Education

Adequate disaster education should include age-appropriate guidelines and must follow a basic format for training that allows evaluation of effectiveness. One recommended format is the establishment of clearly stated objectives (e.g., “The children will be evacuated from the school in under 5 minutes,” or “The physicians will properly recognize nerve agent exposure from symptoms presented during simulation”). These objectives are next used to develop evaluation tools (e.g., a timed drill for the school, written testing, or observed performance for the physicians). Training curricula are then developed to achieve the desired objectives as measured by the evaluation tool. The students, for example, may need little more than general principles (“Follow the teacher’s instructions in an emergency”) and awareness that the alarm bell signals such an emergency. Therefore occasional drills may suffice to maintain the needed level of training for them. The teachers, however, require frequent education and practice to be ready for a variety of scenarios. Adults may be trained using a variety of adult learning techniques, but “just-in-time” education should be reserved for situations where response time is not critical or as a brief immediate refresher.

Target audiences for disaster education include the public, nonmedical responders, and medical responders. The same principles of effective education apply. General public topics include general disaster readiness, sheltering, evacuation, and first aid. Such education can reduce panic, minimize load on evacuation or shelter systems, and mitigate illness and injury. Nonmedical responder topics vary with the type of responder but should include awareness of medical-response issues and plans. Nonmedical responders may include those who provide shelter, evacuation, security, law enforcement, administration, logistics, food and water supply, sanitation systems, transportation, and structural engineering, among many others. Most disaster response is nonmedical, and injury or illness in nonmedical responders can be mitigated through education and safe practices. Medical responders should improve their readiness through frequent training or experience, including knowledge of education provided to the public and nonmedical responders. This inclusive and coordinated approach will optimize readiness, prevention, and mitigation.

Readiness, the ability to perform on request, requires preparedness and the availability of personnel and resources. To improve readiness, an agency could work on communication essential to notify personnel of a request for service and coordinate their actions, equipment logistics, optimal performance of specific tasks, or means to increase the efficiency of performance. Each of these areas can be the subject of a variety of types of research and training and can apply to the public and nonmedical responders, as well as medical responders. For example, is a population ready to evacuate? Are the regional water suppliers ready to secure their facilities and prevent an effort to contaminate public drinking water? What is the best way to pack medical supplies in kits to optimize paramedic effectiveness? A variety of research exercises linked to training programs can improve readiness in such areas.

Communication, a common challenge in disaster response, can be improved with use of robust and redundant technology that is familiar to all users, and adequate staffing to manage that technology. Communication staff levels adequate for routine practice are inadequate for disaster situations. Flexible and scalable communications response includes both sufficiently redundant technology and the staff to operate that technology. Practical research can assist agencies in the selection and adoption of flexible communication systems likely to remain functional during disaster events. Research parameters for such systems might include features such as interagency interoperability (including linkage with remote responders from other states or agencies), simplicity and flexibility of use, sufficient power sources and operational range for anticipated events, and the ability to move data between variable system elements. Drills, technical demonstrations, and prospective data-gathering during real events are some research methods for the evaluation of communication systems, but successful daily use of systems designed to scale up for disaster response also provides useful data.

Similar to readiness, prevention may encompass public health, engineering, zoning, security, or other measures that trap errors that would otherwise, in certain circumstances, lead to disaster. In most cases, a disaster (defined as “an overwhelmingly damaging event”) results in few if any immediate medical casualties. Loss of computer data, defective products, and financial crisis are a few events that can have disastrous results without illness or injury, depending on those affected. Nevertheless, “atraumatic” disasters should be considered in disaster planning, education, and research alongside casualty-producing disasters, at least for health care systems if not for all community entities. The disruption caused by a loss of computer data, by revelations of administrative scandal, or by bankruptcy of a relied-on local service can be significant and can create stress and damage comparable to an event that causes injury or illness, and may eventually result in need for medical care.

Many models of adult education can be used to train disaster responders: self-study, distance learning, direct education, hands-on learning, drills and exercises, and, most recently, simulation laboratories. The types of education must be matched to the audience and the task to be taught, and must take into account available resources. For example, although the best method of teaching personnel how to do a particular skill may be intensive hands-on experience, there may not be the time or money for large-audience training of this type or there may not be adequate actual experience available for the number of interested students. Types of education include the following:

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  Self-study: It allows self-paced learning, either from a text or Internet source. This type of learning lends itself well to those with episodic downtime during their workdays and with time to study that may be off shift or off hours for other educational opportunities. Because it is often location and time independent, it accommodates a wide variety of learners, but the ability for discussion and feedback is somewhat limited.

