The Surgeon’s Role in Disaster and Counterterrorism Medicine

Abstract

Medical and surgical care remain a critical feature of disaster preparedness. The evolution of modern warfare introduces elements manifesting as both domestic and foreign terrorism. The fields of disaster and counterterrorism medicine continue to evolve in response to these looming threats. While perhaps not common, education, preparedness, and medical/surgical capabilities are paramount to an effective disaster and counterterrorism medical (and surgical) response. The present study examines the specific role of the surgeon within the scope of disaster and counterterrorism medicine.

Introduction

The threat of natural and man-made disasters (terrorism) necessitates an efficient and effective medical response. The incidence of terrorism is on the rise, to include the threat of chemical, biological, radiologic, nuclear, and explosive (CBRNe) attacks. ¹ This includes the incidence of active shooter incidents in a multitude of soft targets (schools, hospitals, offices, etc.). The need for specific medical and surgical expertise in response to such incidents is paramount.

While specific medical and surgical disaster teams exist as well as cutting edge trauma centers, disasters and terrorist attacks can happen anywhere with minimal to no warning. Additionally, such mass casualty events typically do not occur at the site of convenient care and often mandate special medical care delivery based on a variety of factors (austere environment, weather, ongoing conflict, etc.). Thus, the ideal response personnel are often not immediately available directly at the scene of an incident. This emphasizes the benefit and responsibility of teaching various levels of response to a wide variety of personnel. The medical response would be best served by trained and ready physicians; however, this is typically not immediately available on scene. The immediate local response is emphasized to include the ability to enact an effective and scalable response on command. Education should target both medical and nonmedical personnel, as the immediate medical response to any incident may or may not include physicians (or any healthcare worker [physician assistant, nurse, medical assistant]) present on site. ² This highlights the disparity between local community response as compared to state/federal response capabilities.

Natural Disasters

The surgeon has historically served an integral component with disaster response. Additionally, the medical and surgical response to natural disasters has been widely published.^3-8 The World Health Organization (WHO) deploys four different emergency medical team (EMT) types with surgical capabilities: 1) type one mobile and fixed, 2) inpatient surgical emergency care, 3) inpatient referral care, and 4) specialized care teams. ⁹ There are many types of natural disasters that may broadly be categorized as weather phenomena (tropical storms, floods, drought, and famine) and geophysical phenomena (earthquakes, land/mud slides, volcanoes, and tsunamis). ³ Bartholdson and Schreeb ⁴ reviewed specific natural disasters and their respective injuries in relation to the surgeon. Briggs ⁷ noted the multidisciplinary nature of disaster response, including disaster surgical care. Disaster surgical care emphasizes a fundamental change in response and management as a mass casualty incident, which requires a unique approach to the care of victims. This modified approach calls for the “greatest good for the greatest number of patients.” ⁷ Briggs summarized key elements to include the following: search and rescue, triage, definitive surgical care, and evacuation.

Current responses involve multiagency coordination that begin at the local level and activate higher levels (state, regional, federal) as required and dictated by the National Incident Management System (NIMS) and Incident Command System (ICS). ¹⁰ NIMS consists of three core components: 1) command and management, 2) communications and information management, and 3) resource management. These coordinated systems serve to integrate all responses via a common language and protocol. A common language is critical in effective communication across a wide variety of organizations. Key to this system is the expansive and scalable response that can be requested if and as needed. However, this process may require time for both activation and response—thus, careful planning and decision-making is critical to ensure activation when needed but without an abuse of the system. The overall process aims to deliver five critical mission areas to include prevention, protection, mitigation, response, and recovery. Hospitals develop their own hospital ICS to activate in a disaster setting—this is a required protocol for most facilities under Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC) regulation. An example of modifications defined by the hospital ICS include surge capacity in a disaster setting. The triad of staff, supplies and equipment, and facilities must continue to function in a manner to best care for patients despite a straining surge of patient demand. It is thus critical that surgeons, hospitals, and communities understand the process to communicate and interact with collaborating organizations.

