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Then and now: How Sept. 11 shaped disaster response education

On the morning of Sept. 11, 2001, Kenneth J. Steier, DO, was on New York’s Long Island, making rounds at Nassau University Medical Center (NUMC) in the hospital’s cardiac care unit. On hospital TVs, Dr. Steier saw that the first plane had hit the World Trade Center. Like many others, he thought it was an accident.


Erin Philpott, OMS III, assists with stabilizing a “victim“ during disaster response training at RVUCOM. The medical school is the only one in the U.S. requiring all students to take both of the NDLSF’s Basic and Advanced Disaster Life Support courses. (Photo courtesy of RVUCOM)

Dr. Steier and his colleagues went to the top of the hospital building. Twenty stories up and 25 miles away from the World Trade Center, they watched giant clouds of smoke rising from the city. Dr. Steier and his staff heard about a second plane hitting, about planes crashing in other places, and quickly understood that this wasn’t an accident.

The hospital staff emptied beds to make space for victims and sent a team into New York by ambulance. But the bridges to Manhattan were closed, and most victims were treated locally, Dr. Steier says. Still, he and his staff were overwhelmed.

“Everybody knew people who worked at the World Trade Center,” he says. “If you didn’t know someone who worked there, you certainly knew people who were responding. We were worried about people who were responding because you could see all the smoke and soot, all the ground-up stuff that people were breathing.”

Dr. Steier eventually treated many of the attack’s first responders. A number of them were firefighters and policemen who lived on Long Island but worked in Manhattan. NUMC received state and federal grants to set up a 9/11 clinic where first responders could go for free medical treatment. A lot of the clinic’s patients worked at ground zero without masks and eyewear, which led to eye and lung problems and possibly cancer, Dr. Steier says.

9/11 drives change

Working with first responders after 9/11 informed his approach to medical education, says Dr. Steier, who was in charge of NUMC’s residency program at the time. Educators at many osteopathic medical schools were inspired by 9/11 to re-evaluate and ramp up their institution’s disaster prevention and response offerings. “Sept. 11 was a tremendous stimulus toward education in disaster preparedness,” Dr. Steier says. “People were very unprepared.” Along with increased drills, there was a boom in disaster response courses and a greater emphasis on preparation.

Dr. Steier learned there was a greater need for disaster preparation, and he incorporated that into the residency program at NUMC. He discovered and then taught his residents the importance of the complete history of a patient’s exposure to toxic environments.

Now a clinical dean and a professor at the Touro College of Osteopathic Medicine in New York City (TouroCOM), which opened in 2007 nine miles north of ground zero, Dr. Steier says TouroCOM integrated 9/11-related disaster response training into its curriculum. The school’s pulmonary module of the clinical coursework, for instance, includes a case presentation of a first responder to ground zero. TouroCOM also has a member of the New York City Disaster Response Team speak to the faculty and students each year, and it has a patient representing a ground zero first responder in its objective structured clinical examination lab.

“Sept. 11 was a tremendous stimulus toward education in disaster preparedness.”
Dr. Steier

Medical education expert Tyler C. Cymet, DO, says the proximity of the attacks underscored the importance of disaster medicine because it became clear that disasters of this scale could happen within U.S. borders, not just internationally.

“We’ve always had one hour of radiation exposure training in medical school, but it was more of an overview,” says Dr. Cymet, the associate vice president for medical education at the American Association of Colleges of Osteopathic Medicine. “Sept. 11 made it real. We need to know this because it might really happen here.”

Dr. Cymet, who treated some of the anthrax victims in the months following 9/11, says the attacks led to an increased focus on public health and prevention at osteopathic medical schools. He specifically points to the Institute for Disaster and Emergency Preparedness at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, Fla. Established in response to 9/11 with grant funding, the center puts out educational materials on bioterrorism and all-hazards preparedness for osteopathic physicians and students and other health care professionals.

