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Volume 3, Number 3, May/June 2008

Disaster : A history

Geoff Williams 

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Geoff Williams

In 1937, after a natural gas explosion destroyed a For instance, there was the case of a delegation of high school in New London, Texas, near the end of a 30 doctors who showed up in a city, prepared to help school day, nearby oil workers ran from the fields to thousands of victims in the wake of a , find a pile of smoldering rubble. Underneath the but the police authorities turned them away. Later debris, they could hear the screams of teenagers and that day, another contingent of was teachers.1 informed their services weren’t needed. As it turned In the hours after what was then the second worst out, each medical team returned to their respective disaster in Texas history—the actual death count was communities to read in the newspapers that there never determined but approximately 300 lives were were at least 52 towns in the area that hadn’t yet lost—President Franklin Roosevelt put out a request for received medical help. medical aid over the radio, and by that evening, doctors That was in southern Italy, after an and nurses had descended on the town, coming as far on November 23, 1980,19 but without those details, away as Dallas, 134 miles away, and Shreveport, one might have easily assumed this was a tale con- Louisiana, 75 miles away. Hundreds of vials of anti- cerning New Orleans after passed tetanus serum were driven to the scene of the blast. Help through the city on August 29, 2005. was certainly needed. The oil workers pulled out over 200 are, by their nature, chaotic, and the victims, flagging down passing cars that hauled the medical community hasn’t been immune to getting injured and dying to the nearest sickbay. caught up in the turmoil. But history is repeating The Associated Press reported, “The itself, and the repetition is welcome: Just as in previ- were jammed, but it seemed that those who needed ous eras, physicians examined their techniques when medical attention were getting it.”2 responding and treating victims in disasters, this lat- That hasn’t always been the case. From earth- est generation of healers is adapting to new, varied quakes to wars to and hurricanes, the history of and horrific threats. disaster medicine is replete with success and failure As any student of history knows, for centuries, when it comes to the results of the physicians and nurs- physicians were mostly concerned with minimizing es and medical administrators who assist during and in pain and suffering. Before the days of , that the aftermath of a crisis. And it’s a long history. “Really, often meant amputating a limb and hoping for the when you look at where disaster medicine started, it best, and because germs and proper hygiene were lit- goes back to the Civil War battlefields, and even pre- tle understood, the doctor was often something of a dating to Roman times,” says Gary M. Klein, MD, MPH, walking disaster himself. But that began to change MBA, who practices acute care medicine in Atlanta.3 during the Napoleonic Wars. “The concept of As a general rule, it’s never been a lack of willing- was coined by, I believe, a French military ness of the medical profession to help as a tragedy with Napoleon, and then you had Clara Barton, dur- unfolds, but the execution has sometimes been lack- ing the American Civil War, creating the American ing, notably during some high-profile catastrophes in Red Cross. All of that’s a part of disaster medicine, the last few years. and then during each of the wars that the United

www.disastermedicinejournal.com 125 States has been involved in, disaster medicine has “Catastrophe organization might well include experts been ramped forward,” says Captain James W. assigned to the scene of the disaster to determine the Terbush, MD, MPH, of the US Navy Medical Corps, nature of the trauma, the presence of noxious fumes and a NORAD-USNORTHCOM Command Surgeon and so on, not solely to fix responsibility from a legal at Peterson Air Force Base in Colorado.4 standpoint, but to aid in the treatment of casualties,” Indeed. During the Napoleonic Wars, Dominique- the lengthy study suggested.6 Jean Larrey was a surgeon in the French emperor’s Other recommendations included the idea of having army, who not only conceived of taking care of the wound- an immediate examination of the dead by competent ed on the battlefield, he also created the concept of ambu- pathologists and keeping casualties in one group for