Many countries have invested in various research projects that aim to improve the efficacy of disaster management [8,9,10,11,12]. However, despite the increasing threat of terrorism, training for this type of threat and other disasters has been focused on health care professionals and has neglected to include medical students [8, 13]. There have been multiple papers describing the importance of training and educating healthcare staff at all levels. Including a paper in the BMC Medical Education journal in which “a competency-based approach with specific measurable objectives was proposed by a national expert panel for specific levels of disaster training” [14]. The article focuses solely on theoretical objectives and training exercises based on literature searches to identify courses that already exist. To our knowledge, this pilot program is one of the first to detail a replicable disaster training curriculum for the development of a medical student disaster response team, making University Medical Center one of the first medical schools in the nation to have an on-call Medical Student HazMat Team.
One of the most effective ways to practice, troubleshoot, and improve an emergency preparedness plan or protocol is through hospital-wide drills with various simulated incidents and patients [7]. Hospitals and providers that participate in more exercises tend to perform better on objective evaluation tools that have been developed specifically to evaluate the effectiveness of emergency preparedness protocols [13]. The curriculum presented here incorporates a simulation drill following didactic and operational training that is appropriate for medical students at any level of training. We believe that this structured approach is readily adaptable and can serve as a guide and resource for others.
Our experiences with training sessions and simulations have allowed us to discover three main areas for HMRT improvement: (1) equipment access, content, and organization; (2) practical skills and decontamination procedures; and (3) communication.
Equipment access, content, and organization
Durin5g the collection of the PPE, the medical students did not have the clearance to access the storage unit and were forced to interrupt an ED staff member to gain access. This cost the teams about 5 min and prevented another health care provider from performing his or her duties. Thus, it is important that the members of the Medical Student HazMat Team have the appropriate security clearance needed to access the necessary equipment and locations in the hospital. We also suggest a periodic equipment inspection by the team leaders to ensure that the equipment is always properly labeled and stored in an organized fashion. This will also reinforce their familiarity with the equipment.
In an actual Code Orange event that requires mass decontamination procedures, the staging area would be outside the ambulance bay while the decontamination area would be set up using the entire ambulance bay with floor to ceiling dividers splitting it up into three sections. One section would be for men, one for women, and one for families. There are connections in the ceiling for hooking hoses up to the water supply for decontamination. At the time of this drill, we were able to use the ceiling hoses in the ambulance bay but we did not have the dividers. We were able to decontaminate two victims at a time with two separate teams utilizing two separate conveyer belts.
Practical skills and decontamination procedures
During the decontamination portion of the simulation, the teams struggled with safely handling unconscious or non-ambulatory patients. Specifically, they struggled with the transportation and repositioning of unconscious patients from supine to prone. All of the team members were first- and second-year medical students, most of whom had not yet received proper training for transporting and maneuvering patients with possible spinal cord injuries. Thus, it is critical to incorporate these skills into the operational training so that team members can repeatedly practice safe patient handling while wearing the PPE suits. Other key skills that we believe should be addressed include handling of the hospital stretcher, basic life support (BLS), or advanced cardiac life support (ACLS).
Communication
The PPE suits made it very difficult for the medical students to communicate with one another. The suits muffled their voices, and the powered purifying respirator (PAPR) units created a steady hum that blocked out much of the surrounding noise. In addition, background noise from the hoses, sirens, patients, and other personnel all combined to make communication even more difficult. High-performance radio transmitters were utilized for every team member, but for some team members, they were difficult to use because they need at least one hand free to press the button that allows them to talk over the channel. This should improve with practice as team members become more comfortable using radio communication. It is essential that a team leader keeps the communication organized and in check, so as to allow all team members to be able to communicate clearly and effectively. When speaking through the radios in turn rather than all at once, communication between the medical students and with other integral members of the hospital personnel will allow for safer and more efficient decontamination. In light of recent threats of hacking of hospital systems, it is integral that these radio transmitters are encrypted to ensure patient privacy [15]. In the event of radio transmitter malfunction, it is also important to establish non-verbal signals that will allow team members to communicate basic information.
Limitations and future direction
There are several limitations in this process that will make future objective evaluation difficult. Although the curriculum incorporates both didactic and operational training and real-world simulation, single simulations only allow for brief practice with disaster medicine concepts and hazardous materials decontamination skills. Medical school hazardous materials response team curriculums should include periodic workshops and drills that will allow the team members to continuously improve their skills. The observations provided at this stage, while proving valuable for continued improvement of our program, do not quantitatively measure the effectiveness of the training, specifically as it relates to the medical students’ knowledge, skills, and team efficiency. Our plan is to start incorporating objective data and outcome measures in future drills and training sessions so that we can better evaluate the effectiveness of our program. We will likely start by creating and distributing standardized questionnaires to the medical students to evaluate their disaster medicine knowledge and assess skills gained through the simulated drills. We will begin to develop checklists that can be used by an outside observer during a simulated drill that will allow team leaders to quantitatively evaluate each step of the decontamination process. We also plan to video record future drills, allowing the leaders and team to review all positive and negative outcomes and reflect on each drill. Finally, since we do not have any objective data, we cannot provide any evidence that the program positively affects patient outcomes, and there is no evidence that involving medical students in real disaster situations affects patient outcomes. The foundation has been built, however, and with this team in place, we believe that future objective measures will show that medical student involvement in hazardous materials response teams and disaster medicine as a whole will improve both patient outcomes and the competency of the nation’s future physicians in responding to disaster scenarios.