Maurice A. Ramirez, DO, CNS, CMRO

The Choice to Love

We hear the word love throughout modern society.  We are told to love our customers and that as customers we are loved.  We are told to love our neighbor as ourselves.  We are told that there is no greater gift than love.  We even have a special holiday, Valentine’s Day, dedicated to the notion of love.

Love has been described a basic building block of resilience, the foundation of the family, and in the goal of marriage.  But does love have a place in business?

Father Dan Schulte, a Catholic Priest and Philosopher, has defined love as “Love is the unifying thoughts between two people who have cared for and have said ‘yes’ to each other total being.  It implies mutual respect, freedom and trust, and seeks the happiness of fulfillment of each other as a common goal.”

Father Robert Mitchell has stated that love is an act of choice while “life” is an uncontrollable emotional response to our experience of another individual.  Father Mitchell states that while respect is a pre-requisite of love, life is not.  Father Mitchell does posit that respect is the ideal foundation for a love relationship and that from this respect “life” would ideally spring forth to form the framework of the love choice however, life is not the pre-requisite to the act of choice to love.

In the business world the admonishment to “love our customers” has been criticized as minimizing the meaning and importance of love.  As this admonishment is a pride in most businesses that criticism is quite true.  Father Schulte in his definition points out that love is a unifying response, it binds those in the relationship together trading a new individual, the love relationship itself.  In his definition those in the love relationship choose to “care for and face ‘yes’ to each other’s total being.”  Here Father Schulte and Father Mitchell agree completely, love does not require that you “like” the other individual only that you choose to love.  How many of our customers do we have the immediate emotional response of dislike?  Father Mitchell and Father Schulte prove here that we can embrace that “dislike” and still choose to love that customer.

But how can I love somebody whom I dislike?  Father Schulte’s definition answers this question as well by including that love implies mutual respect.  Just as Father Mitchell stated that respect is the foundation for love, Father Schule states it is an absolute pre-requisite.  Even if we dislike our customers we can still find in ourselves respect for them and perhaps even acceptance of them as they are and through these make the choice to love them. 

Finally Father Schulte points out that a love relationship requires that we seek the “happiness and fulfillment of each other as a common goal.”  Is this not the goal of every business?  Few of us work to be unhappy despite the fact that for many this is the end result.  Instead we speak to gain fulfillment and happiness through the work we do.  Father Schulte points out that it is not the work that creates the fulfillment and happiness but the relationships that we garner from that work.  Interestingly, when the relationships from our work provide fulfillment and happiness we need the last pre-requisite to love our customers.

But what if our customer refuses to enter into this love relationship?  What if our customer does not care for us, is not accepting of us and does not respect us, does not trust us or does not seek our happiness or fulfillment as their goal?  Increasingly in American society we find an almost schizophrenic response to the concept of customers and businesses and business people entering into a love relationship. 

When we fill the role of customer we are often impatient, untrusting, unaccepting, unloving.  Yet when we are in our own business and work environment we strive to respect, accept and even love those whom we serve.  Father Mitchell points out that because love is choice we can choose to offer love even when the requirements of a true love relationship are not there.  For Father Mitchell this is a form of self reliance and self respect.  Father Mitchell states that it is the ultimate form of self love to not allow another person to denigrate decisions and the ideal that we have set for ourselves.  This means that even though we may not like our customers, even though our customer may disrespect us we can choose to offer them love.  This is not to say that we should allow ourselves to be abused.  Nor should we allow ourselves to be exploited.  There is a vast difference between offering love and becoming a victim of our own love choice.  In offering love we are respecting our own choice to enter in to a love relationship however, that relationship becomes exploitive when it is not a unified response, when we are not cared for nor accepted.  We may offer love despite apparent disrespect but if disrespect, distrust and a failure to value our happiness and fulfillment by what we receive in return for our love choice then it is not love but masochist to remain in the relationship.

For many years it was the professional responsibility of physicians to constantly evaluate their relationship with their patient.  The doctor/patient relationship was seen as the ultimate love relationship.  In that relationship the physician along with the patient sought health and happiness, however when evaluating that relationship if the physician found that the relationship itself was not healthy either for the doctor or the patient that physician was both morally and ethically bound to end that doctor/patient relationship and assist the patient in finding a new physician. 

