Wilderness Medicine, Event Medicine

Disaster Medicine: Perspectives from the Experts

Disaster medicine is a growing niche in emergency medicine.

According to the National Center for Environmental Information, in the U.S. between 1980 and 2020, there were 125 severe storms, 17 wildfires, 45 tropical cyclones, 33 floods, 27 droughts, 17 winter storms, and 9 freezes that each caused more than $1 billion in damage.1 The COVID pandemic alone is likely to cost the U.S. trillions of dollars in combined health care expenses and economic devastation.2

Where do emergency medicine physicians fit in to all of this? From conducting disaster responses to researching quality improvement to implementing administrative changes for disaster planning and management, there is a need for highly educated and trained EM physicians to be leaders on the local, state, national, and international levels. Due to the diversity of skills involved in disaster medicine, fellowships are 1-2 years long, with many combining the program with an EMS fellowship or an additional degree in public health, public policy, or business management. In disaster leadership, EM physicians are uniquely positioned by possessing both critical clinical thinking as well as an understanding of the greater health care systems.

Two experts in the field, Paul Auerbach, MD, MS, FACEP, and Thomas Kirsch, MD, MPH, FACEP, share further insights in this Q-and-A. Dr. Auerbach is the Redlich Family Professor Emeritus in the Department of Emergency Medicine at the Stanford University and Adjunct Professor of Military and Emergency Medicine at the Uniformed Services University of the Health Sciences. Dr. Kirsch is the Director of the National Center for Disaster Medicine and Public Health and a Professor of Military and Emergency Medicine at the Uniformed Services University of the Health Sciences.

How did you get into disaster medicine?

Dr. Auerbach: I came to disaster medicine later in my career. Prior to that, I did a lot of wilderness medicine, so I had some experience with providing care in austere settings. My first involvement with disaster medicine per se was when I became part of Stanford's response team to the earthquake in Haiti in 2010. We were deployed to the "University Hospital," which was an under-resourced facility. There were about a thousand injured patients on-site and 12 of us in that particular deployment. After a few days, I took on the role of supervising the site. At first, I treated a lot of patients too because it's hard to walk past a person in need of help without doing anything, but I soon realized that I couldn't be effective as an administrator and clinician simultaneously. I was doing greater good by organizing supplies and resources, coordinating the medical teams, communicating with the press, and essentially creating a medical center from the ground up.

My wilderness training came in useful—it had taught me resourcefulness, creativity, and innovation. For example, we estimated that we had approximately one hundred patients with femur fractures, and although we had traction pins, we had to improvise rigging systems with cement blocks, sandbags, and rock-filled buckets to provide traction. Every day was full of new challenges like that, and we had open discussions and contributions from everyone to figure these things out.

Dr. Kirsch: I discovered my passion for disaster medicine early on. When I was a medical student, I found a humanitarian rotation overseas at a refugee camp in Thailand, and even though it involved me missing my graduation and working the whole summer up to my internship start date, I jumped on the chance. That experience changed my life. After one year of a general surgery residency, I quit to pursue a Master's in Public Health and work overseas for a while before returning to start residency in emergency medicine. EM seemed like the optimum skill set to work in global health and disaster. From the beginning I focused on the disaster public health issues, not medical response, with a focus on disaster science and education.

However, it can be hard to balance clinical work, disaster work, and raising a family. Disaster medicine, especially on the international level, is very time-intensive. I switched to domestic preparedness when my kids were born, only returning to a blend of international and domestic disaster management once they were older.

In a disaster event, how do communication and power structure play a role?

Dr. Auerbach: It depends on the hospital and command structure already in place and how badly they were damaged by the disaster. It also depends on the country affected. For example, after the earthquake in Nepal, the country at first was reluctant to accept foreign medical teams. FEMA, WHO, and other organizations can offer help, but the affected country has to allow them entry. We have to respect each country's sovereignty and culture, and how their approaches to disaster might differ from our own.

On the ground, the medical teams are respectful of each other and there's usually little conflict—people see how serious the situation is and work together. There isn't time for politics or power struggles. There's a hierarchy for the sake of organization, but it's a fluid and dynamic situation where everyone is contributing.

Dr. Kirsch: Both globally and nationally there are formal structured response systems. Domestically, FEMA runs the response and HHS coordinates health. Globally, the UNHCR has the lead with WHO on health. Most of the on-ground work is provided by NGOs. With a few exceptions, if physicians want to be part of a disaster response, they have to be part of one of these organizations.

The Haitian earthquake was the only time I provided clinical medicine, because it was a rare example of when international healthcare was needed. Most other disasters, the affected countries and local NGOs handle the clinical medicine. My skills—the skills of any disaster medicine leader—are better utilized for management and public health aspects.

What is one of those difficult parts of disaster medicine?

Dr. Auerbach: It's frustrating for doctors to not be able to give patients the standard of care they are used to giving in non-disaster times. The nuances of triage, the ethical issues, limited resources, supply chain logistics, looser hierarchy—these are all dynamic factors in a disaster.

Dr. Kirsch: Emotionally, some events are overwhelming—seeing so much pain and suffering. Especially Haiti— I don't think anyone walked away from there without PTSD. In general, a career involving disaster response is very difficult. On the practical side, it can be difficult to get the time off from your clinical job to respond to a disaster. I was working in the private sector in Arizona when 9/11 happened and had to beg to get three weeks of shifts covered.

Tell us about some of the mass casualty events that you responded to more locally.

