Preparing for disasters

What should you know, and when should you know it?

As first responders, PAs need to be familiar with the local disaster plan, understand their role in emergencies involving all types of hazards, and know how to communicate with patients, staff, and government agencies.

Charles DiMaggio, PhD, MPH, PA-C; David Markenson, MD, EMTP; Irwin Redlener, MD

Dr. DiMaggio is Director, Program for Healthcare System Preparedness, National Center for Disaster Preparedness; and Assistant Professor of Clinical Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. Dr. Markenson is Director, Program for Pediatric Preparedness; Deputy Director, National Center for Disaster Preparedness; Assistant Professor of Population and Family Health, Mailman School of Public Health; and Assistant Professor of Pediatrics, Columbia University College of Physicians and Surgeons. Dr. Redlener is Director, National Center for Disaster Preparedness, and Associate Dean, Mailman School of Public Health, Columbia University. The authors have indicated no relationships to disclose relating to the content of this article.

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Three waves of terrorism have ushered in a new era in public health, safety, and health care in the United States: The February 26, 1993 explosions at New York’s World Trade Center, the April 19, 1995 bombing at the Murrah Federal Building in Oklahoma City, and the September 11, 2001 attacks, along with the anthrax cases that followed. Those events have awakened federal, state, and local governments to the urgency of improving their disaster-response capabilities. The health professions have also stepped forward to delineate the roles of their members in disasters,^1,2 establish minimum competencies,^3,4 and develop new training programs.⁵

Physician assistants have a strong tradition of responding to crisis.⁶

• Fully 10% of the 42,700 PAs in practice today list emergency medicine as their primary specialty.⁷
• 15% of all ambulatory care provided by PAs in 1997 occurred in emergency department settings, compared with 9.9% of visits for non-PA clinicians.⁸
• PAs or nurse practitioners cared for 3.5 million emergency department patients in 1992.⁹

In all likelihood, PAs will be among the first responders to any disaster in the United States. It is incumbent on the profession and on individual PAs to understand what their roles would be in a disaster and to prepare accordingly.

Take an all hazards approach

While there is an urgent need to prepare for chemical, biological, radiologic, nuclear, or explosive emergencies, the next disaster a PA may encounter will more likely be due to natural phenomena (hurricanes, tornados, floods) or human failures such as a blackout. An allhazards approach addresses any natural or man-made disaster.¹⁰ It does not preclude threat-specific preparations, but requires the use of initial, sound general principles of emergency management (see “The all-hazards approach to disaster preparedness”).

Be prepared for terrorism: Know CBRNE

Being ready for possible terrorist events brings responsibilities beyond knowing the basics of disaster preparedness. At a minimum, PAs should be familiar with CBRNE—the chemical, biological, radiologic, nuclear, and explosive agents with the potential to cause the greatest harm and thus most likely to be used in a terrorist incident. Familiarity means understanding the early recognition and treatment of the harm caused by those agents; it also means knowing how to protect yourself and your patients with isolation techniques, decontamination procedures, and personal protective equipment.

Biologicals have been called “the poor man’s bomb.” They include a number termed Category A agents because of the increased threat they pose.¹ Among them are the causes of smallpox, tularemia, anthrax, and plague (see Table 1). They are easily disseminated, cause high mortality and social disruption, and require special emergency preparation on the part of the health care and public health systems. Some, such as smallpox, are highly contagious, while others, such as anthrax, are unlikely to be spread person to person.^11,12

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Chemicals of concern include nerve agents, anticholinergics, and vesicants. Treatments, such as atropine and pralidoxime (2-PAM), are available in commercial packages known as Mark-1 kits but should not be used indiscriminately. Simple removal of clothing is more than 90% effective as a decontamination measure.¹ Cleansing with soap and water achieves further decontamination. Table 2 summarizes the classes of potential chemical agents and their antidotes.

Terrorist detonation of a nuclear device, which involves a fission reaction, is considered unlikely because of the sophistication required. Much more likely is exposure to radiologic material through the dispersal of powder or pellets using conventional explosives like dynamite (a so-called “dirty bomb”). The first step is decontamination by removing clothing and cleansing with soap and water. Surgery, if indicated, should be performed before the tissue effects of ionizing radiation introduce further complications. Potassium iodide is recommended to prevent thyroid cancer only after exposure to radioactive iodine (¹³¹I). Marrow stimulants, such as epoetin alfa and granulocyte colonystimulating factor, may be indicated.¹

The majority of terrorist incidents involve bombs and explosions. They result in standard penetrating and blunt trauma but may also produce “unique patterns of injury seldom seen outside of combat.”¹³ Gasfilled anatomic structures such as the lung, GI tract, and middle ear are most susceptible. Potential injuries include pulmonary barotrauma (“blast lung”), abdominal hemorrhage and rupture, ocular rupture, traumatic brain injury, tympanic membrane rupture, and middle ear damage.

Be prepared for public health emergencies

The success of any health response to a large-scale disaster will hinge on the ability to integrate medical and public health practice.¹⁴ PAs should be familiar with the principles of health surveillance and the mechanisms for reporting suspicious cases, atypical syndromes, or unusual patterns of patient presentations to local health authorities. Familiarize yourself with the clinical and public health responses to emerging infectious diseases such as severe acute respiratory syndrome (SARS), avian flu, and West Nile virus. The principles of surveillance and disease control are similar to those that would be instituted in response to biological agents of terrorism. Table 3 lists online resources for clinical and public health disaster preparedness.

The concepts of incident command and incident management, while new to health care personnel, are an integral part of disaster planning and have been adopted by many public health authorities. Training in incident management may be available at your institution or via online programs. One of the most comprehensive programs is run by the Federal Emergency Management Agency.

