1. Background
2. Character of a Nuclear, Biological, or Chemical Terrorist Event
   • Psychogenic casualties will predominate.
   • Responding personnel are at risk for personal injury and secondary contamination.
   • An intentional attack is a criminal event and “everything” becomes evidence.
   • A terrorist incident crosses all jurisdictions.
   • The level of violence associated with terrorist acts has produced more victims and higher mortality than is typically seen in natural disasters and hazardous materials accidents.
3. Definition of Terrorism
4. Current Trends in Terrorism
   • Nuclear
   • Biological
   • Chemical
   • Explosive/incendiary
5. Properties and Characteristics of Nuclear, Biological, and Chemical Weapons
   • Nuclear (radiation)
   • Ionizing (radiation)
   • Biological agents
   • Chemical warfare
6. Need for Preparedness

1. Background
2. Disaster Planning Misconceptions
   • Misconception #1: Disaster planning requires large mobilization of resources.
   • Misconception #2: Most of the medical care for disaster victims is provided by pre-hospital personnel.
   • Misconception #3: A disaster plan equals disaster planning.
3. Staff Protection
   • Personal Protective Equipment
   • Decontamination

1. Historical Challenges
2. Disaster Epidemiology
3. Psychogenic Casualties
4. Public Relations and the Media
5. Handling of the Dead

1. Readiness Phase
2. Planning Phase
   • Develop strategies to overcome resistance to preparedness
   • Participate in joint planning
   • Develop mutual aid agreements
   • Develop policies and procedures
   • Acquire necessary equipment
   • Stockpile antidotes
   • Take measures to ensure your hospital remains viable during a disaster
3. Recovery Phase

The Disaster Medicine and Response concentration is an immersive experience into medical management of disasters. The student will complete a series of encounters (field experiences), didactic lecture and seminars in addition to readings and a focused project in an effort to gain mastery into the functions of multiple agencies, organizations and individuals in preparation for emergencies and disasters. Particular emphasis will be given to the study of the interaction and cooperation among key agencies and medical disciplines.

Each student in the concentration will receive didactic lectures on the core topics of disaster medicine and response.  This seminar will take place 2 hours a week during the self-directed learning time in Year II.  The instruction for this seminar will be from a multidisciplinary faculty including the Departments of Emergency Medicine, Surgery, Medicine (Renal, Infectious Disease, Tropical Medicine), Psychiatry, Pediatrics and Toxicology.  The lectures could be held at the Emergency Medicine Conference rooms in Claverick or CORO (The medical Simulation Center) or at a site on the Brown Campus.  The core topics would include.  Medical Disasters, Systems to Respond to Healthcare needs during and after a disaster, National Incident Management System, Incident Command System, Weapons of Mass Destruction, Pandemic Influenza, Refugee health care (in cooperation with the Global Health concentration), Mental Health in disasters and after terrorist events, Syndromic surveillance, Hospital Surge Capacity, Evacuation, Care of Special populations, Community planning, Hospital disaster planning, Alternative care sites, Community-Government interface in disaster planning and response, Communications, Technology insertions (for detection, treatment and rehabilitation) Case studies (Tokyo Sarin, 9-11, SARS, US Anthrax, Katrina, Pacific Tsunami), medical team work training, the ethics of rationing care in large scale disasters (in cooperation with the medical ethics concentration).  

This seminar series will be supported by readings from textbooks, published manuscripts, policy statements and on-line training modules (FEMA: NIMS, ICS).  Students will have access to other lecture series and seminars during this time period and throughout their 4 years (Rescue Rounds-monthly, RI Disaster Medical Assistance Team Lecture series, monthly, etc.).  In addition grand rounds and related seminars will feature nationally recognized guest speakers.

Potential encounters would include attending disaster preparedness meetings at the RI Department of Health; Emergency Management Association, RI Hospital Disaster Preparedness Committee; Pandemic Flu planning at RIH and Brown. Other activities may include EMS time with Lifeguard Critical Care Transport Ambulance service, Simulation Center Experience, relevant Emergency Medicine Residency conferences. Potential field experiences include (depending on timing of events): participation at mass gathering events to provide health care with the Rhode Island Disaster Medical Assistance Team (Tall ships, Snickers Soccer Tournament, RIANG Airshow, etc.).  The annual Rhode Island Disaster Initiative Disaster Conference.  Field experiences in the offices of HHS and FEMA in Boston or Washington DC. 

