant reporters on the potential effects of some burned depleted uranium. Net result: one year afterwards 5000 people suffered from a post traumatic stress syndrome requiring professional support.
Was this PTSS due to < 10 microsievert or due to mass psychological effects ?
How one attributes these effects very strongly affects estimates for the risk of low dose radiation.
Nobody gets PTSS from an X-ray of the thorax, so I bet it is due to mass psychology.
With doses far below 100 mSv and yearly doserates below 10 mSv I am both very careful and reluctant to attribute health effects.
The health effects of those ove- emphasizing such health effects should be mentioned too. Their effects are real and serious and costly to society. Journalists do induce PTSS !!! News that does not excite people is selectively suppressed in most modern journalism.
We should be careful with radiation, but also with mass psychological effects !!!
The first topic is easily agreed upon, but the latter so far has hardly appeared on any public agenda.
As the latter [mass-psychological effects] are also known to affect the immunological response and therefore *by definition* potential tumour response, radiation protection should take that effect into account too!!!
In general preparing people for disaster boils down to teaching self help / first aid / medicine in primitive situations and setting up a flexible partly autonomous organization with strong support from locals.
These preparations themselves also act as stress-reducing, thereby acting as 'antidotes' . So including disaster medicine in the medical curriculum should be just one of several measures. All people [the able ones] should learn first aid in high school, basic fire-fighting in the first year of employment etcetera.
In the west we now live in societies with maximized helplessness while our governments make a mess of may things, including disaster preparedness and prevention of mass-psychological effects of any disaster.
Dear Judocus Borm
Thank you very much for the a amazing comprehensive report
A brief introduction to Disaster Medicine should be part of the core medical school criteria. Rationale: (1) When major multi-patient, multi-jurisdiction, mulit-agency response events occur, the standard priorities for care and transportation are shifted, (2) physicians who are knowledgeable about disaster medicine guidelines can be valuable participants on response teams, while those who have no understanding about disaster medicine practices and procedures often require more time and support than they provide, and (3) the cursory fundamentals of disaster medicine can be provided fairly briefly in the context of the full curriculum, and the knowledge is applicable throughout many situations and possible events. For example, responding to an earthquake, a bombing, a tsunami or a tornado event have more in common than they have differences,
Dear Bill Raynovich
So, let us proceed to introduce it in many institutes
I agree and have done so in three medical schools and advocated for this at conferences. The national boards will always drive the curriculum, however.
In The Netherlands we have [in addition to the common civil and criminal legal system] a third system in place for certain professions, where you can be judged by peers. Their standard is "what would an average competent collegue have done". This system of "tuchtrecht" or disciplinary law already recognizes that doctors should prepare themselves for disasters.
So, although it is not formally in the curriculum, a bare minimum is required for medical professionals here.
In addition, we have a system of regional organisations, headed by a specific medical health officer, [GHOR] that coordinates disaster capacity with all institutions in the region.
Basically: fire brigade does the basic rescue
Police and fire brigade do any search activities
ambulancer staff [sometimes aided by medical staff from hospitals] administer medical care outside the hospitals
this specific medical hospital is responsible for coordination and distribution among all the hospitals in the region
If certain capacities are subsequently flooded [i.e. burn patients] we have an inter-hospital network. So back on Jan 1st 2001 we had a very large number of burn victims to deal with. This network cooperated so extensively that even some patients were placed in Belgium and Germany. So that network can be scaled up across national borders.
In hospitals the "porte déntree" [entrypoint] is through the fist aid departments.
All departments have plans that are regularly tested for how to deal with a disaster. A typical department must be able to quickly discharge / transfer about half their patients to make room for more urgent patients.
The number of doctors actually trained to deliver acute care "in the field"is relatively low. All past large incidents in Holland showed that we have an overcapacity of ambulances and skilled paramedics. In Holland neighbouring regions usually send a few ambulances immediately to the border of their region to be at hand for assistance.
In case of a really big disaster, we can ask the military. They can deliver and man field hospitals, but do take a couple of hours to scale up, whereas the ambulances are available 24/7/365 for immediate dispatch.
In addition we do have a number of trauma helicopters with all weather capability for urgent evacuation of severe cases.
The question now is: to what extend must we further advance the medical capacity?
I think much more is gained if we learn the entire able population first aid / ABC / basic fire fighting, than further expanding the health system as we have it in Holland.
Dear Judocus Borm
Thank you very much for your comprehensive reply
Please, We need to know if the military doctors are graduated from civil or military institutes? Therefore if they are exposed to this course in their undergraduates courses?