Dr. Auerbach: Local mass casualty events are disasters in their own right and require a similar set of skills. For example, during residency at UCLA, in the midst of the fuel crisis, a disgruntled person drove into a crowd of people waiting at a gas station—suddenly our ED had an influx of 10-15 traumas. A similar incidence occurred the summer after I graduated residency, up in Cape Cod. An intoxicated person drove into a block party and mowed down a whole bunch of people. It happened near where I had just rented a house, so I came onto the scene and immediately started triaging and helping patients. After, I went to the hospital where I was supposed to start working the next day, introduced myself, and just began taking care of patients. Incidences with 10-20 people can be disasters on a smaller scale, because any time you overwhelm your existing resources, you have a disaster situation.

Dr. Kirsch: I've responded to dozens of domestic disasters, everything from wildfires to hurricanes, even more globally. Mostly, my role was not as a clinician but rather as a public health expert and scientist. For example, during 9/11 I was with the Red Cross health coordinator in NYC; during Hurricane Katrina I worked with the Red Cross in Louisiana on public health, shelter, safety issues; during Hurricanes Sandy and Harvey I deployed with FEMA to assess hospital impact and preparedness. That's not nearly as romantic as working in a hot tent, but even more important in the long run.

Tell us about your current work.

Dr. Auerbach: Right now, I'm a visiting scholar at the National Center for Disaster Medicine and Public Health. We’re working on a public-private partnership that will train communities to be their own first responders and recognize and deal with disaster scenarios if no one can get to them in time. We are in an age of ever-increasing natural disasters caused by climate change. There just aren't enough first responders to go around when you have one disaster after another—when you have 10 fires simultaneously instead of 1 or 2. Communities—citizens—need to be aware of what to watch out for and how to avoid or handle potentially dangerous situations.

Dr. Kirsch: I'm currently the director of the National Center for Disaster Medicine and Public Health, which means that I work for the federal government. Our center focuses on disaster health research and education. My job entails a lot of meetings—mostly public policy based. One project involves researching health system preparedness and capacities in the time of COVID. In general, we work across the different government agencies to figure out healthcare worker safety and mental health care issues. It isn't the adrenaline-filled side of disaster medicine where you're running around triaging and doing field medicine, but we are trying to fix the system and that has the potential to impact populations everywhere.

Where do you see the field of disaster medicine headed in over the next 10-20 years?

Dr. Auerbach: There's going to be a lot of epidemiology, and we're going to have to believe it. Moreover, our response to disasters right now is a hodgepodge of approaches—we need something more unified. Science and technology will improve our responses, but we also need education, community engagement, health policy, and legislation. It's a wide-open field, and I hope that there will be a groundswell of interest in disaster medicine—and that emergency medicine physicians can take on those leadership roles.

Disaster medicine is coming into its own, especially as we realize that we're going to be facing more and more climate-related disasters. Ideally, we need a way to predict these natural disasters and mitigate them ahead of time—and where that's not possible, we need citizen engagement and preparedness.

Dr. Kirsch: With climate change, there has been a steady and continuous upward trend of life lost and economic impact of disasters, and that’s only going to increase in coming years. The real issue is how do we build health care resilience, both population-based in regard to protecting people from these events and hospital-based in regard to creating systems that can handle large surges in demand.

Moreover, the one thing our country is not prepared for is a massive catastrophe—an earthquake or a nuclear bomb in a major city. The hurricanes and wildfires we've seen have great economic impact, but our health care systems have adapted to evacuation plans and the smaller increases in patients such events can bring about. What we have little infrastructure in place for is for events injuring tens or even hundreds of thousands of people. COVID has shown us the limits of our hospitals—if COVID had even a slightly higher mortality rate, the healthcare systems would have been overwhelmed, and they very nearly were, especially in New York.

What is your advice to EM residents looking to get involved in disaster medicine?

Dr. Auerbach: As a resident, become really good at what you do. These years are the foundations of emergency medicine as well as disaster medicine, and once you have a solid grasp of it, you can start to branch out into learning about structures, teams, and public health issues. Most people think of disaster medicine as the initial response, the medical triage and treatment—that's only the first phase. After that, it becomes a public health issue. It's about infectious diseases, food and shelter, migration. Emergency physicians are not necessarily trained in those areas, but it is and should be part of studying disaster medicine.

Dr. Kirsch: Residency is a time to learn the bread and butter of emergency medicine, but you can supplement your experience by diving into the research in disaster medicine. It’s important to understand the structure of our national and international response system, and to think about where you'd like your career to take you. There's such a variety of disaster medicine opportunities out there, but most are bureaucratic, not clinical. Disaster fellowships offer a good opportunity to explore a career. They often concentrate on different aspects, such as public policy or administration or EMS. Emergency medicine physicians also work across all the federal agencies such as DoD, FBI, FEMA, HHS, the White House, and DOT. How you want to shape your career will determine where and how you should get involved in your local community. The wonderful thing about disaster medicine is that it gives you an opportunity to make a difference. It's not an easy career path, but if you're dedicated, there's a lot of good you can do.


References

  1. National Centers for Environmental Information. Billion-Dollar Weather and Climate Disasters: Events. Sept. 21, 2020.
  2. Centers for Disease Control and Prevention. Daily Updates of Totals by Week and State: Provisional Death Counts for Coronavirus Disease 2019 (COVID-19). Sept. 28, 2020.
  3. Auerbach PS, Norris RL, Menon AS, et al. Civil-military collaboration in the initial medical response to the earthquake in Haiti. N Engl J Med. 2010;362(10):e32 .

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