1. To understand some of the misconceptions in disaster epidemiology- evaluated through 
2. To list essential components of hospital disaster preparedness.
3. Be able to describe the various types of chemical warfare agents and recognize the signs and symptoms of exposure.  
4. Be able to describe how to properly manage, decontaminate, and treat victims of a chemical attack.
5. Understand how to protect against the threat of cross-contamination by verifying the adequacy of patient decontamination.
6. Be able to describe the various types of radiological hazards.
7. Understand the acute health effects from radiation contamination and exposure.
8. Know the principles of self-patient rescue, triage, and transportation of radiation casualties.
9. Be able to describe the various types of biological warfare agents and recognize the signs and symptoms of exposure. The student will also be able to describe how to properly manage and treat infectious victims and know which agents are a risk for secondary transmission and how to protect against this spread using personal protective equipment (PPE).

Students will be evaluated on their participation in discussions of readings and lecture materials.  For final scholarly products, a review committee will be established.  The members of the committee will be chosen based on the specific project to include subject matter experts and a broad representation.  The committee will meet after receiving the final project and generate a consensus review.  The committee will also help the instructor advise the student as she/he is working to develop the project.

Disaster Medicine. Eds: Ciottone, Darling,Anderson,Auf Der Heide, Jacoby,Noji and Suner, Mosby 2006.
Medical Response to Terrorism: Preparedness and Clinical Practice. Eds: Keyes, Burstein, Schwartz and Swienton.  Lippincott Williams and Wilkins 2005.
Disaster Medicine Eds: Hogan and Burstein .  Lippincott Williams and Wilkins 2002.
The Great Influenza.  John M. Barry.  Penguin Group, 2004.
Holy Terror: Armageddon in Tokyo.  D.W. Brackett.  Weathehill, New York, 1996.
Emergency Relief Operations.  Ed. Kevin Cahill, MD.  Fordham University Press, New York, 2003.
Emergency Medicine Clinics of North America: Disaster Medicine.  Eds: Morres,Burkle, Lillibridge.  W.B. Saunders, Philadelphia, May, 1996.
Health and Medical Aspects of Disaster Preparedness. Ed: Duffy.  Plenum Press, New York, 1990.

References for the Crush Injury module are listed below as an example:

