Medical student disaster medicine education: the development of an educational resource
© Springer-Verlag London Ltd 2010
Received: 8 July 2009
Accepted: 4 November 2009
Published: 16 February 2010
Disaster medicine education is an enormous challenge, but indispensable for disaster preparedness.
We aimed to develop and implement a disaster medicine curriculum for medical student education that can serve as a peer-reviewed, structured educational guide and resource. Additionally, the process of designing, approving and implementing such a curriculum is presented.
The six-step approach to curriculum development for medical education was used as a formal process instrument. Recognized experts from professional and governmental bodies involved in disaster health care provided input using disaster-related physician training programs, scientific evidence if available, proposals for education by international disaster medicine organizations and their expertise as the basis for content development.
The final course consisted of 14 modules composed of 2-h units. The concepts of disaster medicine, including response, medical assistance, law, command, coordination, communication, and mass casualty management, are introduced. Hospital preparedness plans and experiences from worldwide disaster assistance are reviewed. Life-saving emergency and limited individual treatment under disaster conditions are discussed. Specifics of initial management of explosive, war-related, radiological/nuclear, chemical, and biological incidents emphasizing infectious diseases and terrorist attacks are presented. An evacuation exercise is completed, and a mass casualty triage is simulated in collaboration with local disaster response agencies. Decontamination procedures are demonstrated at a nuclear power plant or the local fire department, and personal decontamination practices are exercised. Mannequin resuscitation is practiced while personal protective equipment is utilized. An interactive review of professional ethics, stress disorders, psychosocial interventions, and quality improvement efforts complete the training.
The curriculum offers medical disaster education in a reasonable time frame, interdisciplinary format, and multi-experiential course. It can serve as a template for basic medical student disaster education. Because of its comprehensive but flexible structure, it should also be helpful for other health-care professional student disaster education programs.
Disaster medicine education is indispensable for catastrophe preparedness. Although disasters have always been a part of world events, recent large-scale natural and man-made disasters have increased the focus on disaster medicine. As a consequence, medical schools in many parts of the world have begun to incorporate disaster-related topics into their curricula. In 2003, the Association of American Medical Colleges (AAMC) in the United States recommended that bioterrorism education be included in all medical school programs . In Germany, federal laws have been enacted requiring that medical students be familiar with disaster medicine principles .
Analysis of the peer-reviewed literature indicates that few curricula for medical student disaster medicine education have been published. The AAMC report on bioterrorism training is more of an outline of educational objectives and activities than a specific curriculum. Its target group is US medical students in their last year of training, and builds on their growing knowledge and skills . Covering a few aspects of medical disaster management, Parrish and colleagues  provide a description of a medical school course for 2nd year US students by briefly listing major subject headings. First taught by military experts, this course includes simulation exercises, such as a refugee scenario, and an infectious disease outbreak tracking exercise. In this format, however, operation execution appears to be the priority with less focus on medical care delivery. Markenson et al.  suggest core competencies and subject areas for terrorism, disaster, and public health emergency preparedness for health-care students based on professional school outlines. Referencing a proficiencies list, curricular matrices are proposed, but no steps or samples for implementation are presented. In a course for senior dental students, Glotzer and et al.  describe core competencies and dentists’ roles within disaster response efforts focusing on bioterrorism; participation in a 4-h disaster life support course of the American Medical Association is also recommended to provide guidance regarding incidents with weapons of mass destruction.
Because a fully developed and comprehensive medical school disaster medicine curriculum was not available, the German government commissioned the development of a core medical student disaster medicine curriculum that could serve as a standardized template.
