Disaster medicine
Disaster medicine is the area of medical specialization serving the dual areas of providing health care to disaster survivors and providing medically related disaster preparation, disaster planning, disaster response and disaster recovery leadership throughout the disaster life cycle. Disaster medicine specialists provide insight, guidance and expertise on the principles and practice of medicine both in the disaster impact area and healthcare evacuation receiving facilities to emergency management professionals, hospitals, healthcare facilities, communities and governments. The disaster medicine specialist is the liaison between and partner to the medical contingency planner, the emergency management professional, the incident command system, government and policy makers.
Disaster medicine is unique among the medical specialties in that unlike all other areas of specialization, the disaster medicine specialist does not practice the full scope of the specialty everyday but only in emergencies. Indeed, the disaster medicine specialist hopes to never practice the full scope of skills required for board certification. However, like specialists in public health, environmental medicine and occupational medicine, disaster medicine specialists engage in the development and modification of public and private policy, legislation, disaster planning and disaster recovery. Within the United States of America, the specialty of disaster medicine fulfills the requirements set for by Homeland Security Presidential Directives, the National Response Plan, the National Incident Management System, the National Resource Typing System and the NIMS Implementation Plan for Hospitals and Healthcare Facilities.
Definitions
– 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 – 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 – 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 – The time line for disaster events beginning with the period between disasters, 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 – 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 – The 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 – The restoration or return to the former or better state or condition proceeding a disaster event. Disaster recovery is the fourth phase of the disaster life cycle.
Disaster response – 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 – The act of devising a methodology for meeting the medical requirements of a population affected by a disaster event.
Medical surge – An influx of patients, 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 – 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 – The separation of patients based on severity of injury or illness in light of available resources.
Psychosocial triage – The separation of patients based on the severity of psychological injury or impact in light of available resources.
History
The term "disaster medicine" first appeared in the medical lexicon in the post-World War II era. Although coined by former and current military physicians who had served in World War II, the term grow out of a concern for the need to care for military casualties, or nuclear holocaust victims, but out of the need to provide care to the survivors of natural disasters and the not-yet-distant memory of the 1917-1918 Influenza Pandemic.The term "disaster medicine" continued to appear sporadically in both the medical and popular press until the 1980s, when the first concerted efforts to organize a medical response corps for disasters grew into the National Disaster Medical System. Simultaneous with this was the formation of a disaster and emergency medicine discussion and study group under the American Medical Association in the United States as well as groups in Great Britain, Israel and other countries. By the time Hurricane Andrew struck Florida in 1992, the concept of disaster medicine was entrenched in public and governmental consciousness. Although training and fellowships in disaster medicine or related topics began graduating specialists in Europe and the United States as early as the 1980s, it was not until 2003 that the medical community embraced the need for the new specialty.
Throughout this period, incomplete and faltering medical responses to disaster events made it increasingly apparent in the United States of America that federal, state and local emergency management organizations were in need of a mechanism to identify qualified physicians in the face of a global upturn in the rate of disasters. Many physicians who volunteer at disasters have a bare minimum of knowledge in disaster medicine and often pose a hazard to themselves and the response effort because they have little or no field response training. It was against this backdrop that the American Academy of Disaster Medicine and the American Board of Disaster Medicine were formed in the United States of America for the purpose of scholarly exchange and education in Disaster Medicine as well as the development of an examination demonstrating excellence towards board certification in this new specialty. In 2008, the United States National Library of Medicine formed the Disaster Information Management Research Center in support of the NLM's history of supporting healthcare professionals and information workers in accessing health information. DIMRC provides a specialized database, Disaster Lit: Database for Disaster Medicine and Public Health, an open access resource of disaster medicine documents, including guidelines, research reports, conference proceedings, fact sheets, training, fact sheets, and similar materials.
Ethics in Disaster Medicine
The Disaster Medicine practitioner must be well-versed in the ethical dilemmas that commonly arise in disaster settings. One of the most common dilemmas occurs when the aggregate medical need exceeds the ability to provide a normal standard of care for all patients.Triage
In the event of a future pandemic, the number of patients that require additional respiratory support will outnumber the number of available ventilators. Although a hypothetical example, similar natural disasters have occurred in the past. Historically, the influenza pandemic of 1918-19 and the more recent SARS epidemic in 2003 led to resource scarcity and necessitated triage. One paper estimated that in the United States, the need for ventilators would be double the number available in the setting of an influenza pandemic similar to the scale of 1918. In other countries with fewer resources, shortages are postulated to be even more severe.
How, then, is a clinician to decide whom to offer this treatment? Examples of common approaches that guide triage include "saving the most lives", calling for care to be provided to "the sickest first" or alternatively a "first come, first served" approach may attempt to sidestep the difficult decision of triage. Emergency services often use their own triaging systems to be able to work through some of these challenging situations; however, these guidelines often assume no resource scarcity, and therefore, different triaging systems must be developed for resource-limited, disaster response settings. Useful ethical approaches to guide the development of such triaging protocols are often based on the principles of the theories of utilitarianism, egalitarianism and proceduralism.
Utilitarian Approach
The Utilitarian theory works on the premise that the responder shall 'maximise collective welfare'; or in other words, 'do the greatest good for the greatest numbers of people'. The utilitarian will necessarily need a measure by which to assess the outcome of the intervention. This could be thought of through various ways, for instance: the number of lives saved, or the number of years of life saved through the intervention. Thus, the utilitarian would prioritize saving the youngest of the patients over the elderly or those who are more likely to die despite an intervention, in order to 'maximise the collective years of life saved'. Commonly used metrics to quantify utility of health interventions include DALYs and QALYs which take into account the potential number of years of life lost due to disability and the quality of the life that has been saved, respectively, in order to quantify the utility of the intervention.
Egalitarian Approach
Principles of egalitarianism suggest the distribution of scarce resources amongst all those in need irrespective of likely outcome. The egalitarian will place some emphasis on equality, and the way that this is achieved might differ. The guiding factor is need rather than the ultimate benefit or utility of the intervention. Approaches based on egalitarian principles are complex guides in disaster settings. In the words of Eyal "Depending on the exact variant of egalitarianism, the resulting limited priority may go to patients whose contemporaneous prognosis is dire, to patients who have lived with serious disabilities for years, to young patients, to socioeconomically disadvantaged patients, or to those who queued up first. This approach prioritizes simplification of the triage and transparency, although there are significant ethical drawbacks, especially when procedures favor those who are part of socioeconomically advantaged groups. Procedural systems of triage emphasize certain patterns of decision making based on preferred procedures. This can take place in the form of a fair lottery for instance; or establishing transparent criteria for entry into hospitals - based on non discriminatory conditions. This is not outcome driven; it is a process driven activity aimed at providing consistent frameworks upon which to base decisions.
These are by no means the only systems upon which decisions are made, but provide a basic framework to evaluate the ethical reasoning behind what are often difficult choices during disaster response and management.