Unfortunately as healthcare became more a business and less a relationship physicians began to abandon this professional responsibility remaining in relationships where they were neither respected nor trusted and where they failed to respect or trust their patient.  Over time the professional decisions to find the patient a more supportive relationship became replaced with the legal decision to “severe the doctor/patient relationship”.  It is interesting to note that about the same time the number of malpractice lawsuits in the United States began an exponential rise.

In any choice to enter into a love relationship there must be the inherent choice to end that relationship if it fails to meet the basic requirements of love.  This is a prospect that is frightening too many businesses however, if a business is to be financially resilient, if it is to be able to extend the same love relationship to its employees as it frequently extends to its customers than it must obey the moral imperative to love its customers enough to seek for them the best business relationship possible even if it is with another business.  How often had a business garnered our undying loyalty by referring us elsewhere for service that they can not truly meet?

The choice to love is the basic building block not only of friendships, marriages and resilience, it is the basic building block of business.

The “Microbe Mule”

Paul Purcell paints a terrifying picture of the newest potential “dirty bomb” in his recent posting to www.disaster-blog.com (http://www.disaster-blog.com/2007/01/suicide_bombers.html). 

His concept is not wholly new although the application that he describes represents a concerning variation on an old Hollywood theme.  Movies over the past decade and books over the past two decades have described terrorist events ranging from the transportation of contaminated corpses to the kidnapping of a Ebola infected nun to create terrorist weapons out of human bodies. 

Mr. Purcell takes this concept to the next level.  Disaster medicine specialist such as myself have long been concerned about the possibility of hepatitis, HIV, and other infectious diseases being spread via the exploding remains of suicide bombers and their victims.  Even in the area of accidental blast injury area cleanup and contaminated bystanders has been a great concern.

Mr. Purcell’s article only confirms the concerns of such forensic greats as Cyril Wecht and terrorism response agencies such as the Israeli Musad. 

The reality is that the “microbe mule” is in all likelihood the terrorist combatant of the future.  The Department of Homeland Security and before it the Centers for Disease Control were concerned that terrorists infected with small pox would simply visit our shores and contaminate large groups in the population.  Unfortunately active disease is now no longer a requirement.  Simply infectivity will do. 

Paul Purcell has again outdone himself both with his understanding of the terrorist mind and the limitless bounds of the human imagination.

Suicide Bombers and the “Microbe Mule”

By Paul Purcell

Given the fact that numerous terrorist organizations have indicated an interest in biological warfare, and given the fact that many have also made attempts to gather radioactive material for the creation of a “dirty bomb,” it stands to reason that one threat we may face might be a combination of the two concepts.

One such scenario is that of a terrorist who is intentionally infected overseas with a virulent disease and brought over here before becoming symptomatic, in order to smuggle in a disease in much the same way a “drug mule” smuggles drugs.  Before becoming non-ambulatory, and after acting as a "Petri dish on the hoof," providing infectious bodily fluids for bioweapons (via other methods of dispersal), we may see such an individual perpetrate a suicide bombing.

No terrorist would want to die in a sick-bed, and a suicide bombing in a crowd where survivors would be exposed to infectious bodily fluids and remains would unfortunately be a perfect bio attack since authorities would most likely pay attention only to the bombing itself.

In such a bombing, the perpetrator’s bodily fluids would be turned into a fine mist and inhaled by the panicked and hyperventilating crowd of survivors, or droplets would fly into open mouths or open eyes.  Add to this the bone and other bodily fragments of the bomber acting as human shrapnel that will imbed itself into victims and it’s easy to see that the risk of disease transmission is high.

There is little to no prevention for this type of scenario other than vigilance on the part of security personnel at venues and locations where crowds gather, which may prevent a bomber from gaining access.  However, the purpose of this short article isn’t prevention, but to discuss the follow-up steps that should be taken by first responders, law enforcement, medical personnel, and coroners or medical examiners in the wake of a suicide bombing.

