Educating the Podiatric Physician in Disaster and Emergency Preparedness

Historical Context

Even before 9/11 there had been increased incidents and threats of domestic terrorism in the United States. Among these incidents were the 1993 bombing at the New York City World Trade Center parking lot, the bombing in 1995 at the Oklahoma City federal building (killing 168 people, 19 of whom were children), and the pipe bombing at the Summer Olympic Games in Atlanta. In addition, in 1996 there were the deaths and injuries resulting from the release of the toxic nerve agent sarin in a crowded Tokyo subway.

Bioterrorism also has occurred in the United States and globally. In 1763 at Fort Pitt on the Pennsylvania frontier, British General Lord Jeffery Amherst obtained blankets and handkerchiefs from patients with smallpox to be given to Delaware Indians at an alleged peacemaking event. In the 1980s, a cult used Salmonella to poison citizens living in a small town in Oregon. More than 700 individuals became ill, and more than 40 required hospitalization [1–3]. Historical documents record biological agents that have been studied or deployed as weapons since the 14th century and continuing to the present. In 1340, attackers catapulted dead horses and other animals at the castle Thun-l’Evêque in Hainault in what is now northern France. The defenders reported that “the stink and the air were so abominable. . .. They could not long endure” and negotiated a truce. Scientists of the infamous Unit 731, a bioweapons project of the 1930s, used human subjects, mostly Chinese and political prisoners, to test the lethality of various disease agents, including anthrax, cholera, typhoid, and plague. As many as 10,000 people were killed. During a variety of military campaigns, several hundred thousand people, mostly Chinese civilians, fell victim. In October 1940, the Japanese dropped paper bags filled with plague-infested fleas over the cities of Ningbo and Quzhou in Zhejiang province. Other attacks involved contaminating wells and distributing poisoned foods. By the end of the Gulf War in 1991, Iraq possessed an impressive bioweapons arsenal that included anthrax, botulism, and other lethal weapons. Although Iraq is known to have used chemical weapons during the Iran-Iraq war and against the Kurds in northern Iraq, their use of bioweapons is unknown.

However, it took Americans witnessing the loss of more than 3,100 lives on national television for the entire population to appreciate that the potential for bioterrorism and weapons of mass destruction is real and no longer only a theme for science fiction novels and movies [3]. Even after 9/11, it is still questionable whether health professional schools place a high enough priority on the importance of education and training in all-hazards preparedness at the undergraduate and graduate medical levels. An Internet-based survey was sent to 48 undergraduate and fellowship representatives, with receipt of 24 responses. The survey outcome demonstrated that 22 programs before 9/11 and 14 programs after 9/11 taught principles of disaster medicine concepts. The conclusion was that there has been a decline in the number of programs offered after 9/11 [4].

Most hospitals in urban, suburban, and rural areas have well-organized disaster preparedness planning projects in accordance with city planning efforts. Many hospitals, including government institutions, such as Veterans Affairs medical centers, county health affiliates, and medical schools, collectively engage in exercises to demonstrate proficiency for public safety reasons in the skills of appropriate disaster preparedness programs. However, it was demonstrated after Hurricane Katrina that one cannot rely solely on these facilities because disasters can make them nonfunctional. It is, therefore, essential that local communities, including current and future health professionals, receive interprofessional all-hazards preparedness training to work as teams that could respond to the multiple community needs that will need to be addressed.

Shortly after the carnage of 9/11, the use of anthrax as a weapon created more terror, beginning with a death in Boca Raton, Florida, followed by more cases and deaths as well as many anthrax hoaxes. However, besides intentional man-made disasters, there is a broad spectrum of unintentional man-made disasters as well as natural disasters, such as hurricanes, floods, wildfires, tsunamis, earthquakes, and tornadoes, in addition to the recent H1N1 pandemic [5–8].

The amount of devastation that these occurrences cause greatly stress local and national resources, often kill hundreds or even thousands of people, and cost billions of dollars. What is also stressed is the community infrastructure, overburdening the health-care and emergency preparedness systems. Physicians, other health professionals, and first responders are often inadequate in numbers or are not adequately trained to respond to the unique demands of a disaster. A well-organized all-hazards undergraduate and graduate podiatric medical education program can result in making a significant contribution to the emergency preparedness system when such a surge capacity is needed in a major disaster.

Lessons learned from Hurricane Katrina in New Orleans include the fact that many members of the response team did not show up, had no personal preparedness plan, and were fearful about the safety of their families. Most of the hospitals and clinics were destroyed, and people were cut off from the emergency assistance they were accustomed to receiving. Streets and roads were often impassable.