Helpful online resources include those retrievable by entering the search term “terrorism” on the American Academy of Physician Assistants’ home page (www. aapa.org).¹⁵ In addition, you can take advantage of numerous clinical training opportunities relevant to disaster preparedness, such as basic, advanced, and pediatric life support courses and Advanced Trauma Life Support. Also consider specific disasterrelated continuing educational programs on incident command and incident management, terrorism, decontamination and personal protective equipment, and public health emergencies.

Have a disaster plan, and know it

The disaster plan has been called “the most important preparedness tool.”¹⁶ While most commonly associated with hospitals and large institutions, officebased practices also need a plan. The time to read and familiarize yourself with your plan is now, not while you are waiting for the ambulances to arrive.

It is of paramount importance to understand your role in an emergency. This will be primarily defined in your institutional disaster or emergency plan and may be listed as your emergency functional job description. Your emergency role may differ from your daytoday job, but it will be within the scope of your knowledge and skills. You may also be expected to report to a different location and to a different supervisor.

Disaster response activities can be grouped according to 4 Rs: recognize, respond, report, responsibility.

• Recognize that a potential bioterrorism or disasterrelated event may be occurring. Be familiar with possible CBRNE agents. Know the routes of exposure, their epidemiology, and the signs and symptoms with which they are associated.

• Respond appropriately to the acute-care needs of your patients during acts of terrorism, public health emergencies, or disasterrelated events. Be familiar with current treatments and their contraindications, as well as the principles of decontamination and isolation.

• Report potential or actual bioterrorist events to the appropriate local, state, and federal authorities. The link between medical care and public health is crucial. Knowing how to contact your local health department is a first step. Public health surveillance varies by municipality; familiarize yourself with the system in your community and what your role is. Understand that you may be expected to collect forensic evidence and to know the lead law enforcement agency for possible bioterrorist incidents in your community.
  

• Responsibility refers to your duty to address your own needs and those of your family by developing personal disaster plans (see “The best form of disaster preparation begins at home” and “How to develop a home disaster plan,”). This principle recognizes that you work within the limits of your ability and authority, and that you consider other ethical concerns such as patients’ refusal of isolation and treatment, the allocation of limited resources,⁴ and the prospect of pressure by patients, friends, or family to provide the antibiotics or other agents they could not obtain from emergency departments or physicians.

Fortify student competencies

A number of clinical professions are developing bioterrorism and emergency preparedness competencies for practitioners and students.³⁵ Competencies are the skills, knowledge, and abilities necessary for effective and efficient functioning of an organization or profession.³

For PA programs, the challenge is to add material to an already full curriculum. Much of the relevant material may already be in the training program; incorporating discussion of bioterrorism and emergency preparedness may simply be a matter of providing the appropriate emphasis and context. Some entirely new material may have to be added, however. For programs that share campuses with other health professions, these activities might be interdisciplinary. Resources can be standardized, and aspects of the curriculum may be incorporated into distancebased learning modules that can be shared across departments and even institutions. Faculty development will be necessary, supported by continuing education activities, training opportunities, and fellowships. Some of these tools may come from a number of projects currently under way to enhance existing health sciences curricula.¹⁷ PA schools should consider interdisciplinary hands-on senioryear activities such as tabletop exercises or case studies.

An interdisciplinary group from Columbia University’s health sciences campus in New York, NY—representing the College of Physicians and Surgeons, the School of Nursing, the School of Oral and Dental Surgery, and the Mailman School of Public Health—is defining a set of core competencies for all health care professionals. A draft set of competencies applicable to PAs is presented in Table 4.

Expanding the scope of PA practice in an emergency

If the medical system is overwhelmed, it may “fall to nonphysicians to provide many services ordinarily supplied by physicians (such as performing triage, dispensing medications, and providing general medical support).”² By virtue of their training and experience, PAs are positioned to respond to this need for crisis surge capacity. An increase in minor injuries may necessitate a demand for clinicians “skilled in managing minor surgical emergencies.”¹⁸ PAs may also contribute to “the prompt reestablishment of normal curative and preventative health activities,” which is a priority after a disaster.¹⁹ In addition, PAs may be called on to assist public health authorities with mass vaccination, public health surveillance, and outbreak investigation.

There should be a framework for expanded scope of practice and the assumption of nontraditional roles during times of emergency. Since PAs practice medicine within unique state legislative niches, the profession should contribute to the policy making process. Of particular concern are the implications for liability and indemnification, given the need for supervision. The AAPA has advocated for exemptions to state supervision laws “to allow PAs to respond to exceptional circumstances created by disasters or emergencies in the field.”²⁰AAPA model language was used in recently passed Arizona legislation “to facilitate PA practice in disasters and emergencies.”²¹ It remains your responsibility to be familiar with applicable state laws regarding your participation in disaster settings.

Conclusions

The goals of disaster preparedness are to anticipate, mitigate, and rehabilitate. All health professionals can and should contribute to this process. Among the most essential competencies are the ability to locate your institutional or office disaster plan, to understand your role in an emergency; and to know how to communicate with patients, ancillary staff, and governmental agencies during an emergency.³ As clinicians, you have the added responsibility of becoming familiar with the chemical, biological, radiologic, nuclear, and explosive agents of concern.

The PA’s role may change or expand during times of crisis. Many resources are available to train and prepare clinicians on an individual basis. This includes gathering information on personal and family preparation. The PA profession, through its organizations, should address issues of professional education and legislation.

Acknowledgments

Supported in part by Grant No. 5T01HP0134-02-00 from the Health Resources and Services Administration and Grant No. 1 K01 CE000494-01 from the Centers for Disease Control and Prevention.

The authors acknowledge contributions of the Columbia University Bioterrorism Curriculum Development Advisory Committee in developing the draft core competencies presented in Table 4.

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