Indicators the bombing might involve a biological element:

A. Witnesses who saw the bomber before detonation describe him as “looking ill.”
B. No shrapnel in the bomb (to leave survivors).
C. A lesser explosive charge than expected (big enough to obliterate the bomber, but small enough to leave infected survivors).
D. The bomber chooses an open area with a crowd instead of a confined area such as a bus.
E. The bomber chooses a slightly elevated position over a crowd rather than in the crowd.

Whether or not the above indicators were present, we should perform the following steps:

1. Treat the scene as an extreme biohazard.
2. All remaining bits of the bomber should be gathered and screened for infectious disease.
3. Collect contact information from uninjured witnesses for the purpose of later medical treatment and/or ring vaccination, as they may have been infected by airborne droplets.
4. Follow up with all injured survivors for the same reason.

These simple steps might be all that is necessary to prevent a biological sneak-attack from succeeding.  The one missing step though, is to make these first four steps SOP among all involved parties. 

# # #

Paul Purcell is a security analyst and preparedness consultant with over twenty years risk management experience.  He’s also the author of “Disaster Prep 101.”  More information can be found at http://www.disasterprep101.com.

DISASTER MEDICINE: A View from the Trenches

By Geoff Williams, Dr. David McCann and Dr. Maurice A. Ramirez

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 and 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 their efficiency has sometimes been lacking, notably during some high-profile catastrophes in the last few years.

As any student of history knows, for centuries physicians were mostly concerned with minimizing pain and suffering. Before the days of anesthesia, that often meant amputating a limb and hoping for the best, and because germs and proper hygiene were little understood, the doctor was often something of a walking disaster himself. But that began to change during the Napoleonic Wars. “The concept of triage was coined by, I believe, a French military physician with Napoleon, and then you had Clara Barton, during the American Civil War, creating the American Red Cross. All of that’s a part of disaster medicine, and then during each of the wars that the United States has been involved in, disaster medicine has been ramped forward,” says 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.

Indeed. During the Napoleonic Wars, Dominique-Jean Larrey was a surgeon in the French emperor’s army, not only conceived of taking care of the wounded on the battlefield, he also created the concept of ambulances, collecting the wounded in horse-drawn wagons and taking them to military hospitals. Until that time, the wounded were generally cared for near the end of the day, or whenever the battle paused or ended. By the time the Civil War began, Clara Barton learned that many wounded soldiers were dying not from lack of attention, but the need for medical supplies, and she began her own organization to distribute medicine, bandages and other life-saving tools.

The actual term disaster medicine began cropping up in the newspapers with some regularity during the 1950s when medical associations had begun to truly adopt the idea of anticipating a disaster. 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?” Meanwhile colonel and physician, Joseph R. Schaeffer, MD, imagined a massive nuclear attack. “We have 200,000 doctors to take care of 176,000,000 people in this country," he told a Texas hospital medical staff in 1959. “Therefore, the people must learn how to survive for themselves in case of an emergency.” Schaeffer lamented that so few Americans had any proper first aid instruction while Russia required its citizens to take 22 hours in first aid education—every year.

As Cincinnati-based internist John Andrews, MD, who spent 20 years as a Commissioned Corps physician in the U.S. Public Health Service, artfully puts it: “It’s not just that the disasters seem to be coming more frequently, they’re more varied. In the old days, you had natural disasters like hurricanes, floods, tornadoes, and maybe occasionally a chemical spill. But now, somebody’s actually trying to make a disaster.”

While the disaster climate of the last several years has had a profound impact on many laypeople, it has uniquely affected many doctors, who, of course, are prone to having their own opinions on preventing suffering and dying. Dr. Klein, who was a pharmaceutical executive in New York City when the 9-11 attacks occurred, spent around 24 hours at Ground Zero, initially insisting upon dealing “with the worried well,” people he describes as being “absolutely devastated, wandering around in a daze, acutely traumatized.”

The terrorist attacks also had an acute effect on Paul K. Carlton, M.D., the director of Homeland Security at Texas A&M Health Science Center who believes disaster medicine should be a board-certified specialty like General Surgery. As the surgeon general of the Air Force, he had been practicing disaster training with medical students three months before a commercial jet hit the Pentagon. His group had, eerily enough, come up with a similar disaster scenario to practice, only they imagined an aircraft having an unsuccessful take off or landing, resulting in a crash into the Pentagon. In their exercises, they did quite poorly, admits Carlton, but 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 and they managed to pull three people to safety, “and we all got out alive.” No small feat, since Dr. Carlton himself caught on fire. That he’s alive at all is at least partially due to the fire-retardant vest he was wearing.