The Case for Podiatric Physicians Being Part of the Disaster Response Team

Being a trained member of the disaster response team is an essential part of the practice of podiatric medicine. Podiatric physicians have a broad spectrum of professional skills derived from what has become up to 7 years of professional school and graduate medical education.

During their training, podiatric physicians have learned to assess patients through the performance of physical examinations. This skill is first acquired before obtaining the DPM degree and through residency rotations in such medical services as medicine, emergency medicine, lower-extremity trauma, non–podiatric medical trauma, and orthopedic and general surgery.

As a major component of clinical practice, podiatric physicians perform soft-tissue and bone surgery and care for fractures, sprains, lacerations, and other trauma. These skills are transferable to the podiatric and general medical needs of casualties in a catastrophic event. Podiatric physicians also have the legal right and the education and training to prescribe and administer drugs ranging from antibiotics to narcotics and other analgesics. These skills are invaluable in the event that casualties may require such drugs for definitive care in a public health emergency or as preventive measures, such as the administration of inoculations.

Podiatric physicians can participate in preventing the population from acquiring diseases resulting from bioterrorism or when there is the threat of a disease outbreak (eg, pandemic influenza). These skills, when provided with additional training and as part of an all-hazards preparedness response team (eg, Medical Reserve Corps), can make the podiatric physician one of the most invaluable members of the response team in the event of a public health emergency. Such training is essential so that they can be part of the team effort that makes for an effective disaster response. An effective response to catastrophic events includes participation in all phases of the disaster cycle (ie, prepare, prevent and protect, respond, mitigate, and recover).

Specific Role of the Podiatric Medical Profession in All-Hazards Preparedness

All podiatric physicians can be useful members of the preparedness team, but it is important that the well-meaning podiatric physicians not just “show up” at the scene of a disaster without appropriate disaster preparedness training. Their effectiveness can be greatly enhanced if they 1) have personal and professional preparedness plans (which they practice); 2) complete Incident Command System 100 and 200/National Incident Management System 700 courses, which are offered online for free by the Federal Emergency Management Administration; and 3) become part of the Medical Reserve Corps, the Community Emergency Response Team, or the Red Cross.

Functions in the Scope of Podiatric Medical Practice that Will Be Invaluable in Disasters

Inherent in podiatric medical practice are a variety of skills and responsibilities that may be invaluable in the event of a disaster. Among these are diagnosing and treating foot and ankle soft-tissue and bone trauma (burns, puncture wounds, lacerations, sprains, strains, fractures, dislocations, and amputations), prescribing drugs for podiatric medical disorders, performing and interpreting radiographs and other imaging studies of the foot and ankle, and administering tetanus toxoid after podiatric medical soft-tissue injuries.

Podiatric Medical Skills Potentially Transferable to Disasters

Various aspects of podiatric medical and surgical practice include transferable skills that, although falling outside the scope of the podiatric physician, may provide added value and will be desperately needed in a disaster: suture of skin, mass inoculations, administration of drugs, administration of tetanus toxoid, administration of analgesics and narcotics, triage, debridement of skin and soft tissues, intubation (if currently qualified), establishment of a catheter (if currently qualified), basic life support, and advanced cardiac life support.

Education and Training Issues

As is currently evolving in medical schools awarding the MD or DO degree, every podiatric medical school and graduate educational training program (residencies and fellowships) also should be required by the Council on Podiatric Medical Education to provide bioterrorism and all-hazards training. All-hazards training should be included in residency and continuing medical education for podiatric physicians. Podiatric physicians should be required to complete instruction in all-hazards training to renew their license, as do some MDs and DOs. Educational programs and activities should be developed for podiatric medical students, residents, and fellows and for practicing podiatric physicians in urban, suburban, and rural communities, including but not be limited to those in community practice, hospital-based practice, and county facility– and government-based practice structures.

Initial Activities for the Development of Podiatric Medical Curricula

One of the first tasks to address is the identification of knowledge and a database on the most current information about disasters and emergency preparedness. This is a dynamic process since new knowledge and procedures continue to be generated almost daily. Another important activity is the identification and performance of all-hazards preparedness research. This should focus on issues regarding education and training and on various aspects of disasters and emergency preparedness, such as prevention, mitigation, response, and recovery. It is also essential to develop mechanisms to evaluate ongoing programs and the outcomes of each component of the curriculum.