con- lances, collecting the wounded in horse-drawn wagons centrated medical treatment. The report concluded with and taking them to military hospitals. Until that time, some timeless wisdom, “An emergency anticipated and the wounded were generally cared for near the end of the prepared for ceases to be an emergency.” day, or whenever the battle paused or ended. By the time But the actual term disaster medicine begins crop- the Civil War began, Clara Barton learned that many ping up in the newspapers with some regularity during wounded soldiers were dying not from lack of attention, the 1950s when medical associations had begun to truly but the need for medical supplies, and she began her own adopt the idea of anticipating an emergency. They were organization to distribute medicine, bandages and other frequently hosting seminars trying to gauge how doctors life-saving tools. might fare in a post-nuclear attack.7 By the twentieth century, preventative medicine This was grim stuff. Colonel and physician Karl was a concept championed during the late nineteenth H. Houghton spoke to a convention of military sur- and early twentieth centuries among doctors, such as geons in 1955, telling them, “You won’t have sufficient Dr. Andrew Taylor Still, also known of the father of drugs or surgical materials to handle all the casual- osteopathy, and organizations like the Anti- ties and will have to decide rapidly and without hesi- Tuberculosis Society labored to better understand the tation who will receive this perhaps life-saving mate- causes of disease. Meanwhile, government health cen- rial. This is not always simple. Do you save the banker ters came into vogue, overseeing everything from or the truck driver? Do you go right down the line of child welfare departments to hospitals and . casualties taking them as they come, or do you pick The idea was that long before an settled into out those individuals who might be the most valuable a community, physicians and nurses should be pre- in terms of the rehabilitation period to come?” pared for battle. Houghton imagined a world in which physicians But disasters were sometimes self-inflicted. One would, like it or not, be forced to play God. turning point was the raging fire that was accidental- Another colonel and physician, Joseph R. Schaeffer, ly ignited and engulfed the Coconut Grove nightclub MD, imagined that in a massive atom bomb attack, in in Boston on November 28, 1942. It was a devastating which the United States was virtually destroyed, the experience for the rescuers and Massachusetts medical community might almost become obsolete. “We General staff who were involved in the apoc- have 200,000 doctors to take care of 176,000,000 people in alyptic aftermath. As Time magazine reported, this country,” he told a medical staff at a Texas hospital in “Firemen broke down the revolving door, found it 1959. “Therefore, the people must learn how to survive blocked by bodies of the dead, six deep . . . One hard for themselves in case of an emergency.”8 bitten fireman went into hysterics when he picked up Schaeffer lamented that so few Americans had a body, and a foot came off his hand. They found a girl any proper first aid instruction when Russia required dead in a telephone booth, a bartender still standing its citizens to take 22 hours in first aid education— behind his bar.”5 Ultimately, 484 dead were counted. every year. Massachusetts General issued a report to under- Even though Schaeffer’s call to civilians educating stand how to better manage a tragedy unfolding. themselves largely went unheeded, his life’s work is a

126 American Journal of Disaster Medicine, Vol. 3, No. 3, May/June 2008 good example of the type of disaster medicine plan- Disaster medicine as a specialty and mindset was ning that was taking place during the 1960s. Dr. not only a reaction from September 11, 2001, but to Schaeffer was the director of at the numerous subsequent events that seemed to all Santa Rosa Hospital in San Antonio, Texas, he was too quickly follow: random anthrax attacks in the also a consultant on disaster medicine and planning weeks afterwards, the SARS outbreak in pockets of for the American Medical Association (AMA)—as well the world, the blackout in the summer of 2003 that as the American Hospital Association, the American took the power out in New York City and surrounding College of Surgeons, the United States cities and states, the December 26, 2004 Indian Ocean Service, the United States Office of Civil Defense and , the Pakistan earthquake of 2005, a tumul- the Department of