1. Zager RA. Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int1996; 49: 314–326
2. Ron D, Taitelman U, Michaelson M, Bar-Joseph G, Bursztein S, Better OS. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med1984; 144: 277–280
3. Lameire N, Matthys E, Vanholder R et al. Causes and prognosis of acute renal failure in elderly patients. Nephrol Dial Transplant1987; 2: 316–322
4. Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine1982; 61: 141–152
5. Poels PJE, Gabreëls FJM. Rhabdomyolysis: a review of the literature. Clin Neurol Neurosurg1993; 95: 175–192
6. Brumback RA, Feeback DL, Leech RW. Rhabdomyolysis in childhood: a primer on normal muscle function and selected metabolic myopathies characterized by disordered energy production. Pediatr Clin N Am1992; 39: 821–858
7. Bywaters EGL, Beall D. Crush injuries with impairment of renal function. Br Med J1941; 1: 427–432
8. Rutecki GW, Ognibene AJ, Geib JD. Rhabdomyolysis in antiquity. From ancient descriptions to scientific explanation. Pharos1998; 61: 18–22
9. Rizzi D, Basile C, Di Maggio A et al. Clinical spectrum of accidental hemlock poisoning. Neurotoxic manifestations, rhabdomyolysis and acute tubular necrosis. Nephrol Dial Transplant1991; 6: 939–943
10. Lopez JR, Linares N, Cordovez G, Terzic A. Elevated myoplasmic calcium in exercise-induced equine rhabdomyolysis. Pflügers Arch—Eur J Physiol1995; 430: 293–295
11. Lopez JR, Rojas B, Gonzales MA, Terzic A. Myoplasmic Ca2+ concentration during exertional rhabdomyolysis. Lancet1995; 345: 424–425
12. Lane JT, Boudreau RJ, Kinlaw WB. Disappearance of muscular calcium deposits during resolution of prolonged rhabdomyolysis-induced hypercalcemia. Am J Med1990; 89: 523–525
13. Shieh SD, Lin YF, Lin SH, Lu KC. A prospective study of calcium metabolism in exertional heat stroke with rhabdomyolysis and acute renal failure. Nephron1995; 71: 428–432
14. Odeh M. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N Engl J Med1991; 324: 1417–1422
15. Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med1990; 322: 825–829
16. Better OS. History of the crush syndrome. From the earthquakes of Messina, Sicily 1909 to Spitak, Armenia 1988. Am J Nephrol1997; 17: 392–394
17. Collins AJ. Kidney dialysis treatment for victims of the Armenian earthquake. N Engl J Med1989; 320: 1291–1292
18. Richards NT, Tattersall J, MacCann M, Samson A, Mathias T, Johnson A. Dialysis for acute renal failure due to crush injuries after the Armenian earthquake. Br Med J1989; 298: 443–445
19. Noji EK. Natural disasters. Crit Care Clin1991; 7: 271–292
20. Collins AJ, Burzstein S. Renal failure in disasters. Crit Care Clin1991; 7: 421–435
21. Baba S, Taniguchi H, Nambu S, Tsuboi S, Ishihara K, Osato S. The great Hanshin earthquake. Lancet1996; 347: 307–309
22. Kuwagata Y, Oda J, Tanaka H et al. Analysis of 2,702 traumatized patients in the 1995 Hanshin-Awaji earthquake. J Trauma1997; 43: 427–432
23. Oda J, Tanaka H, Yoshioka T et al. Analysis of 372 patients with crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma1997; 42: 470–476
24. Lameire N. Preliminary report of the action in Turkey of the International Society of Nephrology Renal Disaster Relief Task Force. Nephrol Dial Transplant1999; 14: 2614–2615
25. Sever MS, Erek E. Sincere thanks of Turkish nephrologists to their European friends. Nephrol Dial Transplant (in press)
26. van der Reijden HJ. Ervaringen met nierdialyse in het rampgebied van Armenië. Ned Tijdschr Geneeskd1989; 133: 567–570
27. Solez K, Bihari D, Collins AJ et al. International dialysis aid in earthquakes and other disasters. Kidney Int1993; 44: 479–483
28. Lameire N, Vanholder R, Clement J et al. The organization of the European Renal Disaster Relief Task Force. Renal Failure1997; 19: 665–671

Potential projects include:

1. Pandemic Flu Planning for Rhode Island – affects on altering standards of care.  Project may include surveys of ICU, ED directors; review of potential ethical considerations; review of plans from other jurisdictions, etc. culminating in a publication quality manuscript and a presentation of results and recommendations to the state DOH.
2. Evaluation of state preparedness.  With this project, the student could review evaluation methodology for preparedness activities used by FEMA, HHS and other agencies, modify the criteria and improve methodology and apply the new criteria to evaluate the state of preparedness for emergencies in Rhode Island.  The project could culminate in manuscript and report to the state EMA or DOH
3. Syndromic surveillance.  With this project the student could utilize the statewide syndromic surveillance database to determine if the parameters could be modified to use this platform to perform surveillance for trauma and other conditions.  The student will produce a publication quality manuscript and report to the state trauma care committee.
4. Technology to enhance disaster preparedness.  With this project, the student could review the literature for technology insertions which could improve disaster preparedness and response.  Working with the department of engineering at brown and with the Memorial Hospital center for bioterrorism and emerging pathogens, identify the projects which are currently under development and hypothesize potential applications for disaster response.  The project would culminate in a publication quality manuscript.

2009 Accepted Students & Scholarly Concentration Projects:

Maximum Number of Students

The number of students is only limited by the availability of funding for summer grants and availability of faculty to sponsor and mentor projects.  We have a large number of faculty available to mentor students in this concentration.

Faculty Mentors

Bruce Becker, Community Health; Andrew Artenstein, Medicine; Christopher Born, Orthopaedic Surgery; Michael T. Bailin, Anesthesiology; David M. Dosa, Geriatrics; Kim Boekelheid, Environmental Studies, The Watson Institute;  Kenneth Williams, Emergency Medicine; Angela Anderson, Pediatrics, William Kirkpatrick, Clinical Social Work, William Cioffi, Surgery.

Funding Opportunities (alternatives to Summer Assistantships)

Depending on the project funds could be available from DHHS, DHS or other agencies (unlikely).