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DISASTER MEDICINE: A View from the Trenches
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.
By Geoff Williams, Dr. David McCann and Dr. Maurice A. Ramirez
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