Health, Education and Welfare. tuous hurricane season in 2005 culminating with the He was also the editor of the official disaster medi- arrival of Hurricane Katrina, and, of course, terrorist cine manual of the North Atlantic Treaty attacks throughout the world including Spain, Organization and was responsible for the care of England, Bangladesh and Bali—all against a back- 20,000 residents during Hurricane Carla, a category drop of conflict in Afghanistan and Iraq. 4 storm in 1961 that only killed 43 people thanks to a As Cincinnati-based internist John Andrews, MD, massive evacuation. By the time he died in 1966, at who spent 20 years as a Commissioned Corps physi- age 73, he had amassed quite a legacy in the field of cian in the US Public Health Service, artfully puts it: disaster medicine.9 “It’s not just that the disasters seem to be coming When Oklahoma City suffered a terrorist attack more frequently, they’re more varied. In the old days, almost 30 years later, with 168 dead and 914 people you had natural disasters like hurricanes, floods, tor- injured,10 Dr. Schaeffer would have been pleased by nadoes, and maybe occasionally a chemical spill. But the response. This was a world, after all, in which the now, somebody’s actually trying to make a disaster.”11 Emergency Mobilization Preparedness Board had A lot of people saw it that way, and while the disaster been created in 1981, which began the National climate of the last several years has had a profound Disaster Medical System, which has teams of first- impact on many individuals, it’s affected numerous doc- responders around the country. This was also a coun- tors, who, of course, are prone to have a few opinions on try that had the Association of American Physicians preventing suffering and dying. Dr. Klein, who was a and Surgeons’ group, Doctors for Disaster Prepared- pharmaceutical executive in New York City, when the 9- ness, had been flourishing since 1982.25 11 attacks occurred, spent around 24 hours at Ground The hospitals in Oklahoma City were naturally Zero, initially insisting with dealing “with the worried overwhelmed with patients, but the consensus was well,” people he describes as being “absolutely devastat- that the system worked—and almost immediately, a ed, wandering around in a daze, acutely traumatized.”3 team of epidemiologists and medical system analysts Klein then assisted colleagues in the gruesome task of gathered at the site of the explosion to examine how to trying to identify bodies at the coroner’s office. From then even better improve the treatment and care given on, Klein has dedicated much of his time toward disaster patients in the aftermath of the disaster.20 They want- medicine; in fact, he’s now a contractor with the ed to study issues such as how long it took to get the Department of Defense. gravely wounded to the hospital and how many rescue The terrorist attacks also had an acute effect on workers visited the psychological debriefing centers Paul K. Carlton, MD, the director of Homeland set up around the site. Security at Texas A&M Health Science Center. In short, individual doctors, nurses and hospital He believes disaster medicine should be board cer- administrators were shaken up by the homegrown tified, and he has some personal experience as to why terrorist attack, but the medical infrastructure he feels that way. As the surgeon general of the Air seemed prepared for just about anything. Force, he had been practicing disaster training with Then two airplanes crashed into two towers. medical students three months before an airplane hit

www.disastermedicinejournal.com 127 the Pentagon. They had, eerily enough, come up with forming study and discussion groups in disaster a similar disaster scenario to practice for, only they medicine, much more frequently in the past. In some imagined an aircraft having an unsuccessful take off cases, the medical schools were already on the front or landing and crashing into the Pentagon. In their lines of this movement—they just accelerated their exercises, they did quite poorly, admits Carlton, but growth, such as the University of New Mexico because of the drills, on September 11, when Dr. Center for Disaster Medicine, which was established Carlton rushed into the Pentagon as a first-responder, in 1989. Meanwhile, elsewhere in the world, there he and his team were understandably pleased by their have been disaster medicine for-credit courses at performance. He led a rescue group into part of the universities in London, Paris, Brussels and building where the landing gear had crashed into