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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 57-61

Simulating a disaster: Preparing responders in India

1 Department of Emergency Medicine, Division of International Emergency Medicine, Columbia University Medical Center, New York, USA
2 Department of Emergency Medicine, Division of International Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
3 Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA

Date of Submission09-Jul-2018
Date of Acceptance26-Sep-2018
Date of Web Publication23-Apr-2019

Correspondence Address:
Dr. Benjamin Kaufman
622 West 168th Street, New York, NY 10014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_28_18

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Objective: This study evaluates the effectiveness of a novel modality created by our team to teach disaster preparedness consisting of tabletop drills and disaster simulation. Based on the Incident Command System (ICS) framework, our system prepares medical providers to respond independently to country-level disasters.
Background: Disaster response remains an important component of emergency preparedness internationally. To this end, the ICS provides a standardized approach to the command, control, and coordination of emergency response.
Methods: A 2-day workshop was conducted with medical providers in Bangalore, India, that used serial disaster simulations to improve disaster response using the ICS. Through increasing responsibility and self-directed tabletops, the participants (doctors, medical students, nurses, and police) gained the skills to respond independently to a simulated countrywide disaster. After the exercise, they were asked to grade the usefulness of simulation and lectures.
Results: Forty-four providers responded to the questionnaire, all of which (n = 44, 100%) recommended the course. They graded the final disaster drill as most useful (n = 36, 82%) and also graded lectures from topic experts as useful (n = 36, 83%). Based on qualitative written feedback, participants felt drills helped them in communication and leadership.
Conclusion: This novel teaching modality, using simulation and tabletop drills, is an effective tool to teach the ICS to medical providers. Participants felt that they benefitted from training and would respond better to future disasters.
The following core competencies are addressed in this article: Systems-based practice, Patient care, Interpersonal and communication skills.

Keywords: Disaster response, Incident Command System, international emergency

How to cite this article:
Kaufman B, Jarrett B, Daniel P, Freedman J, Bloem C, Arquilla B. Simulating a disaster: Preparing responders in India. Int J Acad Med 2019;5:57-61

How to cite this URL:
Kaufman B, Jarrett B, Daniel P, Freedman J, Bloem C, Arquilla B. Simulating a disaster: Preparing responders in India. Int J Acad Med [serial online] 2019 [cited 2023 Mar 28];5:57-61. Available from: https://www.ijam-web.org/text.asp?2019/5/1/57/256799

  Introduction Top

Disaster preparedness is increasingly important in the modern age. Technology creates devastating weapons, travel increases the spread of disease, and climate change worsens natural disasters. The concepts of disaster response and the specialty of disaster medicine are essential to emergency medicine practitioners worldwide. Although training is mandated by international regulatory bodies and state actors, there remains a challenge in disseminating training to communities. This study aims to fix this gap through a novel teaching modality created to teach disaster preparedness using the Incident Command System (ICS) framework. We hypothesize that providers who are not familiar with these systems can improve response to a disaster setting using this framework.

The specialty of disaster medicine emerged in the 1980s,[1] incorporating principles from different disciplines, including emergency medical services (EMS) and public health. It is meant to provide care for injured victims in disasters using available resources. A disaster medicine practitioner aims to go beyond the hospital and emergency room in a disaster to manage the entire disaster cycle of prevention, preparedness, response, and recovery. In 1976, the American College of Emergency Physicians released a policy statement describing the role of emergency physicians in a disaster. In 1990, the first core curriculum for disaster medicine was proposed in the United States.[2] Since this time, fellowships have trained emergency medicine providers in the field of disaster management, leading to improved care for the patients in a disaster.

The ICS framework originated in 1968 at a meeting of Fire Chiefs in Phoenix, Arizona.[3],[4] This system was used to fight wildfires in California and Arizona and was further developed following catastrophic wildfires in California. It seeks to allow a disparate group of agencies to work together, preventing their specific training and procedures from clashing with each other. The ICS framework enables flexibility and a clear chain of command in these incidents. Since this time, the ICS framework has become a model for command structures at major incidents in the United States. In 2004, the Department of Homeland Security developed the National Incident Management System that incorporated the ICS. At present, the Federal Emergency Management Agency has expanded the ICS into its National Response Plan, and in practice, almost all EMS and disaster agencies in the United States use the ICS. In addition, the United Kingdom, New Zealand, Canada, and Australia have adopted this system, and the United Nations has recommended the use of the ICS as an international standard in disaster management and preparedness.

In 2015, the United Nations met in Sendai, Japan, for the Third UN World Conference on Disaster Risk Reduction. In this conference, the United Nations Office for Disaster Risk Reduction put forward four priorities for action set forth in the Sendai Framework.[5] These priorities mimic the four stages of the disaster cycle – understanding disaster risk, investing in risk reduction, enhancing preparedness to improve response, and “building back better” to recover from disasters.