Terrorism

The nature of (surgical) disaster medical care continues to evolve and especially with the increasing presence of both domestic and global terrorism. ⁷ Terrorism occurs globally although the September 11, 2001, terrorist attacks marked a defining point for the U.S. in the global war on terrorism. Our more focused and continuously evolving response to terrorism led to the foundation of counterterrorism medicine as a distinct subset of disaster medicine.^8,11,12 This subspecialty evolution has occurred largely due to the increasing frequency of terrorist attacks and the more unique weaponry utilized by terrorists (CBRNe). Additionally, the indiscriminate targeting of anyone and everyone with little to no regard for expected protections under International Humanitarian Law and the Geneva Convention emphasizes the need for ready and able healthcare provision immediately at the scene of a terrorist incident. ¹²

The aforementioned multiagency and multiorganizational operational collaboration was demonstrated in the response of the Las Vegas shooting incident in 2017. Prior planning and established relationships among a wide range of local, state, and national organizations allowed for the best care that could be provided given the terrible circumstances. ¹³ An active shooter was responsible for the death of 58 individuals and another 800 injured. Existing collaborative relationships between local authorities, hospitals, and the Nevada National Guard offered the best care that could occur for such an event. After-action reports noted significant training in multi-assault counterterrorism action capabilities, hostile mass casualty incident training, and other collaborative formal training by and with involved organizations. ¹⁴ Extensive pre-incident drills, training, and surgical surge capacity planning were effectively utilized to mitigate the incident as best possible.

Hybrid and asymmetric warfare complicate existing response (to include medical) methods, as healthcare workers themselves may become intentional targets of a terrorist attack. Secondary attacks on healthcare workers responding to a primary attack have been reported. ¹² Specific attacks on healthcare facilities have occurred in warfare (hospital airstrike, Mariupol [March, 2022]; Chechen War [1999–2009]); however, this has now also occurred within the homeland most often in the setting of an active shooter scenario.^14-17 This increasing frequency of healthcare attacks has led to hardening of many hospitals and a greater sense of awareness. ¹⁶ Facilities considered to represent easy targets (ie, soft targets) typically include schools and offices; however, medical facilities also represent increasingly common targets for active shooters, largely due to the overall easier intrusion and lack of defenses.

Disaster and Counterterrorism Medicine

These new challenges in medical response and care for mass casualty, disaster, and terrorist incidents spurred the development and foundation of the field of counterterrorism medicine.^1,8,11,12,18 Counterterrorism medicine has evolved to include medical and surgical responses to the unique weaponry of terrorism, as such attacks have unfortunately increased in incidence across the globe. ¹⁹ This includes a myriad of unique medical challenges to include CBRNe weapons. ¹² This unique responsibility warrants greater education and preparation in both training and practice. Fellowships for disaster medicine are available primarily for emergency medicine physicians—these fellowships often include fundamentals of counterterrorism medicine.^1,18 However, medical care for any mass casualty type incident benefits from physicians of all specialties, both in the leadership and treatment realms. ¹

The principles of counterterrorism medicine are founded on the unique weaponry utilized (CBRNe), the asymmetric nature of attack (ie, soft targets for example), and the medical response founded in mass casualty principles. Mass casualty triage and treatment mandates the greatest good for the greatest number of individuals, and thus standard medical decisions and care may not be available to all. Difficult decisions may be required that focus on assured survival of one patient over another who is unlikely to survive. This is in contradistinction to standard medical care but is primarily based on the lack of availability of medical and surgical resources. This underscores the effectiveness of widespread education for even basic medical care to individuals of all medical skill levels.

The Surgeon’s Role

The American College of Surgeons states that “the surgical community has an obligation to participate actively in the multidisciplinary planning, triage, and medical management of mass casualties following all disasters.” ²⁰ This is also emphasized by the American Medical Association. ²⁰ This push warrants emphasis as education, training, and preparedness for such incidents is minimal and not standard for the vast majority of physicians. ¹ Surgeons are capable of treating most injuries that may be seen in active shooter, mass casualty, and disaster situations; however, the circumstances are unique and greater training and familiarity would benefit all.

There exist designated personnel and teams to effectively respond to disaster and terror attacks. However, these specialized teams are not usually immediately present or deployable and thus optimal local medical and surgical preparedness serves as the best initial responsive tactic. However, just as widespread education and training of programs such as Stop the Bleed and Basic Life Support have empowered laypersons to assist in medical emergencies, the more awareness and education present within the medical and surgical communities, the better prepared we will all be both in the field and in the hospital. ²¹