it, Bordeaux since at least the early 1980’s. they pulled three people to safety, “and we all got out Frederick Slone, MD, a visiting assistant profes- alive.” No small thing, since Dr. Carlton himself sor at the University of South Florida College of caught on fire. That he’s alive is at least partially due , is one of the new pioneers in disaster medi- to his fire-retardant vest that he was wearing.12 cine. Within two years after the terrorist attacks, as For Dr. Philip Merideth, MD, JD, a psychiatrist in part of their required curriculum as well as continu- Jackson, Mississippi, his evolution in thinking came ing education, the USF College of Nursing began after Hurricane Katrina. He spent two weekends in offering a disaster and bioterrorism training program, Mississippi and Louisiana, doing what he could, pre- featuring eight one-day classes and an intense two- scribing medicine and simply listening to people pour day program. One class focuses on working with peo- out their grief. “Everyone had a story of what hap- ple subjected to chlorine gas. Another educates health pened in the hurricane, and they wanted to tell it,” professionals on patients who are suffering from blast says Merideth, who offers one chilling example—talk- trauma. Yet another: anthrax, smallpox and plagues. ing to a little boy who had been the only survivor of his In determining whether it would be a worthy household, and that had been because he had swam offering, they did a survey of 179 healthcare profes- out the second story window.13 sionals,21 asking if they felt they had the necessary In the last several years, as disasters have seemed equipment to handle a biological attack related to ter- to be on the increase, careers have been created and rorism. Forty-seven percent replied that they were ill- defined, government plans were put into action, and equipped to handle a biological attack; forty-five per- first-responders such as police and firefighters began cent gave the same answer for a chemical attack. crafting plans on how best to handle a disaster. In “There’s a lot of confusion in the beginning,” says Dr. 2003, long-time internist and a specialist in infectious Frederick Slone, referring to when students are practic- diseases, Robert Cox, MD, of Englewood, Colorado, ing clinical scenarios using human patient simulators. had just started his company, Bioforecasts, with the “But everyone seems to come away feeling like they’ve idea that he would talk to medical groups and non- benefited from the program.” He adds that a number of medical organizations about what we can expect in their students have gone onto assist with caring for vic- the future in relation to our health. For instance, we tims of natural disasters, including Hurricane Katrina.15 may want to live to be 100, but we are financially pre- Much of what needs to be taught is a mindset, pared to? However, Dr. Cox has since expanded his says Dr. Carlton, who cites an example of a suicide talk to include disaster medicine topics, like bioterrorism bomber who attacked a cafeteria on an American mili- and how to inoculate your business from the avian flu. tary base in Mosul, Iraq. “The kids there had a small “I had been thinking about those topics from the team, where they did nine operations in the operating beginning,” says Dr. Cox, “but after awhile, there was room and 10 in the hallway. That’s the kind Plan B no way I couldn’t not discuss them.”14 operation that stands us in good stead when we That’s how everyone seemed to feel. Certainly need it. Our medical students need to realize that the medical establishment in North America began we’re not always going to have technology they’ve

128 American Journal of Disaster Medicine, Vol. 3, No. 3, May/June 2008 become accustomed to. I think of Hurricane Katrina, weapons of mass destruction attacks inside Texas. In where a woman was in labor, and all of the lights Washington state, Robert Cross, MD, is a retired went out. The doctors performed a C-section—by physician, a 77-year-old who for several years has flashlight. It’s not an ideal circumstance, but they been toiling to create an organization of retired doc- did a beautiful job.”12 tors who can respond to disasters in his home state. The education that Carlton is discussing and that He, like many doctors, wanted to do something con- Slone is a part of is a big movement. New York’s structive in the wake of the terrorist attacks, and sud- Columbia University, for instance, soon offered two class- denly he could see how shortsighted the medical com- es that, as their web site