In India, the Disaster Management Act of 2005 created the institutional and coordination mechanisms for effective disaster management at the national, state, district, and local level.[6] This created the National Disaster Management Authority as well as State Disaster Management Authorities and District Disaster Management Authorities. The recently created National Disaster Management Plan[6] establishes national practices for disaster management. This plan uses the Sendai Framework from the United Nations' Third World Conference on Disaster Risk Reduction to guide the country of India through the ICS and the four stages of disaster management: prevention, preparedness, response, and recovery. To this end, disaster management in India is progressing toward adoption and use of the ICS framework.

Unfortunately, in India and other low- and middle-income countries (LMICs), this national commitment often fails to reach the communities affected by disasters on the ground. In May 2017, the Supreme Court of India criticized many states for not complying with the Disaster Management Act of 2005.[7] This was evident in the states of Assam and Gujarat in 2017 where over 200 deaths were reported during recent floods.[8] It is likely that improved weather forecasting, team deployment, and proper training at the grassroots level of medical providers will improve response. However, there remains a need for medical training in disaster response at the health-care provider level.

  Study Design and Methods Top

INDUSEM is an academic partnership that began with the INDO-US ER Trauma collaborative, spearheaded through the All India Institutes of Medical Sciences that has championed emergency medicine as a recognized specialty in India, achieving board certification in 2009. Each year, this collaborative holds a conference to bring together academic innovators in emergency medicine and trauma to advance the specialty in India and to further advance academic medicine in India. The conference brings together leaders in emergency medicine and trauma from the United States and India to exchange ideas and improve acute care systems and health-care delivery.

In this setting, our group conducted a workshop on disaster training at the 2016 conference in Bangalore, India. This 2-day workshop used simulation and controller facilitated learning to teach disaster preparedness to a group of medical providers from India. The workshop draws on the ICS framework and uses interactive and self-directed learning to enhance concept retention and improve participation. Through tabletop drills, the participants (doctors, medical students, nurses, and police) gain the skills to respond independently to a simulated countrywide disaster.

Using the ICS framework, participants are taught how to create a risk assessment and hazard vulnerability analysis. Then, the disaster team is created through the Incident Command Center with specific roles including an incident commander, safety officer, liaison officer, operations officer, and information officer. Together the team identifies local and community resources that could supply materials and people to assist in disaster response as well as national and international agencies to help coordinate the response.

To enforce the lessons of this framework, 2 days of lectures, interactive simulations, small-group sessions, and tabletop drills were created. The 1st day focused on small-group sessions with tabletop drills designed to enhance teamwork and creative thinking. During this day, cohesive teams were created and these small groups had to find workable solutions to simulated disaster exercises.

In the 2nd day, a disaster manual was introduced to the participants. This manual described multiple cities in India, for which each team took charge. These cities had specific populations, physical infrastructure, and nearby resources in health care and logistics. Each city had experienced disasters previously, and the teams were responsible for preparing these cities for future disasters using the ICS framework. They created a city-specific risk assessment and hazard vulnerability analysis as well as an incident command team with specific roles and mutual aid agreements between cities and local resources.

At the end of the 2nd day, a countrywide disaster due to an infectious disease occurred in a large simulated tabletop between the multiple groups. Participants had to put their disaster plans into action and respond to this tabletop drill. They had to find creative solutions to multiple scenarios with patient boluses, increasing levels of responsibility, and community requests to keep their city and country effectively responding to this disaster. At the end of this drill, participants came together to discuss lessons and to create a mock press conference for the country to ensure a worried public that the disaster was being handled effectively.

After the workshop was completed, a questionnaire was given to the participants. This questionnaire asked the participant's profession and prior experiences with disaster training and response. Finally, participants were asked if they would recommend the course in the future and to leave any specific comments or future directions for the workshop.

These questionnaires were used to create summary statistics that were analyzed to assess the usefulness of traditional lecture format and self-driven education in a largely untrained group of disaster responders. These summary statistics are used to draw conclusions to inform future trainings.

  Results Top

Forty-four providers responded to the questionnaire (n = 44), which was made up of 16 board-certified emergency medicine providers, 13 emergency medicine residents in training, 4 other doctors, 8 nurses, 2 policemen, and 1 medical student. Of these providers, 23 had never been trained in disaster and 24 had never participated in a disaster response. Twenty had participated in some training and responded to some disasters and only one provider graded themselves as having extensive training in disaster medicine [Table 1].
Table 1: Overall cohort characteristics

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Every provider in the workshop (n = 44, 100%) would recommend the course to future providers and wrote that they would take the course again. Each of the 11 different aspects of the course was graded as useful by the providers, with over 70% of the providers grading these aspects as very useful. The most useful aspect of the course was the topic lectures from the US faculty who were fellowship trained in disaster medicine with each lecture receiving top marks from over 80% of providers (n = 38, 86%; n = 37, 84%). Of the hands-on aspects of the course, participants graded the final disaster drill as most useful, with over 80% of providers awarding it top marks (n = 36, 82%) [Table 2].
Table 2: Participant evaluation of workshop

