The Evolution of Disaster and Counterterrorism Medicine—An Introduction

Abstract

The specialties of disaster and counterterrorism medicine have continued to evolve based on the demand for medical responses to these unique and demanding environments. These medical responses are relevant to all medical specialties; however, surgeons play a particularly critical role. This is evidenced from decades of humanitarian and military surgical involvement. Numerous roles are present and include both administrative/leadership and active response.

The practice of medicine continues to evolve and adapt to the underlying goal of providing care to others. Extreme weather, austere environments, industrial accidents, warfare, and terrorism all add additional challenges to the provision of medical care. While these varying medical environments may seem distant for many surgeons, the immediate medical and/or surgical needs that are mandated from these unique scenarios warrant at least a general familiarity with disaster and counterterrorism medicine. Additionally, the unexpected nature of many of these scenarios necessitates preparation to best care for our patients.

The specialty of disaster medicine arose as a subspecialty of emergency medicine, with the more recent evolution of counterterrorism medicine. ¹ This unfortunately arose due to increasing terrorist attacks, to include the use of chemical, biological, nuclear, radioactive, and explosive (CBRNE) weapons. ² Physicians of all specialties play a role in disaster and counterterrorism medicine. ³ The role of surgeons in disaster and counterterrorism medicine is central to these responses. There exist three core areas where physicians, and especially surgeons, play a critical role in disaster and counterterrorism medicine responses. First, immediate on-scene management is perhaps the critical response most important for saving lives. This immediate care exists on multiple levels; however, basic hemostatic pressure or more advanced surgical airways all help save lives that mandate time-critical action. Disaster and conflict scenarios have a high prevalence of traumatic injuries, hence the frequent inclusion of physicians embedded within domestic and international urban search and rescue teams. Second, surgeons are relied upon for their expected surgical management of triaged victims, to include a multitude of surgical specialties. Proper operating room triage and prioritization are critical and no one understands this better than the surgeon. ⁴ This may occur at multiple points within disaster scenarios ranging from the incident site to the operating room. Finally, hospital and community leadership are paramount and surgeons are well suited for this realm.

There is currently minimal education on these topics in medical school, with the most specific training occurring only in specific residency (emergency medicine primarily), fellowships (trauma surgery and disaster medicine), and within the military. ⁵ Specific courses such as Advanced Trauma Life Support (ATLS; taught by the American College of Surgeons (ASC)), Tactical Combat Casualty Care (TCCC), and Tactical Emergency Casualty Care (TECC) represent core training that is directly related to this type of critical medical response. Civilian-based TECC was derived from its military counterpart (TCCC) and stems from recognition of a changing global environment that includes a higher frequency of terror-derived threats. ⁶ More and more frequently, civilians will either be victims of or responding to disaster and terrorist scenarios. While the role of physicians in such situations is apparent, there is a strong push to educate non-medical individuals on basic medical care such as direct hemostasis. A majority of victims at these scenes require immediate hemorrhage control that often cannot wait for trained medical assistance. For medical personnel, additional basic training and education exist but are often inadequately utilized, such as the disaster training section of ATLS and the Disaster Medicine course offered by the ACS.^7,8 This information is already published and ready to use; however, this coursework is likely underutilized. In fact, teaching the existing ATLS curriculum (which includes an optional appendix on Disaster Preparedness and Response) need only be applied with a focus on disaster and counterterrorism medicine. The same is true for TECC (civilian) or TCCC (military), although the latter is already taught in the military with battlefield trauma response in mind. Training of TCCC in the military promotes a basic (but effective) level of trauma care that may be provided by every individual present. Training in disaster and counterterrorism medicine begins with the individual, necessitating a foundation in situational awareness and preparedness.

Medical responses to active shooter incidents fall within the scope of counterterrorism medicine and mandate an effective and efficient method of response. The potential for an active shooter with resultant traumatic injuries demonstrates the need for both familiarity and the presence of pre-established protocols. These protocols are grounded in the universal language established by the National Incident Management System (NIMS) and Incident Command System (ICS). ⁹ These best practices and protocols establish a hierarchy of leadership and communication, along with the ability for a scalable response on demand. They create an existing framework that adapts to all situations. It additionally allows for organization and communication among government, state, local, and military organizations. The NIMS serves as a guide within all levels of government, nongovernmental organizations, and private sector organizations—it is organized via core components that include preparedness, resource management, command and coordination, supportive technology, and communications and information management. ⁹ The NIMS is founded on its flexibility, standardization, and unity of effort. ⁹ The ICS itself is a management system designed to yield rapid, effective, and efficient coordination and action. It allows coordination of command, operations, logistics, planning, intelligence, and finance (and administration). Familiarity of the concepts is important for surgeons involved in disaster and counterterrorism medical responses. A complete review of the NIMS and ICS, full glossary of this language, and related concepts is outlined by the Federal Emergency Management Agency (FEMA). ⁹ Additionally, multiple, free, online courses regarding these protocols and procedures are available from FEMA. ⁹

All medical specialties play a role in disaster and counterterrorism medicine; however, surgeons play a particularly critical role. These roles generally involve both administrative roles (planning and preparation) and active response/treatment roles. Additionally, response roles of the surgeon may include immediate care in an active threat environment as well as the more traditional roles of the surgeon in the operating theater. Surgical staff are also critical components of the treatment paradigm. Surgeons should be aware of and participate in facility all-hazards emergency plans. This is standard for those who function within the scope of a facility Emergency Management Committee.

The evolution of modern warfare continues to adapt to new advancements and technology. Encroachment of terrorism (domestic and foreign) within the homeland United States has brought these otherwise distant and unfamiliar medical needs to the immediate forefront. The present symposium aims to introduce these concepts and to review the role of the American surgeon in these scenarios.