  
  
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  Distance learning: This type of learning uses live two-way video technology and is most often Internet-based. It allows many to be trained in a “live environment” where their questions and issues can be addressed by the teacher and allows group interaction. Although somewhat location independent, depending on technology, it is time dependent—learners must “log in” at the specified time.

  
  
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  Direct education: This involves a lecturer delivering content in person to an audience. Although this type of education facilitates questions and feedback, as well as group discussion, it requires a ready pool of both expert educators and available learners that may not exist in a particular subject of interest, period, or geographic area.

  
  
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  Hands-on learning: Particularly suited for teaching skills, such as the use of protective equipment, this training is labor and time intensive and requires the use of local expertise and small-class-size-to-instructor ratio. However, it is very effective for learning manual tasks.

  
  
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  Feedback and quality improvement: Useful for measuring compliance, honing skills, and correcting errors, this type of education involves either direct educator presence (such as faculty mentoring a resident physician) or review of documented performance (such as medical director review of emergency medical service [EMS] charts).

  
  
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  Drills and exercises: Effective drills and exercises combine features of hands-on learning, direct education, and feedback. The event size can vary, but it typically involves more than one learner. Technology (computer simulations, communications links between simulation centers, etc.) can facilitate very large exercises. Extensive full-scale events are expensive and time consuming but offer significant training, error trapping, and networking opportunities for the agencies and personnel involved. Drills and exercises are an excellent place to solidify training, identify future needs, and conduct some types of research.

Simulation Training

The goal of simulation is creation of an immersive environment that mirrors reality. Learners should feel like the situation is real in a successful simulation, or at least real enough for their thoughts and actions to be realistic. In many cases, such realism allows research where manikins substitute for actual patients.

Human-patient simulation is reaching a larger audience as the technology improves and becomes more accessible. Distinct from the training offered by simple cardiopulmonary resuscitation manikins or personal computer–based multimedia software, high-fidelity medical simulation features integrated life-sized “patients” with programmable, reproducible, and physiological response capabilities. Interactive communication, the ability to undergo procedural interventions, and real-time recording of events are key features. Flexibility is improved with expert manikin control, allowing adaptation to a variety of learner actions. The application of these tools and techniques to disaster-medicine education is now taking place.

Both manikin and virtual reality (VR) simulated patients have been used to train health care personnel in various fields. Detailed patient presentations in realistic treatment settings, accurate modeling of human physiology, and dynamic changes in response to interventions contribute to these educational experiences. Otherwise unachievable training is also made possible when clinical events and care settings would harbor significant risk and enormous consequences to real patients. Difficult medical resuscitation and intraoperative crisis management are representative subject areas; learners can make mistakes in a simulated environment without risk to actual patients.

Self-contained high-fidelity manikin-based systems are useful in disaster training because of the relative ease of setup and maintenance compared with VR counterparts. Expanding from their original role in anesthesia and resuscitation instruction, these manikins are being applied to disaster training in an ongoing exploration of their capabilities. Re-creation of the physical barriers and material impediments to patient care at disaster scenes is a prime area of inquiry. For example, practicing intravenous access, medication administration, and endotracheal intubation while garbed in personal protective equipment (PPE) has been investigated using manikins. Such training and research would be hazardous using real patients and would lack fidelity in a VR environment.

Total-immersion VR (TIVR) and associated technologies are also being applied to disaster education. Featuring fully computer-generated environments and patients with multisensory interactivity (i.e., visual, auditory, and haptic), TIVR advances the “perceptual illusion of non-mediation.” This capacity to establish the presence of participants within the TIVR-constructed world seamlessly hints at the potential for tremendously flexible and virtually unlimited simulations for training. Early endeavors were conducted at the University of Michigan 3D Lab, ^, University of Missouri-Rolla, and the University of Padova, where researchers implemented TIVR-enhanced disaster scenarios. Additional TIVR-based disaster-medicine work is ongoing. Lack of standardization and significant startup requirements still limit TIVR’s accessibility for the time being.

Civilian and Commercial High-Fidelity Simulation Applications in Disaster and Weapons of Mass Destruction Education

With the increasing number of civilian sites featuring various forms of patient simulators, training courses have begun in earnest to delve into disaster-specific content. High-fidelity simulation is now accessible at paramedic training sites and nursing, pharmacy schools, and medical schools. The fundamentals of disaster medical response, such as situational and hazard assessment, triage, patient examination and treatment, decontamination and provider protection, and evacuation have been addressed using these assets. Focused task training and exercises fostering specific cognitive processes and teamwork behaviors ^, have been undertaken. Research comparing approaches to complex resuscitation and research where the responder is the subject (ergonomics, effort, and fatigue, etc.) instead of the patient undergoing complex resuscitation is also facilitated by simulated environments.