For Dr. Philip Merideth, M.D., J.D., a psychiatrist in Jackson, Mississippi, his evolution in thinking came after Hurricane Katrina. He spent two weekends in Mississippi and Louisiana, doing what he could, prescribing medicine and simply listening to people pour out their grief. “Everyone had a story of what happened in the hurricane, and they wanted to tell it,” says Merideth, who offers one chilling example—talking to a little boy who had been the only survivor of his household, and that had been because he swam out the second story window.

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 ideas for effectively handling disasters. In 2003, infectious disease specialist Robert Cox MD of Englewood, Colorado, had just started his company, Bioforecasts, intending to speak to medical and non-medical organizations about what society’s future health and longevity might be like. However, he has since expanded his talk to include disaster medicine topics, like bioterrorism and how to inoculate your business against the avian (bird) flu.

“I had been thinking about those topics from the beginning,” says Dr. Cox, “but after awhile, there was no way I couldn’t not discuss them.” That’s how everyone seems to feel.

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 the 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.”

Physicians are addressing the topic on blogs and are forming groups like the Texas Medical Rangers, which aims to respond to natural disasters and weapons of mass destruction attacks inside Texas. In Washington state, Robert Cross, M.D. is a 77-year-old retired physician, who for several years has been toiling to create an organization of retired doctors who will respond to disasters in his home state. He, like many doctors, wanted to do something constructive in the wake of the terrorist attacks. Suddenly, he realized just how shortsighted the medical community had been in closing hospitals left and right due to the advent of outpatient care centers. “In any disaster, surge capacity is a common problem in the hospitals,” says Cross, knowing that while he may not be able to replace the hospital buildings, he can call upon a cadre of newly trained retired physicians and nurses on call to help the state when needed.

In the midst of all of 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 in approval is Dr. Andrews, board certified in internal, preventive 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 Dr. Terbush, who was in the thick of things after Hurricane Rita and Hurricane Katrina. “It would be exceptionally helpful if primary care physicians were experts in disaster medicine.”

One question is almost begging to be asked: Could the American medical community be doing too much? Are we creating layers of bureaucracy, ensuring that when a crisis comes, there will be hundreds or thousands of organizations mobilizing but not within the same framework as everyone else? Dr. Cox agrees that it eventually could become a problem—that we would suffer from a “lack of coordination and communication among the agencies, like the 9/11 experience. There could also be a dilution of resources being spread out rather than concentrated. This applies to both people as well as finances.”

But Cox doesn’t think the medical community or country should slow down just yet. “I think this is all part of the organizational evolution, and only time will tell what the correct number is.” He also points out that there are some efforts at coordinating disparate groups, citing his home state of Colorado’s “Governor’s Expert Epidemic and Emergency Response Committee,” which includes representatives from the medical community, military, public health, agriculture and many others, so the next time a disaster strikes, no group will feel as if they’re on their own.

But however this most recent history of disaster medicine is written, there seems to be one indisputable upside, according to Dr. Fredrick Slone, visiting assistant professor at the University of South Florida College of Nursing, “The reality is that the more teams that are formed, the more people will be trained for a response, and in the long run, this is what we need.” Across the generations, from those who define their times by an incomplete New York City skyline or a mountain of bricks and blood in a tiny Texas town, few people are likely to argue with that.

About the Authors:

Geoff Williams is a nationally syndicated columnist and author. Dr. David McCann and Dr. Maurice A. Ramirez are co-founders of Disaster Life Support of North America, Inc., a national provider of Disaster Preparation, Planning, Response and Recovery education. Through their consulting firm High Alert, LLC., they serve on expert panels for pandemic preparedness and healthcare surge planning with Congressional and Cabinet Members. Board certified in multiple medical specialties, Dr. Ramirez was Founding Chairperson of the American Board of Disaster Medicine and Dr. McCann is the current Cahirperson of the American Board of Disaster Medicine. Both serve the nation as Senior Physicians-Federal Medical Officers for the National Disaster Medical System.