The military doctors are given additional training in the Netherlands. This is NOT part of undergraduate courses
Absolutely, because of the increasing human population and global warming disasters are becaming a very serious problem. When a disaster happens medical stuff should know how to handle the situation. And i think theoretical education must support with practical education.
I agree with you Hulya Ozcan that both theoretical and practical parts should be included
Warm Regards
Dear Ishdag
Yes it should be part of the curriculum, in fact should also be part of each specialities post graduated specialist curriculum as well as each will have a role to play in mitigation and response- for example without a registry of patients needing dialysis if an event affects the major dialysis centre how will the health service find and transfer patients needing services elsewhere.
In brief yes disaster medicine should be in undergraduate curriculum and medical students are a huge resource in a disaster response setting which are underutilised
mick
Dear Ishdag,
I agree that disaster medicine should be part of the medical student curriculum, since major incidents or disaster is becoming more common nowadays due to rapid development in most countries, climate change and some countries having political instabilities. Doctors will be in part of the frontline team that manages disaster be it natural or man-made.
In my university (Universiti Kebangsaan Malaysia) and few other universities that have medical school, Disaster Medicine have been incorporated as part of our medical student and paramedic student curriculum. It is delivered during their Emergency Medicine posting.
Ismail
It is excellent to hair that disaster medicine has been incorporated as part of curriculum in your setting
When working for the DOD in any of their specialty areas Ie; neutralizing chemical weapons--specialty training is required.
Yes, I think it should. For most medical personnel, it is not a question of "whether" but only of "when" they are called on to work in a disaster response medical situation.
As someone who has worked in several natural disasters I find this a very difficult question.
All training went out the window at the Christchurch earthquake and even though I was prepared to use the models we had been trained in, many others couldnt care less.
So unless you are prepared to continually reinforce the education and why it is necessary, then I wouldnt bother. You are better off teaching people to follow commoands at and emergency rather than any other skills. They just dont remember in the heat of the moment. (Or enough of them don't)
I also agree with Ishags comment. But continuous training requires a preexistent basic knowledge and that was what the initial question was about.
Hi I would like to comment that Disaster healthcare is The provision of healthcare services by healthcare professionals to disaster survivors and disaster responders both in a disaster impact area and healthcare evacuation receiving facilities throughout the disaster life cycle. Disaster behavioral health deals with the capability of disaster responders to perform optimally, and for disaster survivors to maintain or rapidly restore function, when faced with the threat or actual impact of disasters and extreme events. Disaster law deals with the legal ramifications of disaster planning, preparedness, response and recovery, including but not limited to financial recovery, public and private liability, property abatement and condemnation. Disaster life cycle is The time line for disaster events beginning with the period between disasters (interphase), progressing through the disaster event and the disaster response and culminating in the disaster recovery. Interphase begins as the end of the last disaster recovery and ends at the onset of the next disaster event. The disaster event begins when the event occurs and ends when the immediate event subsides. The disaster response begins when the event occurs and ends when acute disaster response services are no longer needed. Disaster recovery also begins with the disaster response and continues until the affected area is returned to the pre-event condition.
Disaster planning is The act of devising a methodology for dealing with a disaster event, especially one with the potential to occur suddenly and cause great injury and/or loss of life, damage and hardship. Disaster planning occurs during the disaster interphase. Disaster preparation isThe act of practicing and implementing the plan for dealing with a disaster event before an event occurs, especially one with the potential to occur suddenly and cause great injury and/or loss of life, damage and hardship. Disaster preparation occurs during the disaster interphase. Disaster recovery is The restoration or return to the former or better state or condition proceeding a disaster event (i.e., status quo ante, the state of affairs that existed previously). Disaster recovery is the fourth phase of the disaster life cycle. Disaster recovery is the fourth phase of the disaster life cycle. Disaster response is The ability to answer the intense challenges posed by a disaster event. Disaster response is the third phase of the disaster life cycle. Medical contingency planning is The act of devising a methodology for meeting the medical requirements of a population affected by a disaster event. Medical surge is An influx of patients (physical casualties and psychological casualties), bystanders, visitors, family members, media and individuals searching for the missing who present to a hospital or healthcare facility for treatment, information and/or shelter as a result of a disaster. Surge capacity is The ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system. Medical triage is The separation of patients based on severity of injury or illness in light of available resources. Psychosocial triage is The separation of patients based on the severity of psychological injury or impact in light of available resources.
I believe Disaster Medicine is a Wide Subject to Study and Teach in the Medical Institute. Community and Behavior Science is Department currently Teaching a Brief Chapter Regarding Disaster Management. I would consider as a Seperate Specialty in Medical Profession. Currently Public Health and Preventive Medicine, Epidemiology teaches the same with other Modules. Regards