Design and implementation of a medical student hazardous materials response team: the Medical Student HazMat Team

In response to the increasing threat of terrorism in the USA, the Association of American Medical Colleges (AAMC) called for better coordination between medicine and public health, as well as the incorporation of disaster education into medical education curricula [1]. Health care experts found this to be highly relevant, and have consistently shown support for the proposed addition of disaster education; furthermore, they have supported increasing the role of medical students in disaster relief efforts [2, 3]. Moreover, polls have shown that the public often turns to their health care providers for guidance in cases of public health emergencies [1, 4, 5]. Even though the US terrorism index is at its highest in the past decade, the majority of medical schools in the USA still lack organized disaster medicine education, and few programs worldwide involve medical students in emergency response teams [6].

The number of host national and international health care providers trained to respond to disaster situations is very limited and can be easily overwhelmed [7]. Thus, medical student training to respond to these unfortunate scenarios should be of the upmost priority. Their involvement can be used to provide much-needed human resources, and previous studies have shown that early involvement is essential in building a strong foundation and adopting a life-long passion for the topic [1, 2]. In response, our team designed and implemented a replicable disaster-training curriculum for the development of the hospital’s first medical student hazardous materials response team. We understand that available resources can vary greatly at different institutions, but we believe that the most important aspects of this training process are quite generalizable and that the processes detailed here can serve as a structured guide and resource for other institutions to implement similar programs.

In May 2016, the Medical Student HazMat Team joined our host academic hospital in participating in a citywide drill that simulated a large scale aerosolized release of Bacillus anthracis. The exercise was designed to address multiple Hospital Preparedness Program (HPP) capabilities and evaluate improvements based on information learned during 2015 hospital response efforts. The objectives focused on optimizing strategies in managing massive medical needs, coordination between emergency operations at different hospitals, information sharing, responder health and safety, and volunteer management. This citywide drill was used as an opportunity to run a small-scale Hazardous Materials Response Team (HMRT) decontamination simulation in the ED with our recently trained first-year and second-year medical students.

With 28 medical students present at the drill in May, 25 of the students performed the duties required by the simulation, while the three team leaders led the separate sections of the exercise including donning and doffing of the equipment, proper decontamination of the victims, and effective collaboration with the Emergency Department staff. The leaders worked alongside the HazMat Branch Director to ensure that all protocols were followed precisely. Due to the limited time available to initiate and complete the drill, and because the medical students had other various responsibilities, it was necessary to allow the students a 6-h window to receive a Code Orange notification and arrive at the ED for the simulated Code Orange.

Participating students were warned that they would be called in sometime between 0900 and 1500 and the day of the drill. At 0930, the team leader utilized multiple communication modalities to notify the students via email, group SMS text message, and a pager system that a Code Orange had been initiated. All modes of communication were confirmed to have been received within 5 min of sending the message, and all students arrived in the Emergency Department within 20 min of the initial notification. The team leader was informed beforehand by a Code Orange page and was waiting at the decontamination station. Other communication modalities that were considered but not used include phone trees, host hospital’s internal alert system, and social media outlets. Once all the students arrived, the personal protective equipment had to be transported from the storage closet to the staging area.

Students were broken up into five groups of five at the time of the drill, and each group had the opportunity to fully don the equipment, run through the decontamination simulation, and then safely doff the equipment. A buddy system was used so that each student had help with the proper donning and doffing of equipment. Each group then worked as a single unit to decontaminate three dummy patients: an infant, a child, and an unconscious adult. The dummy patients were dressed in hospital gowns, so the students had to first remove them with trauma shears before beginning the decontamination. Shaving cream and toothpaste were used to represent the hazardous material exposure and were distributed throughout the body including on the sites that are difficult to decontaminate such as behind the ears, behind the knees, and the axilla. Each team member rotated through the various roles with each dummy patient: cutting off the patient’s clothing, scrubbing the patient, flipping and handling the patient to clean the difficult sites of exposure, rinsing and drying, and preparing the patient for transport into the cold zone. Students had a difficulty in properly flipping the mannequins safely according to the training protocol, especially the adult mannequins that were larger in size.

At the end of the drill, each student’s mannequin was assessed for satisfactory decontamination. From start to finish, the five groups of students were able to fully decontaminate the mannequins in an average time of approximately 10 min (Fig. 2). In a true decontamination scenario, it is more efficient to assign each team member to a single role, which allows for safe doffing of the equipment after completing his or her task. But in this drill, the rotation allowed every team member to experience each task while maneuvering around in the PPE suits. Spending an extended period of time exerting oneself while inside the suit can put the team members at risk of feeling dizzy, nauseous, and overheated, so we recommend limiting the time inside the suit to no more than 45 min. This is not a firm limit, however, and can be adjusted based on the weather and level of exertion required in the response to a given hazardous materials event. Additionally, we recommend monitoring the vital signs of the team members before donning and after doffing the suits. It is also continuously emphasized during training and simulations that team members should immediately remove themselves from a decontamination situation, whether real or simulated, if they do not feel well and are at risk of compromising the safety of themselves, their teammates, or the patients. It is also important for team members to monitor each other to monitor for any signs of fatigue.

Many countries have invested in various research projects that aim to improve the efficacy of disaster management [8–12]. 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.

According to the national security experts, it is not a matter of if a terrorist attack will take place on US soil; it is a matter of when [16]. However, despite this increasing threat, the majority of medical schools in the USA still lack organized disaster medicine education. In response, we designed and implemented a pilot program for the development of the first-ever on-call medical student hazardous materials response team. The program detailed here, while still in its early workings, allows students to develop critical knowledge and practical skills in the realm of hazardous materials response and provides the groundwork and opportunity for further study of the effects of incorporating medical students into various roles on disaster medicine response teams.