Kids Rule – My Experience at the Give Kids the World Village

By: Alfredo L. Rabines (Featured Guest Author)

The project was grand. The location was Orlando, Florida. The site was created by one man and titled Give Kids the World Village. We arrived there for an orientation that introduced its origin and development. The enthusiastic directors emphasized that the children are the bosses and the number one rule is to have fun.

The first night I was paired up with Aaron, a medical student from Chicago, and a six year old boy named Justin from Brooklyn for the Village Idol Competition. Typically the volunteers do not participate in the contest but since Justin was the boss he insisted we show some moves as his back up dancers. Instantly we agreed and listened carefully to Justin’s choreographic instructions. We cross arms first, do a one arm handstand, switch sides in the back with a slide, and improvise. Justin insisted I also pick up Aaron, catapult him in the air, he flips, and lands on both hands. Due to a lack of acrobatic talent and a potential danger to the community at large we held back on that great feat.

Justin had a contagious smile and witty sense of humor. I suggested we toss him around during the routine and catch him in midair to rebuttal his humor. It is then that he mentioned that he had a heart condition that would not allow him to do that. I was reminded that Justin was a terminally ill six-year old boy amongst over a hundred others visiting the village that week. The village houses just over a hundred families and provides them through generous donations a week stay in Orlando. The child gets full access to all the Disney attractions with V.I.P. front-of-the-line-cutting privileges. It’s a dream come true. And even though I’ve spent countless years hovering over textbooks, implementing diagnoses, and treating illnesses with antibiotics and surgical procedures there was absolutely nothing I could do to save my new friend.

We quickly changed the subject. The performance ended in a standing ovation and we were sure a shoe in for first place, the next Village Idol. All the performers were brought up on stage and the judges unanimously announced everyone a winner. In my true competitive nature I probably would have thought we were robbed but amongst all the winning smiles my dream of being the next American Idol, I mean Village Idol, withered amongst the applaud.

For the next three days, all ninety-seven medical student volunteers from across the country completed shifts at the Gingerbread House, Ice-Cream Shoppe, Carousel, Castle, and many more. The village is designed with a Candyland theme with a choo choo train as transportation. Did I mention that I personally got to drive families to and from their homes! This four day experience reminds me of how amazing it is to give to those in need. There are many people out there that have a personal story that is much tougher then getting through medical school and may just be a life story that comes to a quick ending. As a physician you will care for patients that will expect a lot from you. They may demand it as a privilege without realizing you’ve already given yourself to them. It shall be our goal as health care providers to treat those in need holistically in mind, body and spirit.

What a great ending to a year that’s past and a positive outlook to 2007. Happy New Year!

Alfredo L. Rabines is the National Vice President & Speaker of the House for the National Student Osteopathic Medical Association. Alfredo is a fourth year medical student at the Philadelphia College of Osteopathic Medicine, Class of 2007.

Disaster Medicine: A Historical Perspective

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.

The Secrets of Teaching Disaster Preparedness

Headlines are full of hurricanes, earthquakes, bird flu, terrorism, and other dangers of the world in which we live.  However, most civilians aren’t prepared to face a disaster or even a family emergency.  This begs the question “Why not?”  This article is intended for those who want to change this fact by teaching others, including their own families, to be better prepared, safer, and more self-reliant. 

We’ve identified several “learning obstacles” that prevent individuals and families from being as emergency ready as they should be.  We’ll list them here quickly then cover each in more detail and discuss ways to jump these learning hurdles.

Since we’re talking about educating families – the cornerstone of all reaction plans - let’s use the acronym F.A.M.I.L.I.E.S.:

Fear – “It’s too scary to think about.”

Attention Span – “I’m too busy to learn or do anything new.”

Media – “There’s always a weatherman in the hurricane.”

Info Levels Now – “A 72-hour kit is all I need.”

Lifestyle Ties – “I don’t want to change the way I live.”

Income – “I can’t afford to buy the gear or take the steps.”

Ego – “I’m so important that others will look after me.”

Selflessness – “I’m not worried about me, I want to help others.”

