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ARTICLE |
a San Antonio Military Pediatric Center
b Department of Clinical Investigations, Wilford Hall Medical Center
c San Antonio Military, Pediatric Center, Lackland Air Force Base, Texas
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. A survey was e-mailed to a comprehensive list of all US pediatric, family practice, and emergency medicine residency programs 3 times between September 2003 and January 2004. The survey measured the perceived risk of terrorist attack, level of training by type of attack, level of training regarding children, method of training, and barriers to training.
RESULTS. Overall, 21% of programs responded (46 of 182 pediatric, 75 of 400 family practice, and 29 of 125 emergency medicine programs). Across all of the event types, emergency medicine programs were more likely to report adequate/comprehensive training. However, <50% of emergency medicine programs report adequate training for children. Didactic classroom-based lectures were the most commonly used method of training. Emergency medicine programs were more likely to use scenario-based exercises. Among programs that use scenario exercises, 93% report that they never (40%) or only sometimes (53%) incorporate child victims into the scenarios. Time, funding, access to subject matter experts, and availability of training material are the most important barriers to effective training.
CONCLUSIONS. Children are a precious national resource and a vulnerable population in disasters. Despite the availability of terrorism preparedness funding, these data suggest that we are failing to provide adequate training to front-line providers who may care for children in a catastrophic domestic terrorist event.
Key Words: terrorism • residency training • medical education • child • pediatrics • emergency medicine • family practice • biological agents • chemical agents • thermomechanical explosions • radiation
Abbreviations: EM—emergency medicine • FP—family practice
Events of the last few years have made domestic terrorism a real threat that has focused policy makers and the public on our need to engage in emergency preparedness planning and training with the goal of developing effective response systems. Consequently, there has been significant allocation of funding to homeland security and the public health system. Front-line physician providers who would have first or early contact with casualties are an important component of any emergency preparedness plan.
The potential modes of attack used individually or in combination include dispersal of biological agents, chemical agents or radiation, and thermomechanical explosions. The potential victims of an attack reside anywhere in our nation and include children at least in proportion to their numbers in our population. Some evidence suggests that terror groups have considered directly targeting children to maximize the psychological impact of an attack. Children have unique vulnerabilities to many weapons of terror and introduce significant additional logistic consideration in a mass casualty event.1 Front-line providers need to have adequate training to understand the emergency response structure, to participate in local disaster planning initiatives, and to recognize and treat potential casualties, including children.
We conducted a survey of pediatric, family practice and emergency medicine residency programs in the United States to assess the current state of terrorism preparedness training in their residency curricula to include preparedness for child victims. We also assessed what factors were associated with a strong terrorism curricula and what barriers existed to establishing effective training.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Data for program size for nonresponding programs were collected using the American Medical Association FRIEDA Web site2 for residency programs. Data for population size were derived from the US Census Bureau 2003 estimates.3 When a smaller town/city fell within a major population density area of a major metropolitan area, it was assigned the population size of that major city.
Survey Instrument
A survey instrument was developed to address 4 main goals. The first was to evaluate the extent to which residency programs have incorporated terrorism response training into their curriculum, including child specific training. Adequacy of training was assessed using the dichotomous variables of "no/minimal training" or "adequate/comprehensive training."
The second goal was to determine whether the program's perceived risk of attack in the community, city size, or program affiliation (university, community hospital, or military) was associated with a higher likelihood of having adequate/comprehensive training and whether certain features of the community increased their perceived risk. Perceived risk was assessed using a 4-point scale (1: no risk, 2: minimal risk, 3: moderate risk, and 4: high risk).
Third, we wanted to describe the educational methods in use as part of existing terrorism response curricula. Finally, the survey sought to describe the barriers perceived by programs to the incorporation of training. The survey was pilot tested via e-mail to several academic physicians and content modified to improve clarity before final mailing.
Analysis
We used the Pearson 
2 test to look for significant differences between variables. When the number of respondents in a category was low, the Fisher's exact test was used. Comparisons made included perceived risk with city size, as well as adequacy of training with program type, perceived risk, and program affiliation. Barriers to incorporation of training were also reviewed. SPSS software (SPSS, Chicago, IL) was used to facilitate calculations, with statistical significance set at the P < .05 level.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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When asked to describe their perceived risk for the 4 major types of terrorist events, 37% of programs reported a moderate-to-high degree of risk for a thermomechanical event in their community, 29% for chemical, 58% biological and 37% for radiation. City size >500000 significantly correlated with a moderate-to-high perceived risk for a bioterrorist event (P = .006) but not for other forms of terrorism. Forty-seven percent of programs responding felt that being a population center increased the perceived risk of potential attack. Fewer programs (19%–28%) cited another feature of their location (ie, major transportation hub, presence of military in the area, presence of local industry, or other) as contributing to their risk.
