What exactly is disaster medicine? If you have decided to purchase and read this book, it is likely a question you have wrestled with. Disaster itself is not an easily defined entity, thus the new medical specialty evolving around it is continuously undergoing metamorphosis. Because a disaster is a local event, throughout history, the local medical responders have cared for the victims of disaster. The same medical personnel who provide health care on a daily basis also assume the responsibility of providing care to patients with illness or injury resulting from a disaster. Unlike other areas of medicine, however, the care of casualties from a disaster requires the health care provider to integrate into the larger, predominantly nonmedical multidisciplinary response. This demands a knowledge base far greater than medicine alone. To operate safely as part of a coordinated disaster response, either in a hospital or in the field, an understanding of the basic principles of emergency management is necessary. Now we begin to see the evolution of the specialty of disaster medicine. To respond properly and efficiently to disasters, all health care personnel should have a fundamental understanding of the principles of disaster medicine (which incorporates emergency management in its practice) and what their particular role would be in the response to the many different types of disasters.
In the mid-1980s, disaster medicine began to evolve from the union of disaster management (now called emergency management) and emergency medicine. Although disaster medicine is not yet an accredited medical subspecialty, those who practice it have been involved in some of the most catastrophic events in human history. Practitioners of present-day disaster medicine have responded to the aftermaths of the tsunami in Southeast Asia, Hurricane Andrew, the Haiti Earthquake, the Madrid Train Bombings, and the World Trade Center Attacks, to name a few. During the past several decades, we have seen the first applications of basic disaster medicine principles in real-time events, and as demonstrated by the devastation caused by Hurricane Sandy in 2012 and the devastating Ebola Outbreak of 2014-2015, there is sure to be continued need for such applications.
The impetus for this text grew from a realization that as the specialty of emergency medicine grows, emergency physicians must take ownership of this new field of disaster medicine and ensure that it meets the rigorous demands put upon it by the very nature of human disaster. If we are to call ourselves disaster medicine specialists and are to be entrusted by society to respond to the most catastrophic human events, it is imperative that we pursue the highest level of scholarly knowledge and moral conduct in this very dynamic area. Until there is oversight from a certifying board, it is our responsibility to the public to maintain this high level of excellence. As in medical ethics, where patients rely on the virtue of their physicians to compel them to abide by moral standards, so must we exercise virtue in how we conduct the medical response to disaster.
The disaster cycle
Because disasters strike without warning, in areas often unprepared for such events, it is essential for all emergency services personnel to have a foundation in the practical aspects of disaster preparedness and response. The first step is to understand that disaster can strike here at home. I can assure you the people of Haiti minutes before the earthquake of 2010 and the people of Japan minutes before the earthquake and tsunami of 2011 all were going about their normal daily routine, not expecting disaster to strike. Then it did.
As is discussed in other chapters throughout this text, emergency responders have an integrated role in disaster management. All disasters follow a cyclical pattern known as the disaster cycle ( Figure 1-1 ), which describes four reactionary stages: preparedness, response, recovery, and mitigation or prevention. Emergency medicine specialists have a role in each part of this cycle. As active members of their community, emergency specialists should take part in mitigation and preparedness on the hospital, local, and regional levels. Once disaster strikes, their role continues in the response and recovery phases. By participating in the varied areas of disaster preparation and response, including hazard vulnerability analyses, resource allocation, and creation of disaster legislation, the emergency medicine specialist integrates into the disaster cycle as an active participant. Possessing a thorough understanding of the disaster medicine needs of the community allows one to contribute to the overall preparedness and response mission.
Natural and human-made disasters
Over the course of recorded history, natural disasters have predominated in frequency and magnitude over human-made ones. Some of the earliest disasters have caused enormous numbers of casualties, with resultant disruption of the underlying community infrastructure. Yersinia pestis caused the death of countless millions in several epidemics over hundreds of years. The etiologic agent of bubonic plague, Y. pestis , devastated Europe by killing large numbers of people and leaving societal ruin in its wake. During the writing of this chapter, an Ebola outbreak raged in West Africa, along with concern that a worldwide pandemic might ensue. The 2014 and 2015 Ebola and Middle East respiratory syndrome (MERS) outbreaks have proven that, despite the passage of time and the great advances in medicine, the world continues to be affected by disease outbreaks. In addition, diseases that have been eradicated have the potential of being reintroduced into society, either accidentally from the few remaining sources in existence around the world, as in the 2015 measles outbreak in the United States, or by intentional release. Such events have the potential of devastating results, as the baseline intrinsic immunity the world population developed during the natural presence of the disease has faded over time, putting much larger numbers of people at risk. Finally, with the advent of air travel allowing people to be on the opposite side of the world in a matter of hours, the bloom effect of an outbreak is much harder to predict and control. Disease outbreaks that were previously controlled by natural borders, such as oceans, no longer have those barriers, making the likelihood of worldwide outbreak much greater now than it was hundreds of years ago. We saw evidence of this in 2014, with Ebola-infected patients arriving in Spain and the United States from West Africa. During that outbreak, naysayers to intrusive actions such as quarantine and travel restrictions cited following the “science” learned since the disease emerged in central Africa in the 1970s. The problem with such logic was that Ebola had never before been seen in urban settings such as Nigeria, New York City, and Dallas, Texas. Transmission parameters in such settings were truly uncharted waters for the medical community.
In addition to epidemics, with each passing year, natural disasters in the form of earthquakes, floods, and deadly storms batter populations. One need only to remember the destruction in terms of both human life and community resources caused by the Indian Ocean Earthquake and Tsunami of 2004, the Haiti Earthquake in 2010, or the earthquake, tsunami, and radiation disaster in Japan in 2011 to understand the need for preparedness and response to such natural events. Considering that the earthquakes that caused these tsunamis occurred hours before the devastation, it is difficult to understand how today’s advanced society, able to travel far into space among other great achievements, was unable to mitigate against some of the most deadly natural events in recent history. The realization that disaster can strike without warning and inflict casualties on the order of the 2004, 2010, and 2011 earthquakes and tsunamis, despite our many technological advances, serves as a warning that mitigation, preparedness, response, and recovery to natural disaster must continue to be studied and practiced vigorously.
Today, the possibility of terrorist attack threatens populations across the globe. Both industrialized and developing countries have witnessed some of the most callous and senseless taking of life, for reasons not easily fathomed by civilized people. It is unusual to read an Internet news article or watch a television newscast without learning of a terrorist attack in some part of the world. With the advent of more organized groups such as the Islamic State of Iraq and Syria (ISIS), Boko Haram, the Revolutionary Armed Forces of Colombia (FARC), and the Epanastatikos Agonas (EA), these attacks are more frequent and deadly, often using horrifying means of execution. The commonplace nature of a terrorist attack in modern society ensures it is unquestionably something that will continue long into the future, and will very likely escalate in scale and frequency.
The multilayered foundation on which ideological belief evolves into violent attack is beyond the scope of analysis that this book ventures to undertake. These ongoing events do demonstrate, however, that the principles studied in the field of disaster medicine must include those that are designed to prepare for and respond to a terrorist attack. Because there are very intelligent minds at work designing systems to bring disaster on others, equally there must be as robust an effort to prepare for and respond to those disasters. Such response involves the deployment of law enforcement, evidence collection, and military personnel and equipment, which are typically not seen in the response to a natural disaster. The integration of these unique assets into the overall response is essential for the success of the mission. The disaster medicine specialist must have a thorough understanding of the role of each.