explains, “bring the events of munity had been when closing hospitals left and right, Sept. 11 into the classroom.” The first course is Public thanks to outpatient care centers. “In any disaster, Health Consequences of Forced Migration; the second is surge capacity is a common problem in the hospitals,” Emerging Infectious Diseases, the manmade germ war- says Cross, knowing that while he may not be able to fare as opposed to a natural occurrence. In Pennsylvania, replace the hospital buildings, he can a cadre of newly the Albert Einstein Medical Center developed, “A Primer trained retired physicians and nurses on call to help on Bioterrorism for Physicians,” giving medical students the state when needed.16 an overview of anthrax, smallpox, botulism and the In the midst of all of this change, what once plague, including how to recognize the symptoms in seemed improbable now seems inevitable: the cre- patients, as well as containing the disease, managing and ation of a medical in disaster medi- treating it. Vanderbilt University Medical Center in cine. It’s an idea being championed the American Tennessee now offers a course called “Weapons of Mass Board of Physician Specialties. Destruction Awareness and Treatment” for physicians, Nodding in approval is Dr. Andrews, board certi- nurses and staff. The UCLA Medical Center organized a fied in internal, preventative and occupational medi- Task Force on Bioterrorism Preparedness. The list is cine. “Most of us have many patients in a day, but we seemingly endless.22 don’t handle a disaster, say, once a week. They come In 2003, the AMA partnered with four medical cen- every so often, and to be trained in disaster medicine, ters and three national health organizations, establish- and updated, I think is a neat idea.”11 ing the National Disaster Life Support (NDLS) training And necessary, says F. Matthew Milhelic, MD, who is program. The AMA also formed a Center for Public an assistant professor at the Center for Homeland Health Preparedness and (CPHP- Security Studies at the University of Tennessee’s DR), and about this time, the American Osteopathic Graduate School of Medicine. “I think the way that this Association and the American Association of Colleges of board has proposed this idea, making it an inclusive Osteopathic Medicine formed the AOA/AACOM Task board, will do two things—raise the level of competency Force on Bioterrorism. The AOA also opened an AOA among physicians to deal with problems in a disaster, Office of Emergency Response.23,24 and it will also raise awareness across the medical com- Of course, at this point, some five years after munity for the need of preparedness . . . and I think this September 11, 2001, medical schools, organizations, board is looking at disaster medicine as much broader associations and hospitals that aren’t forging creden- than just a brief medical response over a short period of tials in disaster medicine are something akin to a time, and that all medical providers, all medical disci- hotel that doesn’t offer its guests an Internet connec- plines, specialties, , and so on, will have a tion in every room: they are behind the times. It helps role in any major disaster.”17 explain why disaster medicine is a field that is grow- “The majority of physicians are in primary care, ing exponentially, more than any time in history. family practice, general medicine, and, of course, Physicians are addressing the topic on blogs and are there are pediatricians and ob-gyn,” concurs Dr. forming groups like the Texas Medical Rangers, Terbush, who was in the thick of things after which aims to respond to natural disasters and Hurricane Rita and Hurricane Katrina. “It would be

www.disastermedicinejournal.com 129 exceptionally helpful if primary care physicians were who define their times by an incomplete New York City experts in disaster medicine.”4 skyline or a mountain of bricks and blood in a tiny Texas Some critics think board certifying disaster medi- town, few people are likely to argue with that. cine is too much. Eric Grosch, MD, based in Fort Geoff Williams, Freelance Journalist, Author of several history Meyers, Florida, is no fan of board certifying—any books, Loveland, Ohio. specialty. He feels that there’s no evidence that sug- gests that a board certification makes anyone a better References physician, equating the certification to another age: 1. Associated Press. 