Why is it important to increase the level of civilian preparedness training over what we have through sites like ready.gov?  That question can be a series of articles on its own, but the 4-part short answer is one, most free websites have only the bare minimum info; two, the fewer victims we have in a disaster the better off we’ll all be; three, all business continuity plans rest on the ability of employees to return to work; and four, the term “civilians” includes the families of first responders.  The more prepared the family, the more able is the responder to report for duty.

As we cover each learning obstacle below, you’ll find a brief description of the problem followed by a few specific tips on how to deal with that particular issue.  When teaching, remember that people have different learning styles.  Visual learners do best by watching.  They are receptive to videos, PowerPoint, or live demos.  Auditory learners prefer verbal communication such as podcasts, or books on tape.  Kinesthetic learners benefit from hands-on experience.  Try to incorporate a little of each into your presentations.

Fear

Fear is probably the number one reason people don’t prepare.  Too many people focus on the dangers they may face in disasters, rather than the benefits of self-reliance.  Worse, many so-called experts dwell on nothing but the threat since they have little to no new preparedness information. Let’s look at ways to teach readiness while avoiding fear:

1. Take a tip from insurance salespeople.  They focus on the benefits of the policy rather than the reasons you might need one.  Accentuate the positives of preparedness, not worst case scenarios.
2. Use “mundane” threats to get people to prepare for more dire situations.  For example, people living on the coast understand hurricanes and are receptive to helpful tips regarding evacuation.  However, you might get a negative reaction with a “nuke in the harbor” scenario.
3. Teach preparedness without mentioning a threat.  For example, focus on financial planning.  It’s more economical to buy groceries in bulk and cook at home, and it’s also healthier.  Guess what?  This means you’ll have more food at home in a shelter-in-place situation.  Also, encouraging families to take up camping as a hobby inadvertently helps prepare them for an evacuation.

Attention Span

With microwave ovens, ATMs, email, and so forth, we live in a world of instant gratification.  We have become a society whose mantra is “Just give me the condensed intro, not the whole pamphlet.”  We rarely take time to do a thorough and detailed job of anything, and the notion of adding things to the list, even something life-saving, is out of the question. 

1. Most people don’t realize that being prepared for disaster takes only subtle modifications to your life and doesn’t require extensive study or training.
2. People in this category appreciate “helpful hints,” so break things down into bite-size pieces.  Use simple (though detailed and thorough) checklists and bulleted lists rather than wordy text or long speeches.  For one such list, see “50 Emergency Uses for Your Camera Phone” at http://www.disasterprep101.com/news.htm.
3. Show them how some aspects of preparedness can save time.  For example, having more food in the pantry saves shopping time.  Also, being current and comprehensive with your insurance policies and personal documentation will save months worth of time getting your life back on track after a disaster.

Media

News channels can be a double-edged sword.  They’re great for emergency warnings, but sometimes contradict themselves.  For example, weather stations will pass along evacuation warnings in advance of a hurricane, but then they’ll send a reporter out in the middle of it to give a live report.  Some people see this and think hurricanes are no big deal. We’ve seen the same in minor chemical spills.  Let your preparedness students know that:

1. Things are always smaller and friendlier on TV than in real life.  A picture of a snake isn’t the least bit alarming.  However, turn one loose in your classroom….  (No, don’t actually do this!)
2. News sources live and die on ratings, viewers, and subscribers, and therefore take risks.  However, these are usually controlled risks, since, for example, the weather reporters are usually in a side area and not in the direct path of the eye of the hurricane.  So don’t do what they do, do what they say.

Info Levels Now

Most “emergency” sites on the internet with “readiness information” have nothing but variations of the 72-hour kit checklist.  The other end of the spectrum finds all the “survivalist” info concerning edible plants and living off the land.  These two extremes can mislead the public in two distinct ways.  One, the simplistic info might tell people that a 72-hour kit is all they’ll need and the government will come protect them.  Two, the other extreme relates to fear since it tends to tell people that “things will be so bad that you’ll need these survival skills.”  The extremes should be avoided. Shoot for the more realistic middle ground. 