On a broader scale, some osteopathic medical schools now offer elective or mandatory courses developed by the National Disaster Life Support Foundation (NDLSF) in response to 9/11. The courses provide an overview of disaster management, prevention and preparation concepts as well as information about federal, state and local disaster response systems. Osteopathic medical schools are leading the charge in offering the courses, says Italo A. Subbarao, DO, the recently departed director of the Public Health Readiness Office at the American Medical Association.

Lifelike drills, real-world exposure

Rocky Vista University College of Osteopathic Medicine in Parker, Colo., made headlines recently for its disaster drills. It’s the first medical school in the country to incorporate what’s called a “cut suit” into its disaster response education. Usually worn by an actor, the lifelike costume can bleed and be arranged to simulate wounds such as those from gunshots, explosions and stabbings. Students can use the suit to practice performing surgery, applying tourniquets and other procedures.

Resources: Disaster response

  1. NSU-COM’s Institute for Disaster and Emergency Preparedness offers free CME courses on all-hazards preparedness to health care professionals.
  2. National Disaster Life Support courses teach health professionals the principles of all-hazards disaster response.
  3. Physicians can apply to join a federal Disaster Medical Assistance Team, where they will learn national disaster response procedures and have the opportunity to provide treatment during a disaster.
  4. Volunteering with a local Medical Reserve Corps chapter is a way to stay in tune with disaster response in one’s community.
  5. The Federal Emergency Management Agency’s Community Emergency Response Team Program educates civilians about disaster preparedness and response where they live.

RVUCOM is also the only medical school in the U.S. requiring all students to take both of the NDLSF’s Basic and Advanced Disaster Life Support courses. Bruce D. Dubin, DO, the acting president and dean of RVUCOM, says his interest in disaster medicine was sparked after 9/11 when his then-boss, Ronald R. Blanck, DO, the former surgeon general of the U.S. Army, encouraged his interest in researching first response medicine and weapons of mass destruction.

Around the same time, Dr. Dubin was seeing his students on clinical rotations in rural areas. They were often asked to work as or with first responders in local disasters—for instance, an overturned truck on the freeway, a house fire, a tornado. Hearing their stories made Dr. Dubin realize that all medical students could benefit from learning disaster response skills.

Dr. Dubin then developed an advanced disaster training program for all students at the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth, where he was working. He brought the program with him to RVUCOM, where he expanded it.

“Disasters can and do happen anywhere and everywhere,” Dr. Dubin says. “We have to be prepared for these kinds of things on U.S. soil.”

Students worked in a mock emergency room in one of the most recent RVUCOM drills, says Regan A. Stiegmann, OMS III, the president of RVUCOM’s 2014 class. A UH-60 Black Hawk helicopter flew in and students off-loaded a dummy casualty, then triaged three patients with simulated injuries. One wore a cut suit. The students in the mock ER had about 5 minutes warning and no prior knowledge of the patients’ injuries, which included an artery laceration, shrapnel wounds and a blast injury. Everything happened in the span of 30 to 45 minutes—just as it could in real life.

“It put you in a position where you could see what it’s really like,” Stiegmann says, “because the actors were painted, and they had glass shards sticking in their face, or they had an arm blown off, or they were unconscious. You got the full gamut of what you would really see in a disaster.”

‘Not too much to ask’

While 9/11 and other disasters prompted a number of osteopathic medical schools to offer more disaster medicine courses, many U.S. medical students do not feel they receive adequate disaster training, according to a 2009 survey published in Disaster Medicine and Public Health Preparedness.

All osteopathic medical schools should offer disaster response courses in their curriculum, says William Bograkos, DO, a member of the AOA’s Bureau of Scientific Affairs and Public Health and a veteran of disaster medicine. At this point, the profession’s 26 schools have not incorporated a standard set of disaster course work, he says.

“We should have some learning objectives,” he says. “Two hours of disaster medicine is not too much to ask.”