Methods and curriculum development
The dynamic process of curriculum development occurred in several stages
Initial curriculum development and pilot testing
Pilot versions of the curriculum were initially developed and utilized with faculty and student feedback over a 2-year period. The final curriculum resulted from these pilots, which were formally developed according to the six-step approach to curriculum development . This included general and targeted needs assessment, definition of goals and objectives, choice of educational methods, and pilot implementation and evaluation. The pilots’ contents were mainly based on government-funded research projects in which all curricula from German medical schools and postgraduate public health physician courses were evaluated for inclusion of disaster medicine-related themes . It was noted that there was little and unstructured education in this area. The physicians of all (n = 477) German county disaster management agencies and district health authorities were also surveyed for additional input into needed disaster medicine competencies. With a nearly 100% response rate from the physicians surveyed, more than 92% expressed the necessity for better education. This resulted in the development of educational concepts for improving disaster preparedness at the under- and postgraduate level [7, 8]. Key components compiled here, disaster medicine topics of contemporary relevance, and expertise gained from student emergency medicine training were then combined to generate an independent lecture series. This was finally adapted into a disaster medicine curriculum for a 4th-year German medical school program. Medical education in Germany is formatted over 6 years. Students are thus expected to have had 3 years of clinical training in medical school when participating in the course. The implementation experience with the pilots was straightforward: The university dean and the department chair fully supported the idea of providing an introduction to the practices of disaster medicine at the student level. Course realization could thus readily be achieved: A core curricular team of physicians was assembled and scheduled all tasks. Internal and external professionals with expertise in subject areas were identified and invited to become teaching faculty. After coordination with medical school program planners, facilities for the in-house curriculum units (rooms, equipment) were organized with the lecture support staff. For the external units, collaborations with rescue and disaster response agencies were established to permit common exercises. For exchange and drill of non-physician professionals and students, agencies provided equipment, faculty, and their trainees to serve as mock victims for a mass casualty simulation. We presented physicians as preceptors and students in the role of future physicians. Finally, feedback on the curriculum from all participants was utilized to make alterations and improvements as needed.
Revision of pilot curriculum and proposal for the government
When the government requested a medical student disaster education plan, we offered a clear vision for goals and objectives of a comprehensive curriculum of core issues of disaster medicine based on our experience from the pilot courses: The first aim was not only to increase medical students’ familiarity with the ideas and practices of disaster medicine, but to enhance their understanding of what occurs in a disaster, and where the limits and challenges faced by those delivering medical care under austere conditions lie. Second, improving knowledge of public health-relevant information on radiological/nuclear, biological, chemical, explosive, and other disaster-related health risks appeared to be important. Third, the opportunity to refresh and extend familiarity with basic and advanced life support, and to provide some limited experience with triage decision making was an additional benefit. Finally and as a long-term goal, we wished to enhance student interest in pursuing further disaster medicine expertise.
It was determined that scientific evidence—wherever available—should be incorporated and combined with professional expertise to build the content basis of the new curriculum [9, 10]. Following analysis of international guidelines on disaster response training , peer-reviewed publications [3–5, 12, 13], and programs such as the US Department of Homeland Security, Federal Emergency Management Agency (FEMA), and American Medical Association, learning objectives were fixed. After cross-referencing objectives with quality assurance criteria for medical education [14–16], topics were structured into a framework represented by subject headings. To identify the content details, a systematic literature search in Medline, Embase, and the Cochrane Library with the key terms “student, education, training, curriculum, course, competency, disaster, catastrophe, mass casualty, medicine, medical, preparedness, plans, and outcome” was conducted. Due to the relatively small number of relevant publications, complementary Internet searches were performed, and resources from websites such as from the FEMA program were included. Curricular committee consensus on those entities regarded to be most important was required for item inclusion. A blueprint for the core contents was then constructed in the form of modules with the goals as a matrix.
Because learning and memory benefit from multifaceted, stimulating environments [17, 18], we also decided to diversify the instructive strategies. This led us to include interactive discussions, teaching of problem-solving strategies, reviews of real-life experience, role playing, and exposure to exercises in “real-world” environments. Activities were assigned to suitable content modules, with a minimum of one-third of the curricular time being reserved for hands-on training. These units were designed to be performed with other professionals, such as fire fighters.
To evaluate the effectiveness of the curriculum, the results of a knowledge-based, pre-program written examination were compared with post-program examination results. Because the course was created to be part of the obligatory 4th-year German medical school program, the testing at course completion also served to fulfil requirements of the German educational system. Course evaluations for faculty and students were drafted to be used for further curricular developments [6, 14].