1. “72-hour” kits are the absolute minimum.  Recommending only a 72-hour kit is like telling a family on a vacation road-trip to get only enough gas to get to the next exit where there might be another station. 
2. If you teach outdoor survival skills, remind people that these skills aren’t the very next option after their 72-hour kit runs out. They’re there for the most severe cases in isolated incidents.
3. Bridge the gap between these extremes by providing instruction on how families can use simple measures to stay safe and secure for up to four weeks, either during an evacuation or extended shelter-in-place.  A good example is the four weeks of food and water stored in the pantry.  Four weeks is a more realistic figure and fills the void between simple kits and survival skills. 
4. For more thoughts, see “The Disaster Dozen: The Top Twelve Myths of Disaster Preparedness” at http://www.disasterprep101.com/news.htm.

Lifestyle Ties

Essentially, this is another form of fear.  It’s the fear of changing one’s lifestyle to incorporate readiness, and it’s the fear of losing one’s current lifestyle in the wake of a disaster.  Two points come into play here. 

1. One of the main goals of true readiness training is the preservation of our lifestyle as we know it, and not just mere physical survival.  Therefore when discussing disasters, cover their aftermath and what it will take for families to return to normal.  Don’t cut the subject short.
2. Realistic preparedness doesn’t involve major changes, but incorporates subtle modifications to the things we already have and do.  For example, the simple habit of topping off your vehicle’s gas tank three times a week is easy to develop and ensures you have as much fuel as possible in an emergency.  Simple task, powerful results, no appreciable change in your lifestyle.

Income

Many people see ads for high-priced “disaster” goods and gear and assume that protecting their family will be a major financial investment.  This isn’t necessarily the case.  If done correctly, protective measures can actually save a family money, or at least zero itself out on your household budget.

1. In our discussion of the 4-week pantry we pointed out how storing this much food could actually save time and money.
2. You don’t need to buy expensive gear.  In fact, we recommend finding things you need at thrift stores or yard sales, and in other cases, making your own gear.  For example, our “mess kits” were made with leftover plastic dishes from microwave dinners.
3. Part of any comprehensive family preparedness training should include a section on frugality, or how a family might save money by reducing expenses and through better household budgeting.

Ego

Ego can also be called self-esteem, and this can either go high or low.  In the case of high self-esteem, some people may think, “I’m so important that others will take care of me.”  Low self-esteem carries its own peculiarities as well.  These folks might think, “No one will help me,” or “Nothing exciting ever happens here, so why prepare?”  Though not directly ego-related, many people hold that same belief that “Nothing will happen here.  Things happen to other people.”

1. Since we want to avoid generating fear, don’t fight the “I’ll be taken care of” attitude with stories of how bad things could get.  Instead, use this high self-esteem by pointing out that one reason people don’t prepare is because their friends don’t.  Therefore, tell this group the truth that they can help get others to prepare by being prepared themselves, and setting an example. 
2. People with low self-esteem should be shown that self-reliance really is possible for them.  These folks have low confidence levels.  Once they see examples of how easy it is to be far more prepared and protected than they are, they’ll appreciate their new confidence and may continue their education on their own.

Selflessness

Many people are so concerned about others that they neglect themselves.  This is one of the reasons we see incidents of PTSD (Post-Traumatic Stress Disorder) in people that were never in the actual emergency.  This type of distant stress is caused when these folks see bad things happen to other people but they can’t do anything about it.

1. A good reminder for this group is that you’re more able to help others if you yourself are well prepared.  And guess what?  “Others” includes pets!
2. In the stocked pantry example, you’ve helped others by already having your supplies, which makes for shorter lines and more stock on the shelves when the unprepared make that last-minute scramble for supplies at the grocery store.
3. You also help others by setting the example that preparedness is socially acceptable, much in the same way that we wear our seatbelts so our children will.

The most important point of all is that your main goal is to teach both the importance and techniques of disaster preparedness in order to make our world safer.  So, we have one last acronym for you; the word T.E.A.C.H.

Treat each family member as unique.

Emphasize the benefits and not the threat.

Allow for different learning styles and speeds.

Confidence building is goal number one.

Help others to help themselves, and to then help others in turn.

Paul Purcell is a feature writer for Disaster-Blog.com and author of Disaster Prep 10. His website is: http://www.disasterprep101.com