Adequacy of Current Training
Respondents were asked to characterize the degree (no/minimal or adequate/comprehensive) to which their program currently includes general training in the clinical recognition and management of victims in each of the potential types of events (Table 2). Across all of the event types, EM programs were far more likely to report adequate/comprehensive training. However, when asked whether their training specifically addressed the unique vulnerability, disease manifestations, or management of child victims, the proportion of EM programs reporting adequate/comprehensive training significantly decreased (Table 2).
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When comparing adequacy of training by program affiliation, military-affiliated residency programs were more likely to report that they have incorporated adequate or comprehensive terrorism response training into their curriculum (Table 3). Training in biological sources of terrorism was the only category without a significant difference among the 3 types of program affiliations.
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Barriers to Training
Table 5 describes the various barriers, reported by program type, that limit incorporation of ideal general terrorism response training and pediatric or child-specific training into their curriculum. Availability of educational time is the most frequently reported barrier followed by availability of funding. Access to subject matter experts and availability of training material are important barriers for pediatrics and FP but are significantly less problematic for EM. However, when considering child-specific training, these barriers are reported more frequently, even among EM programs. Nearly one third of all of the programs indicated that lack of interest or perceived need remains a barrier to incorporation of ideal training.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Respondents to our survey indicated a belief that large population centers live under a greater risk of attack. However, the validity of this notion may also be challenged. Experts who view toxic industrial chemicals as a significant vulnerability note that these agents are stored and transported often with little security throughout our nation wherever there are industrial plants, railheads, or ports, making many small communities vulnerable.6 In 1999, the Federal Bureau of Investigation thwarted a terrorist explosive attack on an industrial site in California that would have affected a large suburban residential area.7 Commercial nuclear power plants, potential terrorist targets, are also traditionally located away from our largest population centers. Small communities, like Dalles, OR, where a fringe political group dispersed a bioagent into the food supply to disrupt local elections, can be victims of a biological attack.8 The perceptions of risk (both in type and location of attack) expressed by our respondents, educators in EM, FP, and pediatrics, may reflect a common but inaccurate understanding of our societies true vulnerabilities. To the extent that these educators shape the curriculum in their own programs, these misperceptions can lead to misdirected education in terms of content or urgency.
Previous studies assessing terrorism training in residency focused primarily on bioterrorism preparedness. A 1998 survey on the adequacy of bioterrorism preparedness training in EM programs found that 53% reported formal training in this area.9 In 2001, a survey of family physicians in practice found that 18% had previous training in bioterrorism preparedness.10 We could find no published studies of terrorism training among pediatricians or pediatric residents. Our current study indicates that EM programs have made the greatest strides in developing and implementing training, with 83% of EM respondents reporting adequate to comprehensive bioterrorism training and a similar level of training for other events. In 2001, an Emergency Medicine Task Force set out to "assess the needs, demands, feasibility, and content of training for US civilian emergency medical responders" to include EM physicians. The task force concluded that training in response to weapons of mass destruction must be part of the core education of emergency physicians, as well as part of continuing medical education.11 Recommendations for EM resident training specifically included instruction at the "performance level of proficiency" so that "skills can be practiced, demonstrated and maintained." This level of instruction is most often associated with scenario exercises involving multiple providers and mimicking real-life events. Our data suggest that EM programs have a significantly higher degree of incorporation of performance-level training.
Do other specialties need the same degree of preparedness? A report on the EM workforce in 1998 indicated that 40% of physicians working in emergency departments in the United States were not EM trained or certified but were trained/certified in other primary care specialties like family medicine, internal medicine or pediatrics.12 Many hospital mass casualty event plans rely on the physician workforce throughout the hospital to supplement the emergency department. The 1995 Sarin gas attack on the Tokyo subway highlighted yet another unexpected facet of required preparedness. Only 10% of the 5000 casualties arrived at hospitals via the Emergency Medical Services system.3,13 The remainder found their way to hospitals by walking, taxi, or other conveyance and, thus, were not triaged or decontaminated by emergency medical technicians before arrival. Thus, the hospital-based workforce or those who might volunteer to assist at a hospital during a disaster must have an understanding of even prehospital management skills. Even where the emergency department is well staffed with EM-trained physicians, augmentee providers during a mass casualty can expect to have key roles in triage, decontamination, and nonurgent care, as well as the inpatient management of casualties after initial resuscitation and stabilization in the emergency department.