In 2011, the AOA House of Delegates approved a resolution calling for osteopathic medical schools to offer disaster response training and courses. The resolution was co-written by Dr. Bograkos and submitted by the Bureau of Scientific Affairs and Public Health; in it, the team cited the increasing incidence of man-made and natural disasters worldwide. Disaster response typically requires a different skill set than standard emergency care, the authors noted.

“Most of the time, people think disaster medicine, they think lights and sirens, emergency medicine,” Dr. Bograkos says. “But public health plays a very important role because of water, immunization, food, shelter, and basic needs.”

The bureau’s intent, Dr. Bograkos says, was to encourage young physicians to consider disaster preparedness, as they are all likely to work in disaster scenarios at some point in their careers.

Views from ground zero

Two physicians who provided osteopathic manipulative treatment at ground zero after 9/11, Terrence M. Mulligan, DO, and John B. Caramagna, DO, also believe all medical students should learn basic disaster response skills, though neither physician received disaster training in medical school.

Dr. Caramagna

John B. Caramagna, DO, provides osteopathic manipulative treatment to a firefighter at ground zero on Sept. 15, 2001. (Photo courtesy of Dr. Caramagna)

Dr. Mulligan, who had completed an emergency medicine residency prior to 9/11 but was working as an osteopathic manipulative medicine resident in the Bronx that day, says physicians might be surprised by when they need to apply disaster training.

“We always think of disasters being a tsunami or a 9/11, but maybe it’s a school bus accident, and all of a sudden 30 kids pull into your ER,” Dr. Mulligan says. “A place that’s designed to see eight new patients an hour can be easily overwhelmed by something like an apartment building fire.”

Medical students and physicians should know their institution’s and their community’s disaster response procedures, Dr. Mulligan says.

“If you don’t know what to do in order to get more help and more resources, how to activate a disaster plan, then the patients aren’t going to do well,” Dr. Mulligan says. “So it’s worth it to teach all students at least an introduction.”

Dr. Caramagna agrees. Students and physicians who don’t typically work in emergency settings will be well-served to know their local disaster plans, including who will be in charge and where they as physicians fit in, he says.

“A medical professional who is not skilled in disaster management and doesn’t practice it every single day needs to take a disaster response course,” Dr. Caramagna says. When volunteering, it’s best if novices follow the instructions of those who practice disaster response daily, he says.

Also, osteopathic physicians should be aware that they’ll have something special to contribute in a disaster’s aftermath, Dr. Mulligan says.

On Sept. 11, after a morning of learning of colleague’s deaths, trying to locate his friends, and processing what had happened, Dr. Mulligan was talking about the attacks with a fellow resident and DO. When she started crying and ran outside, Dr. Mulligan followed her. Watching the smoke emcompass Manhattan, the pair decided what they were going to do.

“I remember her saying, ‘I just feel so helpless,’” Dr. Mulligan says. “And I said, ‘You’re a doctor, there’s a tremendous amount you can do.’”

The next day, they went to ground zero, where they spent several days a week for three months providing osteopathic manipulative treatment to first responders.

“We really felt like we were contributing because we were providing a service as osteopathic physicians,” Dr. Mulligan says. Physicians in other specialties, he says, had less to offer in the weeks after 9/11 as fewer people required serious medical treatment, but the need for osteopathic manipulation was constant.

The next 9/11

Dr. Steier says he hopes all physicians and medical students will use the knowledge gained from past disasters to better prepare for those yet to come. He says it’s important for the osteopathic medical profession to avoid becoming complacent as 9/11 recedes further into the past.

“We have to make sure to do adequate drills so that we are prepared,” he says.

Disaster response training has made Stiegmann and her classmates at RVUCOM think about future disasters and how to best deal with them, she says. They wonder what the next HIV, the next 9/11 might be, and how they’ll be able to help.

“Nobody can predict the future,” Stiegmann says, “But being as prepared as possible for it is always the best strategy.”