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Qualitatively, participants noted that the course was very useful and they felt that they gained extensive knowledge in disaster management. Specifically, many participants commented on the course's focus on leadership and communication skills. One participant mentioned that it was helpful in that now they “can think beyond the patient in front of me” and felt that this course would be useful for providers in disaster. In the future, participants mentioned that they would enjoy further case studies from the US and India as well as interactive online or video modules to reinforce key aspects of the drill. Overall, comments were generally positive and participants felt that the workshop was successful in teaching the principles of disaster response.

  Discussion Top

These results support this workshop as an effective method to teach the ICS framework to a group of health-care providers with little training in disaster response. The workshop was highly rated subjectively and objectively, and participants were likely to recommend the course and felt that they improved in their understanding of disaster management due to their participation. Through simulation and interactive exercises including tabletop disaster drills, the concepts of disaster management and the ICS were effectively communicated.

As expected in this mixed group of providers, more than half (53%, n = 23) had no prior training in disasters and very few (2%, n = 1) categorized their disaster training as extensive. Given this lack of training, it is not surprising that lectures given by experts in disaster were highly rated by the group. Interestingly, simulation exercises and tabletop drills were comparably rated even in this group of untrained practitioners working in a largely self-directed manner. This points to the importance of self-directed learning for adults as even in an untrained group, this method was rated as similarly useful to listening to international experts on disaster management. As a corollary, it is like that community and grassroots involvement of target population should be a priority in disaster training.

In India and countries throughout the world, there is a need for health-care providers to learn the concepts of disaster management which are endorsed by their governments and international regulatory bodies. This 2-day training represents an interactive and effective method to teach these concepts to health-care providers with little to no prior knowledge of disaster medicine. This workshop is easily replicable and adaptive to the unique needs of each LMIC. Our hope is that it can serve as a model for future efforts in educating this workforce throughout the world.

This study is limited in that the scales and evaluation tools here are subjective evaluations by the participants themselves. There was not an objective assessment of drill performance before and after this workshop. In addition, performance by health-care providers in simulated drills and exercises may differ substantially from performance managing a disaster. To our knowledge, there are no studies proving definitive improvement in disasters from training. However, it is likely that performance in an actual disaster would improve due to education and planning as well as experiences in simulated disasters.

  Conclusion Top

This interactive workshop using tabletop drills and simulation effectively taught the ICS framework to health-care providers in India with little prior experience in disaster management. Since the adoption of the Sendai Framework for Disaster Risk Reduction, this workshop is a useful tool to translate concepts from policymakers to enact effective disaster response on the ground, using the principles of disaster management.

Ethical conduct of research

Research was conducted with consent of participants using best practices. Appropriate Ethics/IRB approval was obtained.

Financial support and sponsorship

This study was financially supported by SUNY Downstate Medical Center.

Conflicts of interest

There are no conflicts of interest.

  References Top

Ciottone GR. Disaster Medicine. 2nd ed. Philadelphia, PA: Elsevier; 2016.  Back to cited text no. 1
Noj EK. Core content development project. American College of Emergency Physicians. Disaster Med Sect News 1990;1:S-6.  Back to cited text no. 2
Dara SI, Ashton RW, Farmer JC, Carlton PK Jr. Worldwide disaster medical response: An historical perspective. Crit Care Med 2005;33:S2-6.  Back to cited text no. 3
Standardized Emergency Management System (SEMS): Introductory Course of Instruction, Student Reference Manual. County of Santa Clara, California. Available from: http://www.scc-ares-races.org/sems.htm. [Last retrieved on 2017 Sep 18].  Back to cited text no. 4
Sendai Framework for Disaster Risk Reduction 2015-2030. United Nations Office for Disaster Risk Reduction (UNISDR); 2015.  Back to cited text no. 5
National Disaster Management Plan. National Disaster Management Authority. New Delhi: Government of India; May, 2016.  Back to cited text no. 6
SC Criticizes States for Lax Approach towards Disaster Management. The Indian Express; 8 May, 2017. Available from: https://www.indianexpress.com/article/india/sc-criticises-states-for-lax-approach-towards-disaster-management -4646558/. [Last retrieved on 2017 Sep 18].  Back to cited text no. 7
Heavy Flooding and Casualties Raise Questions on India's Disaster Preparedness. The Wire; 8 February, 2017. Available from: https://www.thewire.in/164063/heavy-flooding- casualties-raise-questions-indias-disaster-preparedness /. [Last retrieved on 2017 Sep 18].  Back to cited text no. 8


  [Table 1], [Table 2]


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