By Geoff Williams and Dr. Maurice A. Ramirez
In 1937, after a natural gas explosion destroyed a high school in New London, Texas, near the end of a school day, nearby oil workers ran from the fields to find a pile of smoldering rubble. Underneath the debris, they could hear the screams of teenagers and teachers. In the hours after what was then the second worst disaster in Texas history—the actual death count was never determined but approximately 300 lives were lost—President Franklin Roosevelt put out a request for medical aid over the radio, and by that evening, doctors and nurses had descended on the town, coming from as far away as Shreveport, Louisiana. Hundreds of vials of anti-tetanus serum were driven to the scene of the blast. Help was certainly needed. The oil workers pulled out over 200 victims, flagging down passing cars that hauled the injured and dying to the nearest sickbay. The Associated Press reported, “The hospitals were jammed.”
From earthquakes to wars to floods and hurricanes, the history of disaster medicine is replete with success and failure when it comes to the results of the physicians, nurses and medical administrators who assist during and in the aftermath of a crisis. And it’s a long history. “Really, when you look at where disaster medicine started, it goes back to the Civil War battlefields, and even pre-dating to Roman times,” says Gary M. Klein, M.D., MPH, MBA, who practices acute care medicine in Atlanta. As a general rule, it’s never been a lack of willingness of the medical profession to help as a tragedy unfolds, but the efficient execution has sometimes been lacking, notably during some high-profile catastrophes in the last few years.
Disasters are chaotic by nature and the medical community has too often gotten caught up in the turmoil. But history is repeating itself, and in this case the repetition is welcome; just as in previous eras, physicians examined their techniques when responding to and treating disaster victims, this latest generation of healers is adapting to new, varied and horrific threats. But the actual term disaster medicine only began cropping up in the newspapers with some regularity during the 1950s when medical associations chose to adopt the idea of anticipating a disaster. They were frequently hosting seminars trying to gauge how doctors might fare in a post-nuclear attack.
Colonel and physician Karl H. Houghton spoke to a convention of military surgeons in 1955, telling them, “You won’t have sufficient drugs or surgical materials to handle all the casualties and will have to decide rapidly and without hesitation who will receive this perhaps life-saving material. This is not always simple. Do you save the banker or the truck driver? Do you go right down the line of casualties taking them as they come, or do you pick out those individuals who might be the most valuable in terms of the rehabilitation period to come?”
Another colonel and physician, Joseph R. Schaeffer, MD, imagined that in a massive nuclear attack, the medical community might become overwhelmed. “We have 200,000 doctors to take care of 176,000,000 people in this country," he told a medical staff at a Texas hospital in 1959. “Therefore, the people must learn how to survive for themselves in case of an emergency.” Even though Schaeffer’s call for civilians to educate themselves largely went unheeded, his life’s work is a good example of the type of disaster medicine planning that was taking place during the 1960s.
When Oklahoma City suffered the 1995 domestic terrorist bombing resulting in 168 dead and 914 injured, Dr. Schaeffer would have been pleased by the emergency response. This was a country, after all, that had foreseen a need for disaster preparedness and created the Emergency Mobilization Preparedness Board (EMPB) in 1981. The EMPB subsequently developed the National Disaster Medical System, which has disaster medical assistance teams around the country.
Disaster medicine as a specialty and mindset was not only a reaction to September 11, 2001, but also to numerous subsequent events such as the anthrax crisis and Hurricane Katrina. The disaster climate of the last several years has had a profound impact on many physicians, including Paul K. Carlton, M.D., the director of Homeland Security at Texas A&M Health Science Center. He believes disaster medicine should be a board certified medical specialty just like other specialties such as Family Practice and General Surgery. Carlton has some personal experience which led him to this viewpoint.
As the surgeon general of the Air Force in 2001, he had been practicing disaster training with medical students three months before an airplane hit the Pentagon. His group had, eerily enough, come up with a similar disaster scenario to practice for, only they imagined an aircraft having an unsuccessful take off or landing and crashing into the Pentagon. In their simulation exercises, they did quite poorly, admits Carlton. Yet, because of the drills, on September 11, when Dr. Carlton rushed into the Pentagon as a first-responder, he and his team were understandably pleased by their performance. He led a rescue group into part of the building where the landing gear had impacted; they managed to pull three people to safety, “and we all got out alive.” No small thing, since Dr. Carlton himself caught on fire. That he’s alive is at least partially due to the fire-retardant vest he was wearing.