Adoption of final curriculum
Results, course content and implementation
The creation of the final curriculum resulted in a course of 14 modules with each unit requiring approximately 2 h time:
Modules, learning activity
a Medical Student Disaster Medicine Curriculum, Modules 1–3
Module 1, Lecture and PBLD
Introduction to disaster medicine, terminology
To learn definitions of disaster medicine and to develop an understanding for general disaster management
Glossary and common disaster medicine definitions, differences between disaster and emergency medicine, different phases of disaster management
Principles of disaster assistance
Disaster assistance organization, assistance agencies and structure
To consider the heterogeneity of disasters
Natural and technological disasters, terrorism, man-made disasters, civilian disorders, environmental and other threats
Laws and regulations
To understand the legal environment and regulations for civil protection and disaster preparedness
Regulative and administrative issues for civil disaster protection, warfare disaster protection laws, rescue service and hospital laws, governmental resources, and authorities
Module 2, Lecture and PBLD
Disaster medical management
To realize the architecture and organizational management necessary for coping with mass casualty incidents and large-scale acutely ill patients in a coordinated way
Mass casualty disposition, treatment area, transport issues
Tasks of rapid-intervention-units (sanitary/psychosocial care)
Incident command systems
Disaster contingency plans command and control structures, functional operations center
Coordination, integration, and cooperation of multi-agency rescue and assistance response
Functional response roles, e.g., lead emergency physician, organizational leader, and technical command post
Module 3, Lecture and PBLD
Specific disaster medicine
To develop skills in principles of tactically managing mass casualties and large numbers of patients suffering, e.g., from combined conventional trauma and thermal injuries
Patient assessment and triage: triage levels, tags, registration; primary emergency care, multi-tasking and operational management phases (e.g., patient collection, treatment area, transport)
Tactic disaster medical management
Logistical requirements for care of burn-injuries, mine blast, and missile-hit victims (including high-speed bullet injuries), mass trauma management
b Medical Student Disaster Medicine Curriculum, Modules 4–8
Module 4, PBLD and Interactive Review
Hospital preparedness and disaster management planning
To follow orders and principles of hospital alarm and evacuation plans
Hospital disaster laws
Hospital alarm plans
Hospital preparedness plans for
- Management of external disasters with mass casualties suffering from multiple injuries, intoxication, infections, and/or radioactive contamination
- Management of in-house disasters with fire incidents and hospital evacuation
Module 5, PBLD and Interactive Review
Presentation of past disasters and review of assistance experiences
To evaluate and understand feasibility issues of providing medical support and health care in the field and under disaster conditions based on experience from worldwide disaster assistance operations
Presentation of past disasters and disaster assistance experience gained in the field, e.g., from lead emergency physicians, operations in earthquake assistance, explosions, highly contagious infectious diseases, repatriation flights, and with the German Federal Armed Forces Medical Corps in world crisis regions
Module 6, Experiential Training
Preclinical and clinical triage exercise
To perform triage decisions in reality simulation
Triage training exercise: real or virtual scenario simulation rescue exercise, e.g., explosion with mass casualties and blast, mechanical, and thermal injuries of all triage levels
Module 7, Experiential Training
To apply operational principles and steps of action for evacuation procedures
Command post exercise, real or virtual: e.g., evacuation organization and evacuation of a hospital, school, part of town, etc.