Other Specialties

Lane et al ²² examined bioterrorism and disaster preparedness among medical specialties. All medical specialties play at least some role, especially as immediate medical care providers at the scene of an incident. This is analogous to an in-flight emergency, where any physician can offer better medical care than a nonphysician, even if the medical specialty in need is not present. Preparedness for all mandates knowledge, skill, and resources at the initial level of an incident. A scalable response to request higher tiers of aid is possible but takes variable amounts of time to implement and deploy. Local medical capabilities differ among various locales, with contrasting differences at a rural hospital compared to a level I trauma center. Thus, it is imperative that preparedness occurs on a multitude of levels: individual, facility, and community.^23,24

Hospitals, Ambulatory Surgery Centers, and Surgical Offices

Hospitals and ambulatory surgery centers are required to implement all-hazards disaster plans (emergency operations plans) as mandated by Joint Commission and the AAAHC.^25,26 Disaster plans are uncommon in (private) outpatient medical offices and even those that do have such plans rarely practice drills. Even the most prepared individuals and facilities must understand that a true disaster or terrorist (including active shooter) incident will be chaotic and strain even the best of intended plans. Additionally, community communication and collaboration are imperative and should be implemented prior to a crisis situation. Primary care medical specialties (family practice, internal medicine, emergency medicine, general surgery, obstetrics, and gynecology) tended to demonstrate a priority given to bioterrorism and disaster preparedness.^22,25 Emergency medicine residencies expectedly had the highest degree of this training in residency; however, general surgery also demonstrated a significant amount of training, particularly geared toward specific injury types seen in and the handling of mass casualty incidents. ²² Trauma surgeons, in particular, are keenly aware of such incidents and likely remain at the forefront of both treatment and leadership roles within the realm of disaster and counterterrorism medicine.

Training

Developing a disaster/emergency plan for the surgical office does not need to be overly complex. There is a difference in simply creating and having a plan on file vs having one that is understood and most importantly, practiced. Any type of disaster situation will be chaotic and must be rehearsed to be effective. Education can be variable and can be directed from the surgeons, local law enforcement, and/or dedicated professional educators. This most commonly occurs via lectures and presentations but ideally should also include tabletop discussions, simulations, and drills. Just like practicing cardiopulmonary resuscitation (CPR) on a mannequin, this information must be simulated to truly be effective. Situational awareness must be developed and can be applied in every situation in both personal and professional environments. Education can begin this process but each individual must commit to his/her own awareness.

Like situational awareness, preparedness can be learned but must be applied to be effective. This applies to both the individual and the group. While it is impossible to prepare for every possible situation, thoughtful consideration and professional guidance can help the surgeon prepare his/her worksite for a disaster situation. A large degree of preparedness is founded in preexisting relationships and collaborations with administration, local law enforcement, emergency medical services, and other local responding agencies. Communication both within the surgical office and externally is paramount to have in place prior to any disaster situation. Almost all law enforcement agencies will provide free education and training to interested medical offices. Additionally, the use of training drills is one of the most useful methods to analyze weaknesses and develop optimal protocols and procedures.

The surgical facility should address preventive issues. This begins with the individual and spans up to the group, organizational, and facility levels. A hazard vulnerability analysis is a useful tool to examine potential weaknesses. This may help identify an optimal plan of action, evacuation routes, and rendezvous points following an event. The existence of a plan does not equal a useful plan however—it is critical that the surgeon and staff are aware of the procedures and know exactly what to do. This might be compared to surgical office staff responding to a code, where everyone simply knows what to do and immediately acts. This analysis should be comprehensive and include details from the individual level to the facility. Inclusion of potential violence from both patients and staff must be considered.

The components of an ideal disaster plan for a surgical office and/or hospital are numerous; however, they must be rooted in the above philosophies of situational awareness, preparedness, and prevention. There is no single best answer and the response will likely differ greatly. One facility may focus on preventive measures and hardening of the facility to strive to avoid aggression, while another facility may focus on optimal response tactics once an event happens. Ideally, all aspects should be explored. The process begins with interest from the surgeon and his/her administrative support staff. There is an enormous amount of resources available to assist in this process.