Curriculum

In addition to the immediate provision of continuing education for practicing podiatric physicians, the education and training of podiatric medical students, residents, and fellows in all-hazards preparedness is an area of high priority. Time should be identified in the curriculum to ensure that instruction in emergency and disaster preparedness becomes an integral part of the required curriculum leading to the DPM degree and training for podiatric medicine and surgery residency and fellowship programs. Accreditation standards and requirements for colleges of podiatric medicine and residency and fellowship training programs for trainees at each of these levels should include requirements for training in all-hazards preparedness. No podiatric medical student or resident should be awarded a degree or certificate of completion for their course of study without receiving such training.

The following is an outline of curricula content and training methods that may serve as a guideline to be used in the planning of a disaster and emergency preparedness program for podiatric medical students, residents, and practitioners.

Methods

A combination of scenarios, tabletops, and discussions is most effective. Part of the curriculum can be provided online, including pretest and post-test evaluations. All trainees should develop and submit a personal preparedness plan (may be submitted online). Relying solely on lectures, although perhaps efficient, is not likely to lead to outcomes resulting in the necessary competencies.

Objective of an All-Hazards Curriculum at Podiatric Medical Schools

The objective of a curriculum in all-hazards preparedness at a podiatric medical school is to ensure the development of future physicians who will be able to serve as part of a competent health-care workforce with the knowledge, skills, abilities, and attitudes to:

• Recognize the nature of all-hazards events, including manmade and natural disasters.
• Participate in the prevention of, mitigation of, response to, and recovery from disasters.
• Participate in meeting the acute-care needs of patients, including pediatric and other vulnerable populations, in a safe and appropriate manner.
• Participate in local, regional, state, and national responses.
• Rapidly and effectively alert the public health system of such an event at the community, state, and national levels.
• Function as part of an interprofessional team in all-hazards preparedness.

Outline of Curricula Content

• Basic Awareness–level Modules
  • Overview of bioterrorism and all-hazards preparedness
  • Responding to emergency and disaster situations (eg, National Incident Management System/Federal Emergency Management Administration compliance)
  • Vulnerable and hard-to-reach populations (eg, those with physical disabilities, vision and hearing impairments, mental disabilities, the elderly, non–English speaking, migrants, visitors and tourists, etc)
  • Personal and workplace emergency preparedness and response
• Development of a Personal Preparedness Plan
• Intermediate-level Modules
  • The emergency response system
  • CBRNE (chemical, biological, radiological, nuclear, explosives)
  • Psychological implications of a disaster
  • Issues in managing a mass casualty event
• Evaluation

Each module will have a pretest and a post-test including a practical examination (eg, an objective structured clinical examination).

Research

There is a great need for research to acquire new knowledge about the clinical effects of disasters as well as infrastructure requirements, preparedness, and resource management to address mass casualty events. Podiatric medicine should not underestimate its role in this process. Also important is engaging in research activities to better understand health issues associated with emergencies and disasters to prevent or reduce physical and psychological injury and loss of limb or life in victims and responders and to identify effective ways to facilitate the learning of disaster preparedness.

Conclusions

Despite multiple terrorist events worldwide and domestically, the nation’s public health infrastructure remains in great need of major strengthening. Most podiatric physicians remain poorly trained to address a mass casualty event, whether man-made or due to natural disasters. Public health principles of population management during a terrorist attack or other disaster are inconsistently taught, if they are taught at all. Furthermore, few clinicians can readily identify the cascade of signs and symptoms associated with commonly acquired illness from bioterrorism-related illness.

The value and contribution that podiatric physicians and podiatric medical students can make to the evolving problems associated with disaster and emergency preparedness should not be underestimated. The events of 9/11 have demonstrated our nation’s vulnerability to terrorism. Although not new to the United States, man-made and natural disasters present a very real threat to society. Until recently, we have not adequately developed the health-care infrastructure or prepared clinicians in podiatric medicine and other health professions to respond to such threats. To prepare for disastrous events, it is necessary to train existing and future clinicians, including podiatric physicians, to become advocates for greater hazardous materials legislation to help strengthen the public health infrastructure and promote coordination among the many organizations and professions that will need to be involved to protect society. Podiatric medical schools and the organized profession must initiate the cooperation of diverse organizations not accustomed to working together to provide the best resources for the community. Such collaboration is essential as there are many questions that remain unanswered and problems that must be solved in terms of disaster prevention, preparedness, mitigation, and response. This must include the development of educational programs and planning for an infrastructure to conduct research and train students, residents, and practicing podiatric physicians.

Ensuring that current and future podiatric physicians are well-versed in emergency preparedness is a vital step in serving and protecting the public. Podiatric medical schools are in a unique position to be part of the leadership among diverse health-care and public health organizations to prepare for a world where man-made and natural disasters are a reality.

Financial Disclosure: None reported.

Conflict of Interest: None reported.