Introduction

World Health Organisation defines disaster as an event that overwhelms the local capacity to respond and requires assistance from outside the affected community.[1] There are various forms of disasters, including disasters caused by natural hazards and human-made disasters. Disasters could also be acute, chronic, or insidious, based on the timeline. Disasters could be open or closed, depending on the identity of the victims. Disasters could be internal or external, based on the location. 

Disaster medicine is, therefore, concerned with the medical response to disasters. In the mid-20 century, Disaster medicine primarily focused on the surgical intervention of trauma and triaging of victims following armed conflicts and was viewed as a component of military medicine. Research in disaster medicine has shown overwhelming mortality and morbidity resulting from infectious disease epidemics, malnutrition, exposure, psychological effects as well as other effects related to forced migrations.

Disaster medicine has evolved to include components of emergency medicine, community health as well as disaster preparedness, response, and prevention. Professionals of disaster medicine, therefore, include medical as well as non-medical practitioners. The various medical disciplines include emergency medicine, critical care, community health, and all branches of surgery.[2]

Simulation-based training in disaster medicine includes exercises that emulate a scenario or process, enabling the subject to develop knowledge and skills that will be put to use in real-life events. The participants are placed under the same stresses, including time constraints, patient surge as well as other characteristics, in their actual working environment, to develop the cognition, skills, and attitude leading to better outcomes.[3]

Skill assessment is the evaluation of the performance and competency of an individual, based on pre-defined criteria. Skill assessment in simulation-based training needs to be objective and standardized. Some methods include evaluation through questionnaires and surveys, structured assessments, as well as video recording.[4]

Function

The purpose of this article is to explore the vast literature available relating to the medical response to disasters and their effective management, including proactive preparation and prevention.

Numerous public health programs focusing on public health response to disasters have undergone development over the last few decades. In light of their findings, the United Nations Office for the Coordination of Humanitarian Affairs (UN-OCHA), the World Health Organization (WHO) as well as the Pan American Health Organization (PAHO), jointly demanded better coordination and professionalism from the medical fraternity in the face of disasters.[2]

Issues of Concern

The Center for Research on the Epidemiology of Disasters (CRED) showed direct mortality from armed conflict ranged from 2 to 8%. The study also found an extremely variable outcome with regards to the mortality indicators and attributed it to the indirect effects of conflicts, including the devastation of health infrastructure, disease outbreaks, and effective disaster response.[5]

Medical personnel, especially in emergency care, are expected to work under extreme duress regularly. In the case of disasters, there is added stress on the medical staff, which is further aggravated by a lack of human resources and resources, longer working hours, faster patient turnover, inadequate infrastructure, etc. These tend to overwhelm the medical system entirely and therefore require adequate planning and coordination.

The last few decades have seen the development and incorporation of simulation exercises and training into the post-graduate training courses in medical and para-medical institutes all around the globe. There has also been a massive uphaul in the development of medical infrastructure to help prepare medical personnel, including technical and non-technical staff, to cope with disasters. This response has seen a sharp increase in the number of simulation centers and simulation drills in hospitals, medical and para-medical colleges, and universities, as well as the development of specialized organizations with mandates for rapid response and mobilization of trained personnel to assist the local medical structure; this is especially true of multi-disciplinary missions during times of disaster.[6] 

Recent years have seen numerous conferences on disaster medicine as well as disaster victim identification; however, there has been discordance between the emergency medical specialists and the non-medical forensic specialists, including forensic anthropologists, forensic scientists, digital forensic specialists, etc. This disparity leads to a lack of coordination and communication between the specialists resulting in inadequate management of the dead by emergency specialists as well as inadequate management of the injured by forensic specialists.

Curriculum Development

One aspect of medical management of disaster that is often overlooked by Disaster Medicine specialists is the dignified management of the dead in disasters. This process includes the triaging and proper documentation of the deceased to ensure their identification, and subsequent repatriation to the family members and is an integral aspect of disaster medicine. These measures are crucial to ensure the dignified management of the dead and adherence to Disaster Victim Identification (DVI) protocols and international standards, which require incorporation into Disaster Medicine training and curricula.