However, not all weapons of mass destruction events are likely to present as a traditional mass casualty event that concentrates casualties in time and place. In a Journal of the American Medical Association editorial in 2002,14 leaders at the Centers for Disease Control and Prevention cautioned that because infectious agents have incubation periods, bioterrorism victims might present remote in time and location from the "attack/site of release" to any primary care provider. Consequently, all clinicians must have sufficient knowledge of the agents of bioterrorism to recognize a compatible illness, initiate a diagnostic plan, and report their suspicion.
With the recognition that the entire future physician workforce must be prepared for all forms of terrorism, the Centers for Disease Control and Prevention and the Association of American Medical Colleges partnered to convene a panel of experts to provide guidance for a terrorism curriculum to be incorporated into medical school education.15 The Association of American Medical Colleges further urges residency training programs to "identify and integrate immediately appropriate course work for all their resident physicians on how to respond to biological, radiation, and chemical terrorism." The new draft curriculum guidelines written by the Pediatric Residency Review Committee and implemented on July 1, 2005, for the first time contain a specific mandate to incorporate terrorism preparedness training into pediatric resident education.16
Unfortunately our data suggest that despite a need recognized by some educators, pediatric and FP residency programs currently have very limited incorporation of terrorism response training. Of particular concern is the lack of incorporation of specific training directed at the management of the child victim. Report of child-specific training was low even for EM programs. Among all of the programs reporting performance-level training via scenario exercises, 94% reported that they never or only sometimes have child victims in the scenario. This relative deficit in preparing for mass casualty events involving children cannot be explained by a reasonable belief that terrorists would avoid children as targets. A senior Al-Qeada leader has said, "We have not yet reached parity with [the Americans]. We have the right to kill 4 million Americans-2 million of them children."17 A Homeland Security bulletin indicates that "Al-Qeada favors spectacular attacks that meet several criteria: high symbolic value, mass casualties, severe damage to the American economy and maximum psychological trauma."18 Clearly, maximum psychological impact can be achieved through mass casualty events targeting children as we have witnessed through the hostage taking in a school in Beslan, Russia, in September 2004, where >1000 hostages were held and >100 school children ultimately killed.
If we must face the reality that children are potential intentional targets, is child-specific training or preparation necessary? Numerous medical authorities have convened panels and enumerated the many ways that children present unique challenges in effective terrorism response.1,19–21 The developmental limitations of a child may make them unable to flee when appropriate or respond to emergency response personnel, thus increasing their exposure risk in any event. Children are more vulnerable to the effects of exposure to many potential agents because of their physical characteristics (size, surface area/mass ratio, and metabolic and respiratory rates). These same factors affect their treatment needs in terms of decontamination, medications/antidotes, and equipment requirements. Because many treatments were developed in the context of military preparedness, there is very limited evidence-based understanding of appropriate treatment algorithms for the management of child victims, and expert panel recommendations are perhaps not widely known. The presence of children as casualties greatly complicates the logistic planning for an event often necessitating higher staff/patient ratios to accommodate for unaccompanied child patients. Children also have unique mental health needs both in the immediate aftermath of an event and in the long-term consequence management. Individual providers, as well as health care systems, need to be prepared for these special requirements as well.
The most frequently reported barrier to training was availability of educational time. An ever-expanding body of medical knowledge combined with mandated limitations on duty hours has made additions to residency training curriculum very difficult, even when a need is perceived. Because so many, and often more immediate, issues compete for training priority, curriculum mandates expressed via residency review committee requirements may be the only effective way ensure adequate attention to terrorism preparedness. Availability of funding to provide training was another significant barrier. In 2003 the Health Resources and Services Administration offered competitive grants for the development of terrorism training curriculum in health professions schools, and 13 institutions were awarded more than $4 million. Unfortunately, funding was inadequate to continue or expand the program in 2004. However, even if this program were reinstated, dispersal of funding via professional schools and universities may have less impact on nonuniversity-affiliated or community hospital-based residency programs.
The limitations of the survey would include the overall survey return rate of 21%, although each specialty was represented fairly equally with return rates ranging from 19% to 25%. Respondents represented a good cross-section of program and city size, and, thus, the response was reasonably distributed in these areas (Table 1). Responses were from the program director or a program representative and, thus, represent personal perceptions and opinions.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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FOOTNOTES |
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Address correspondence to Shelly Martin, MD, Hasbro Children's Hospital Child Protection Program, 593 Eddy St, Potter Basement 005, Providence, RI 02903. E-mail: smartin5{at}lifespan.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
As first author, Dr Martin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
The opinions and views expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army or Air Force, the Department of Defense, or the US Government.
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This article has been cited by other articles:
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  E. P. Schobitz, J. M. Schmidt, and M. P. Poirier Biologic and Chemical Terrorism in Children: An Assessment of Residents' Knowledge Clinical Pediatrics, April 1, 2008; 47(3): 267 - 270. [Abstract] [PDF]
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