Module 8, Lecture and PBLD
Life-saving disaster emergency medical care
To learn concepts of life-saving emergency disaster medical care
Under disaster conditions: provision of life-saving emergency medical care to adults and children, e.g., shock therapy, pain treatment, and sedation
c Medical Student Disaster Medicine Curriculum, Modules 9–11
Module 9, Lecture and PBLD
Specific disaster emergency medical care for various situations including bioterrorism incidents
To get to know principles of specific disaster medical care
Disaster emergency medical first aid, specific measures
Surgical and medical treatments of burn and thermal injuries and illnesses from explosive, warfare and biological agents
Epidemiology and approaches to terrorist attacks, weapons, and highly contagious infectious diseases, sentinel cases
Module 10, Lecture and PBLD
Radiological and nuclear threats, accidents with radioactive material, radiation illness and syndrome, decontamination
To learn principles and basic medical care for management of incidents with radiologic/nuclear agents and contaminated victims
Specific dangers of radiological/nuclear agents, associated illnesses and radiation syndrome
Self protection, protection and detection equipment, special intervention units
First aid medical treatment, isolation and radioactive decontamination, decontamination operations in case of mass trauma combined with contamination injuries
Decontamination after radiation exposure
To be exposed to practical aspects and procedures of decontamination
Decontamination exercise or decontamination demonstration, e.g., in nuclear power plant or with the fire brigades
Module 11, Lecture and PBLD
Chemical and toxicological threats from hazardous materials and goods, transport risks, acute poisoning and toxic syndromes
To get to know principles of medical countermeasures for management of incidents with dangerous chemical substances, hazardous materials and goods
Identification and risk assessment of hazardous materials, chemicals and goods, and associated toxic syndromes
Management of acute intoxications and poisonings, threats from specific poisons
Self protection, precautions
Poisoning epidemiology, risk assessment for mass intoxications
First aid medical treatment, e.g., enhanced elimination of toxins, use of antidotes, adjunctive services, e.g., poison emergency centers and toxicology laboratories
Decontamination after chemical poisoning
To experience exposure to decontamination procedures
Triage in case of mass casualties with toxic syndromes
Decontamination measures and exercise
d Medical Student Disaster Medicine Curriculum, Modules 12–14
Module 12, Lecture, PBLD, and Interactive Review
Ethics and professionalism
To develop familiarity with ethical codes and the duty of care relevant to disaster conditions
Geneva Convention and amended protocols, ethical codes of conduct, humanitarian imperatives, social, moral, and ethical challenges of disasters
To understand quality improvement efforts and risk management programs for disaster medical response
Quality control performance indicators, incident monitoring, tools for risk and critical event assessment, structured improvement approaches
Module 13, PBLD and Interactive Review
To comprehend concepts of psychic stress response
Case presentations for identification of critical incident stress reactions and review of therapeutic interventions
To learn techniques to deal with psychic reactions caused by exposure to disaster scenarios
Treatment approaches to acute and delayed critical incident stress reactions, acute and chronic stress syndromes, post-traumatic stress disorders
To recognize need for help and to initiate psychosocial support
Structure and tasks of psychosocial emergency intervention units
Operational strategies of psychosocial treatment
Module 14, Course Completion
To demonstrate gain of knowledge and skills
Student final examination, oral and/or written test
Evaluation of educational success
To assess educational value of course
Comparison of pre-program versus post-program student test results
Learner and educator assessment of course
To maintain continuous curriculum development and improvement in course quality
Student and faculty summative and formative course evaluation
Modules 4 and 5 (Table 1b) discuss hospital alarm and preparedness plans, with a focus on in-house and external incidents requiring high surge capacity. As core competencies, notification and mobilization orders are taught, and concepts of an institutional emergency plan are incorporated. Interactive review of past major community-threatening events and experiences from worldwide disaster and relief operations are utilized to built recognition of disaster health-care and medical assistance feasibility issues. Students learn the risks and limitations of relief operations, while focusing on the challenge of implementing care in the field.
Modules 6 and 7 (Table 1b) address knowledge and skills for triage and evacuation through participation in exercises. Students conduct triage and assume functional roles in real or virtual experiential training units.
Modules 8 and 9 (Table 1b and c) teach life-saving and specific emergency medical care for various disaster situations, containing first aid and specific approaches to injuries, burns, explosions, blasts, and illnesses from warfare and biological agents. Emphasising terrorist attacks and highly contagious infectious diseases, core competencies for care of explosive, warfare, and biological incidents are included. Minimally acceptable treatment and limitations for patient-tailored therapy in case of mass casualties are discussed.
Modules 10 and 11 (Table 1c) teach the dangers and management of radiological/nuclear and chemical hazardous materials. Treatment approaches to radiation and/or chemical injuries are discussed as core competencies. Options for protection, first aid, decontamination, enhanced elimination, and antidotes are reviewed. Students learn how victims with combined trauma and toxic injury are triaged. At a nuclear power plant or fire department, the design and state of preparedness of such facilities are evaluated, and equipment is demonstrated.
Modules 12 and 13 (Table 1d) deal with challenges of ethical, professional, psychosocial, and quality control criteria of medical disaster management themes. As key competencies, professional behavior and obligations under disaster conditions are discussed. Students learn critical aspects of acute and delayed stress disorders (anxiety and grief), and the psychosocial resources, such as crisis intervention units, available to provide specialised assistance. To understand quality improvement efforts, students gain familiarity with assessment tools and incident monitoring to evaluate functional components of disaster response systems.