Increased funding for disaster and weapons of mass destruction (WMD) training released since September 2001 has helped prehospital systems in several states experience sophisticated disaster exercises employing advanced medical simulation. These efforts in Florida, Maryland, and Rhode Island have been primarily based at university-affiliated academic simulation centers receiving state and/or federal support. Significant use of high-fidelity simulation technology for nuclear, biological, and chemical preparedness is most apparent internationally in the Israel Center for Medical Simulation’s activities. Their programs address the preparation of physicians, nurses, and paramedics for the casualties of nonconventional warfare. ^{, ,}

In the commercial sphere, various U.S. centers are offering courses using high-fidelity manikin patient simulators for training in WMD and hazardous materials (HazMat). Early disaster-related high-fidelity simulations in the form of Simulation Training in Emergency Preparedness courses (supported by the Health Resources and Services Administration) trained hundreds of first responders and hospital personnel at the Rhode Island Hospital Medical Simulation Center in 2005-2006, along with the Texas Engineering Extension Service that provided WMD-focused prehospital operations and planning curriculum. Similar courses for the EMS community contain assorted applications of patient simulation, ranging from isolated patient care duties to full-scale multimanikin disaster drills.

High-fidelity simulation applications in disaster and WMD education for military forces have become routine to assist with personnel support roles for natural calamities and/or in combat preparation duties. Consequently, many of the issues raised by terrorism and WMDs have been addressed by the military in their established training. Troops engaging in combat have been expected to encounter weaponized chemical toxins, bioweapons, explosives, and radioactive hazards. Whereas the settings in which such exposures can occur have changed, the knowledge and techniques involved in responding to them remain mostly unaltered. However, actual experience in combat theater may vary from training based on expectations. In an example of rapid cycle adaptation using simulation-based training, a program whereby returning U.S. Army Reserve medical personnel were debriefed after deployment in Iraq or Afghanistan and that knowledge used to develop training scenarios for units preparing to deploy was trialed successfully. Numerous similar programs are ongoing. ^,

The U.S. military is developing and running training programs focused on the health care services specialist, known as a “91W,” with a particular interest in chemical, biological, radioactive, nuclear, and explosive qualifications. Component modules include personal computer–based Simulation Technologies for Trauma Care (STATCare) and Nuclear Biological Chemical Casualty Training System (NBCCTS) software. Advanced patient simulation within the various project efforts features prominently under the Medical Simulation Initiative. Several hundred high-fidelity manikins in on-site and distance-learning settings have been integrated into 91W training at various locations. WMD-specific applications are being phased in. Logistical simulation of the mechanics and delivery of medical care at multiple levels in a realistic and complete battlefield environment is also progressing with the Combat Trauma Patient Simulator program.

Future Directions in Simulation

Numerous simulation experts and groups are pursuing scientific validation of simulation techniques in health care education. The disordered environment of a true disaster makes prospective, controlled, and objective studies of educational content transfer difficult. Retrospective analyses may have a role, whereas surrogate markers of training efficacy and improvement in emergency preparedness could serve to demonstrate simulation utility in the interim. For example, response protocol changes developed from the Rhode Island Disaster Initiative (RIDI) Project in 2001-2003 were also noted in a thorough after-action report on the deadly 2003 Station Nightclub Fire, including need for flexible and scalable practices in disaster triage, treatment, and transport. Many responders to the fire had participated in RIDI drills and training sessions.

Enhancement of independent disaster-response abilities can be individually assessed at “skill stations” akin to those in advanced cardiac life-support courses. Global rating scales have surfaced as potential indicators of overall learner competence in educational settings using high-fidelity simulation. Such instruments, using properly defined scoring systems, should help in investigating basic disaster-response competencies in conjunction with fully immersive multiple-manikin disaster drills; investigative efforts are ongoing.

Development and testing of tools to demonstrate improved medical-responder preparedness with proper disaster training are taking place through federally and state-funded projects. Extensively incorporated into these activities, high-fidelity simulation has already allowed objective examination of EMS providers’ scene hazards assessment, triage decision making, use of novel interventions, and resuscitative actions in PPE. Continued work through such ventures is aimed to establish causal associations between high-fidelity simulation training, enhanced responder readiness training, improved disaster medical response, and, ultimately, better patient outcomes.

The greatest challenges for disaster trainers are to maintain the training competencies and certifications initially acquired and to work on continual skill development in an environment where little is changing, and the next disaster may seem far away.