In the last several years, as disasters have seemed to be on the increase, careers have been created and defined, government plans were put into action, and first-responders such as police and firefighters began crafting plans on how best to handle a disaster. Certainly the medical establishment in North America began forming study and discussion groups in disaster medicine. In some cases, medical schools were already on the front lines of this movement—they like the University of New Mexico Center for Disaster Medicine, which was established in 1989. Meanwhile, elsewhere in the world, there have been disaster medicine for-credit courses at universities in London, Paris, Brussels and Bordeaux since at least the early 1980’s.
Within two years after the terrorist attacks, the University of South Florida College Of Nursing began offering a disaster and bioterrorism training program, featuring eight one-day classes and an intense two-day program. In determining whether it would be a worthy offering, USF did a survey of 179 healthcare professionals, asking if they felt they had the necessary skills and equipment to handle a biological attack related to terrorism. Forty-seven percent replied that they were ill-equipped to handle a biological attack; forty-five percent gave the same answer for a chemical attack.
Much of what needs to be taught is a mindset, says Dr. Carlton, who cites an example of a suicide bomber who attacked a cafeteria on an American military base in Mosul, Iraq. “The kids there had a small team, where they did nine operations in the operating room and 10 in the hallway. That’s the kind of Plan B operation that stands us in good stead when we need it. Our medical students need to realize that we’re not always going to have technology they’ve become accustomed to. I think of Hurricane Katrina, where a woman was in labor, and all of the lights went out. The doctors performed a C-section—by flashlight. It’s not an ideal circumstance, but they did a beautiful job.”
The education that Carlton discusses is part of a big movement. New York’s Columbia University, for instance, offers two classes that, as their web site explains, “bring the events of Sept. 11 into the classroom.” The first course is Public Health Consequences of Forced Migration; the second is Emerging Infectious Diseases--manmade germ warfare as opposed to a natural occurrence. In Pennsylvania, the Albert Einstein Medical Center developed, “A Primer on Bioterrorism for Physicians,” giving medical students an overview of anthrax, smallpox, botulism and the plague, including how to recognize the symptoms in patients, as well as limiting the spread of disease while managing and treating it. Vanderbilt University Medical Center in Tennessee now offers a course called “Weapons of Mass Destruction Awareness and Treatment” for physicians, nurses and staff. The UCLA Medical Center organized a Task Force on Bioterrorism Preparedness. The list is seemingly endless.
In 2003, the American Medical Association (AMA) partnered with four medical centers and three national health organizations, establishing the National Disaster Life Support (NDLS) training program. The AMA also formed a Center for Public Health Preparedness and Disaster Response (CPHPDR). About this time, the American Osteopathic Association (AOA) and the American Association of Colleges of Osteopathic Medicine (AACOM) formed the AOA/AACOM Task Force on Bioterrorism. The AOA subsequently opened an Office of Emergency Response.
Now, more than five years after September 11, 2001, disaster medicine is a field that is growing exponentially. In the midst of all this change, what once seemed improbable now seems inevitable: the creation of a medical board of certification in disaster medicine. It’s an idea being championed by the American Board of Physician Specialties. Nodding his approval is Dr. Andrews, board certified in internal, preventative and occupational medicine. “Most of us have many patients in a day, but we don’t handle a disaster, say, once a week. They come every so often, and to be trained in disaster medicine, and updated, I think is a neat idea.”
And necessary, says F. Matthew Milhelic, M.D., who is an assistant professor at the Center for Homeland Security Studies at the University of Tennessee’s Graduate School of Medicine. “I think the way that this board has proposed this idea, making it an inclusive board, will do two things—raise the level of competency among physicians to deal with problems in a disaster, and it will also raise awareness across the medical community for the need of preparedness… and I think this board is looking at disaster medicine as much broader than just a brief medical response over a short period of time, and that all medical providers, all medical disciplines, specialties, subspecialties, and so on, will have a role in any major disaster.”
"The majority of physicians are in primary care, family practice, general medicine, and, of course, there are pediatricians and ob-gyn,” concurs Captain James W. Terbush, MD, MPH, of the U.S. Navy Medical Corps, and a NORAD-USNORTHCOM Command Surgeon at Peterson Air Force Base in Colorado, who was in the thick of things after Hurricanes Katrina and Rita. “It would be exceptionally helpful if primary care physicians were experts in disaster medicine.” That is the goal of the ABPS’ American Board of Disaster Medicine—clearly an idea whose time is now.
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