Module 14 (Table 1d) is designed to assess the educational success of the course. Students demonstrate the acquired knowledge and attitudes in an oral and/or written examination . According to the German regulations, each medical school has the freedom to design the format of the examinations chosen for their student evaluations.
To our knowledge, this curriculum is one of the first publications of a comprehensive medical student disaster medicine curriculum that covers major contemporary aspects of basic disaster medicine management. The developed course offers a cross-professional design in a readily adaptable structure, is focussed on actual scenarios, and has been aligned with quality criteria for improved teaching approaches [14, 16, 19]. At a time when medical schools in numerous countries are struggling to find a place for disaster medicine in their programs, this educational topic is worthy of research and discussion. Our work may be used as an educational resource, with the opportunity to adapt the basic template to various locations, threats, and systems. An introduction to care principles will be of value to preparedness in any locale, even though disaster response plans and conditions may differ among countries, or states and cities of a single country. The curriculum also provides resources for endeavors of organizations such as the Section in Disaster Medicine of the European Society for Emergency Medicine, which has as a current goal the development of a standard European disaster medicine curriculum for medical school undergraduates .
The curriculum is now implemented in nine German medical schools. The analysis of the implementation process and curricular success has been pre-defined for a period of 5 years, and was begun 3 years ago. However, all medical schools that have implemented the curriculum have so far reported that they now teach disaster medicine components with a scope and depth much broader than within emergency medicine, pointing out the additional value for disaster preparedness and disaster medical management. Seven of them report that they have implemented a fully independent course, and five of the medical schools base their teachings on an educational program that is in complete conformity with the curriculum developed.
Because derivation and details for medical student competency definitions differ widely [3, 4, 6, 11], we used a consensus-building approach for outlining competencies and thus the framework for the educational goals of this curriculum. Requests of the Education Committee Working Group of the World Association for Disaster and Emergency Medicine , disaster medicine-related competencies as indicated in emergency medicine or radiology curricula, courses recommended by professional organizations, the literature and expert opinion were addressed as far as available [7, 21–23]. Deriving subject matter from thus pre-defined goals provided the advantage of readily defining the main targets for core contents. The competency structured design also permits flexibility in addressing a multiplicity of disaster situations, including floods, hurricanes, earthquakes, and surveillance-related health problems, as well as care for vulnerable populations such as children and hospitalised patients.
Educational goals were weighted in terms of time allocation to assist medical school planners operating with more limited discretionary curricular time. In our opinion and circumstances, a 14-module course composed of 2-h units provides adequate student education and mock disaster exposure in a reasonable period. Some themes important for disaster preparedness are also addressed in other medical school programs, such as in medical microbiology, toxicology, and environmental medicine . The topics we targeted for this curriculum, however, do not overlap with other student programs. Emergency medicine curricula for medical students, when present in medical school curricula at all, do not typically focus on disaster medicine or disaster response. Introduction to emergency medicine focuses on maximum possible, individual patient-tailored care [9, 21, 23] and—if included—principles of management of mass casualties at a discrete scene. This is intended to address disaster medicine conditions in which extraordinary treatment demands exceed resources, and where incidents of great magnitude requiring external assistance for management may reach epidemiological dimensions .