The assessment of skills can be ensured through formative evaluation using Global Rating Scales and well as Objective Structured Assessment of Technical Skills. The summative evaluation could include OSATS as well as Questionnaires to provide feedback on the needs of the participants to help plan future training. Both formative and summative assessments, using quantitative methods as well as qualitative methods, should be used in conjunction to address the shortcomings in the skills and knowledge of participants as per their requirements. This methodology requires a flexible approach and should not implement “one size fits all” models that would result in the squandering of resources.

Procedural Skills Assessment

While Simulations have gained wide acceptance as a teaching tool, their use for skill evaluation has been more controversial. The major methods of skill assessment in SBTs are questionnaires, objective structured assessments of technical skills, global rating scales, as well as video recording and evaluation.

Questionnaires examine the participants' feedback and are a low-cost assessment tool. However, the method is subjective and qualitative and therefore is not a very good tool. Questionnaires are a form of summative evaluation.

Objective Structured Assessment of Technical Skills (OSATS) is a checklist that evaluates the skill and competency developed by the participant and provides a better assessment of the outcomes. OSATS also has the advantage of being formative as well as summative. However, the evaluator needs to be trained to ensure observer reliability. Due to its nature, OSATS can only be used to evaluate the completeness of a procedure and not the quality of the procedure.

Global Rating Scales (GRS) uses a rating scale to evaluate the quality of the procedure, and so have often been used as an adjunct to complement the OSATS tool. GRS can be developed to assess both objective and subjective criteria and are also useful for evaluating non-technical skills. This means that GRS has disadvantages, including subjectivity, lower observer reliability, and bias.

Video recording is used to allow flexibility to the observer to use other tools like OSATS or GRS at a time convenient to the observer. The recording can also be used by multiple observers to evaluate the procedure. Similarly, the recording could be abridged to shorten the assessment time. Video recording can also be used in conjunction with motion and temporal analysis to help provide an objective analysis of the quality of the procedure. The disadvantages include the cost as well as the need for trained personnel to ensure the quality of the recordings.[4]

Medical Decision Making and Leadership Development

Traditional medical education has focused on the development of knowledge through didactic lectures. This concept has been seen to be extremely inadequate in developing the skills of medical practitioners, especially in times of emergencies and disasters. Traditional methods are now complemented with simulation-based training to develop the communication and co-ordination between multi-disciplinary teams. Additionally, simulation-based training increases the skills as well as knowledge retention of participants. This approach ensures better decision making by the medical teams in times of extreme duress, leading to better performances by the medical personnel, ultimately translating into better patient outcomes.[6]

Clinical Significance

Simulation-based training has long had recognition as a necessary adjunct to traditional methods of teaching. They are most useful in the medical field where they develop the skills of new personnel without putting patients at risk, while at the same time, increasing their performance and retention of knowledge, especially at times of extreme stress.

Simulation-based training has helped improve patient outcomes and helped streamline the medical response to disasters; this is affected by improving communication and coordination in multi-disciplinary teams. Other factors that have led to the success of simulation-based training include the development of evidence-based medicine, with the implementation of standardized protocols, evaluation of the shortcomings, and program outcomes. SBTs also allow for repetitive exposure and practice, which would not only be extremely slow and tedious using traditional methods but may not be possible with regards to disaster response.[6]

Pearls and Other Issues

Simulation-based training help develop the skill and competency of medical personnel to cope with the stress associated with emergencies and disasters. Simulation-based training should focus on the shortcomings dictated by the participants rather than focus on a “one size fits all” model.

The skills learned, and the outcomes should be evaluated using both formative and summative evaluations, ensuring quantitative as well as qualitative assessment. These include questionnaires, objective structured assessment of technical skills, global rating scales, as well as video recording and assessment.

Enhancing Healthcare Team Outcomes

Disaster medicine, by its very nature, is extremely complex and requires both multi- as well as transdisciplinary response to be effective. This fact further demonstrates the need to develop simulation-based training that will assist in the development of not just medical and surgical skills, but also other skills inherent to a team, including communication and coordination.[2]