670 Children, Teachers, Feared Dead in Terrific Texas School Explosion. The Galveston Daily News. March “Long ago, doctors did things to patients that had no 19, 1937. Pages 1 and 19. evidence-basis and harmed them as a result, such as 2. Associated Press. Pathos and Tragedy in School Explosion. The bleeding them to ‘remove evil humors’ or putting Sheboygan Press. March 19, 1937. Page 1. 3. Interview with Dr. Gary M. Klein, October 2, 2006. 18 leeches on them for much the same purpose.” 4. Interview with Dr. James W. Terbush, October 12, 2006. He feels that excluding qualified physicians who 5. Boston’s Worst. Time magazine. December 7, 1942. 6. Associated Press. Disaster Fire Lessons From Nightclub aren’t board certified does a disservice to the patient, Announced. The Galveston Daily News. December 25, 1942 and any slight toward the patient can simply piles on 7. United Press. Hard Role for Doctor Seen in Atomic War. Reno more potential tragedy during a disaster scenario. Evening Gazette. November 10, 1955. Page 30. 8. Public Doesn’t Realize Dire Need for C-D (Civil Defense) The Right or wrong, one question is almost begging to Kerrville Times. April 04, 1959. Page 6. be asked: Could the American medical community be 9. Associated Press article with no headline, mentioning Dr. doing too much? Are we creating layers of bureaucra- Schaeffer’s death and referring to him as an authority in “disaster medicine.” The Gettysburg Times, August 12, 1966, page 14 cy, ensuring that when a crisis comes, there will be 10. Injuries in Oklahoma City bombing: information came from web hundreds or thousands of organizations mobilizing site produced by the state of Oklahoma: http://www.ok.gov/ health/documents/OKC_Bombing.pdf Accessed May 20, 2008. but not within the same framework as everyone else? 11. Interview with Dr. John Andrews, September 14, 2006. Dr. Cox agrees that it eventually could be a problem, 12. Interview with Dr. Paul K. Carlton, October 5, 2006. that we could have, “lack of coordination and commu- 13. Interview with Dr. Philip Merideth, September 29, 2006. 14. Interview with Dr. Robert Cox, August 29, 2006, follow-up nication among the agencies, like the 9/11 experience. email, September 16, 2006. There could also be a dilution of resources being 15. Interview with Dr. Frederick Slone, August 30, 2006, follow-up spread out rather than concentrated. This applies to email, September 18, 2006. 16. Interview with Dr. Robert Cross, October 5, 2006. 14 both people as well as finances.” 17. Interview with Dr. F. Matthew Mihelic, September 27, 2006. But Cox doesn’t think the medical community or 18. Interview with Dr. Eric Grosch, September 8, 2006, follow-up country should slow down yet. “I think this is all part email, September 9, 2006. 19. Altman L K: Doctor’s World. The New York Times. December 9, of the organizational evolution, and only time will tell 1980, page C3. what the correct number is.” He also points out that 20. Brown D: Medical Analysts Will Try to Learn From the Numbers. The Washington Post. Apr 27, 1995, page A.24 there are some efforts at coordinating disparate 21. University of South Florida web site, referring to a study they groups, citing his home state of Colorado’s “Governor’s did of doctors and nurses not prepared for a disaster. Available at Expert Epidemic and Emergency Response http://hsc.usf.edu/nocms/nursing/ResearchCenters/disasterbiot- er.html. Accessed May 30, 2008. Committee,” which includes representatives from the 22. Information on universities with bioterrorism classes, from the medical community, military, public health, agricul- web site of the Association of American Medical Colleges: Available ture and many others, so the next time a disaster at http://www.aamc.org/newsroom/bioterrorism/start.htm. Ac- cessed May 30, 2008. 14 strikes, no group will feel as if they’re on their own. 23. National Disaster Life Support program origins. American But however this most recent history of disaster Medical Association web site. Available at http://www.ama-assn. org/ama/pub/category/12606.html. Accessed May 30, 2008. medicine is written, there seems to be one indisputable 24. On AOA’s role in bioterrorism. AOA web site. Available at upside, according to Dr. Slone, who says, “The reality is http://www.osteopathic.org/index.cfm?PageID=faq_cons. that the more teams that are formed, the more people Accessed May 30, 2008. 25. smallpox plan criticized by the Association of American will be trained for a response, and in the long run, this is Physicians and Surgeons. Available at http://www.aapsonline.org/ what we need.”15 Across the generations, from those press/nrsmallpox.htm. Accessed May 30, 2008.

130 American Journal of Disaster Medicine, Vol. 3, No. 3, May/June 2008