Task assignment for estimation of organizational burden and curricular implementation costs
Development of a local organizational structure responsible for curricular activities: team recruitment, appointment of managers and departmental staff in-charge, task assignment
Identification of internal and external experts and invitation as teaching cadre
Establishment of collaboration with local disaster response agencies and planning of common external units, exercises, and simulations
Teaching and preceptor assignment for internal and external units
Institution of curriculum within medical school program and coordination of units with program planners
Organization of facilities and equipment for in-house units with university’s lecture support staff
Organization of transport to external units
Management of administrative and reporting issues
If necessary: establishment of financial recording, billing, and reimbursement system
Faculty development/continuous professional growth
Future faculty development through involvement in existing teaching activities, plans, and team meetings
Faculty instructor training
Optional: professional growth through participation in related internal and external developmental programs for university educators and disaster medicine preparedness
Quality assurance/continuous curricular development
Development of data collection system
Analysis of ongoing evaluations from learners and educators
Use of course assessments and experiences for orientation, end-of-course team meetings, and future progress
Provision of curricular schedule and learning objectives
Provision of lecture compilation (syllabus or CD) as course content workbook and base for self-directed learning
Development of data collection system and analysis of student examination data
Development of reporting system for examination grades
Maintenance of partnerships/collaborations
Continuous encouragement and support for internal and external partnerships and collaborations
Running of administrative/overhead expenditures
If necessary: management of direct and indirect expenditures, such as telecommunication costs
Designing of plans for course revisions or curricular enhancements, such as integration of e-learning methods
There are several limitations to this work. There is no evidence that introducing medical students to disaster medicine directly affects patient outcomes. Nevertheless, educational efforts for important medical topic areas have to be started at some point in medical school, and this can be evaluated over time. Of course, the provision of one-time disaster medicine training will only allow for a passing familiarity with terms and concepts. To retain competencies, it will be necessary to refresh and assess knowledge and skills periodically, and we are planning to implement educational refresher courses in our German national program. Moreover at present, we cannot comment on how well the curriculum performed, and what the overall success of the course will turn out to be. This evaluation has been designed for a time period of 5 years.
Moreover, exposing students to mock disaster scenarios and simulation exercises is far from real-world conditions. Certainly, students will not intubate patients in full protective gear in real disasters and will of course not be included in first rescue response teams in compromised environments. Nevertheless, based on our experience as university educators, they benefit from the knowledge and skill-building hands-on exercises that may serve as a basic training for future medical practice in all kinds of emergency situations. Our students also receive clear instruction that they are not trained search and rescue personnel. For our course, we thus try to prevent the possibility that simulation-based medical education experiences could cause student over-confidence and misjudgement of competency .
In its first design, our curriculum consists of “traditional, face-to-face, instructor-student interactions and hands-on experiences,” and does not use electronic (e-) learning methods. E-technology holds the promise for distance education of disaster response concepts and virtual reality simulations. Because blended curricular formats integrating e-methods may enhance inter-professional exchange without compromising pedagogy , they may be included in future curricular versions.
A curriculum is provided for medical student disaster medicine education at an advanced level of medical school training, along with information regarding the process involved in creating such a program at a national level. We wish to emphasize that the curriculum has been designed for medical students in a particular system and that there are various concepts for basic disaster medicine education. Due to its comprehensive, interdisciplinary nature, instructive design, and flexible structure, however, the curriculum can benefit other health-care professional systems by serving as a model curriculum, and facilitating refinement and testing of other existing, but perhaps as yet unpublished models.
The work reported in this publication reflects the input from many students, faculty, and representatives of various professional, societal, and governmental bodies. We wish to acknowledge in particular the contribution of the following members of the German Civil Protection Committee: I. Beerlage, MD, Professor, Division of Social and Healthcare, University of Applied Science, Magdeburg-Stendal; L. Clausen, MD, Professor, Disaster Research Division, Department of Sociology, University of Kiel; A. Flieger, MD, Federal Office of Civil Protection and Disaster Assistance, Bonn; W. Marzi, MD, Federal Office of Civil Protection and Disaster Assistance, Bonn; P. Sefrin, MD, Professor, Division of Preclinical Emergency Medicine, University of Wuerzburg; J.W. Weidringer, MD, The State Chamber of Physicians of Bavaria, Munich; W. Weis, MD, Professor, Federal Office for Radiation Protection, Neuherberg, Germany.
This curriculum has been recommended by the Board of Directors of the German Society of Disaster Medicine, the Leading Board of the Civil Protection Committee at the Ministry of Interior of the Federal Republic of Germany, and the German Federal Office of Civil Protection and Disaster Assistance. It has been ratified by the standing conference of the Ministers of Education and Cultural Affairs of the countries of the Federal Republic of Germany and has been recommended by the Minister of the Interior of the Federal Republic of Germany for national implementation.
Conflicts of interest
Apart from departmental funding, no outside support in the curriculum development or manuscript preparation has been received. The authors declare that they have no conflict of interest or disclosure in any way related to this work.
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