With regard to the medical response to terror and disaster scenarios, examination of the education and training of disaster and counterterrorism medicine reveals a paucity of training in medical school, with most specific training occurring in medical specialties geared towards this such as emergency medicine and general surgery (and trauma surgery). ¹ Preparedness and interest in these topics are difficult to promote among those who do not feel an immediate threat; however, once a threat is posed (as seen with the COVID-19 pandemic), interest instantly renews. Implementation of disaster and counterterrorism medicine initiatives were briefly seen in U.S. medical schools following the September 11^th attacks; however, this quickly subsided with time despite a continued upward trend of terror incidents. Medical school already contains a busy schedule with standard curriculums—thus it is not unreasonable that disaster and counterterrorism medicine are not a commonly promoted topics; however, approximately 10% of U.S. medical schools do offer educational material, lectures, courses, and/or experiences associated with counterterrorism medicine (and/or CBRNe medicine). ¹ Additionally, even a minimal amount of focus on these topics could prove useful and promote interest in select individuals. Perhaps the best solution is a practical one that at least introduces the topics to medical students and instructs on basic medical aid such as Stop the Bleed, Basic Life Support, Advanced Trauma Life Support, and Tactical Combat Casualty Care (references). Important roles include both immediate medical aid as well as physician leadership.

Physicians of all medical specialties play critical roles in disaster and counterterrorism medicine. ²⁶ The role of surgeons is comprehensive and includes both leadership roles as well as the expected surgical management of victims of disasters and terrorism. Military surgeons have always served a key part in such management and have unique training and experience for this care. However, this management is increasingly involving civilian surgeons as the prevalence of terrorist-related multiple casualty events continue to increase. ⁵ Greater emphasis on early training of these concepts is seen for medical students and within residency training. Overall concepts are taught (ie, gunshot injury, crush injury, and hypoxia); however, specific characteristics that are unique to disaster and counterterrorism medicine are largely not a part of routine medical school curriculums. Some of these concepts that are unique include surge capacity, mass casualty incidents, CBRNe attacks, and various traumatic injuries that are unique to disaster and/or terrorist attacks. There exists a large amount of material to cover in medical school; however, there are some medical schools that have effectively incorporated these disaster and counterterrorism medicine teachings within their curriculum. ¹ This varies largely and may be consist of a single lecture, a two week course, or the duration of medical school at one institution. ¹ After medical school, specific training in disaster and/or counterterrorism medicine is largely dependent on and at the discretion of each specific residency and/or fellowship program. It is expected that a trauma surgery fellowship would include much of this educational content while other less trauma-focused fellowships would not. A survey by the Eastern Association for the Surgery of Trauma reported that only 33% of (responding) trauma surgeons felt prepared to care for casualties of weapons of mass destruction and CBRNe attacks. ²⁷ Nevertheless, local surgeons within the vicinity of need will be called for and depended on regardless of their specific training for this purpose.

Training at even a basic level would allow more assistance within the field. Regardless of medical specialty, the more physicians who are capable of providing basic life support, advanced cardiac life support, pediatric advanced life support, advanced trauma life support, tactical combat casualty care, stop the bleed, and other similar programs will offer the best chance of survival for the greatest number of individuals involved in disaster and terror incidents.

The American College of Surgeons does offer some of this content for its organizational members, such as the Disaster Management and Emergency Preparedness (eDMEP) course. ²⁰ This online course is available to members and nonmembers and offers a general introduction to basic concepts that are paramount to such medical responses. While seemingly not often utilized, the Advanced Trauma Life Support (ATLS) course also includes optional chapters on disaster situations and management.

The American College of Surgeons Committee on Trauma’s Resources for Optimal Care of the Injured Patient (7^th ed., ref) offers a foundation to frame disaster and emergency planning for a response within the framework of trauma centers.^20,27 This document outlines the criteria necessary for various trauma centers, to include staffing, training, and equipment. Level I adult and pediatric trauma centers require that the surgical liaison of the disaster committee successfully completes the ACS DMEP course. However, individual, facility, and community preparedness is equally and perhaps more important and will significantly impact the medical state of arrival at a given trauma center.

All physicians can play key roles in disaster and counterterrorism medicine.^1,26 This is carried out in two means: 1) physicians can serve in a leadership role and 2) physicians can offer their professional services (as a surgeon in the current overview). The surgeon in particular is well equipped to respond in both capacities due to diverse training that spans these medical needs. The surgical field offers a wide variety of specialties and sub-specialties, many of which carry significant overlap that can offer a tremendous benefit in times of need. Surgical care may be presented in the traditional operating room setting, in makeshift surgical locales, and in the field. Military surgical experience has established a great fund of knowledge and protocols currently utilized, especially in austere environments. The surgeon will continue to play a critical role in all aspects of disaster and counterterrorism medicine and thus must continue to promote preparedness from the individual and facility levels.