Disaster medicine is the area of medical specialization serving the dual areas of providing health care to disaster survivors and providing medically related disaster preparation, disaster planning, disaster response and disaster recovery leadership throughout the disaster life cycle. Disaster medicine specialists provide insight, guidance and expertise on the principles and practice of medicine both in the disaster impact area and healthcare evacuation receiving facilities to emergency management professionals, hospitals, healthcare facilities, communities and governments. The disaster medicine specialist is the liaison between and partner to the medical contingency planner, the emergency management professional, the incident command system, government and policy makers.
Disaster healthcare – The provision of healthcare services by healthcare professionals to disaster survivors and disaster responders both in a disaster impact area and healthcare evacuation receiving facilities throughout the disaster life cycle.[1]
Disaster behavioral health – Disaster behavioral health deals with the capability of disaster responders to perform optimally, and for disaster survivors to maintain or rapidly restore function, when faced with the threat or actual impact of disasters and extreme events.[2]
Disaster law – Disaster law deals with the legal ramifications of disaster planning, preparedness, response and recovery, including but not limited to financial recovery, public and private liability, property abatement and condemnation.[3]
Disaster life cycle – The time line for disaster events beginning with the period between disasters (interphase), progressing through the disaster event and the disaster response and culminating in the disaster recovery. Interphase begins as the end of the last disaster recovery and ends at the onset of the next disaster event. The disaster event begins when the event occurs and ends when the immediate event subsides. The disaster response begins when the event occurs and ends when acute disaster response services are no longer needed. Disaster recovery also begins with the disaster response and continues until the affected area is returned to the pre-event condition.[3]
Disaster planning – The act of devising a methodology for dealing with a disaster event, especially one with the potential to occur suddenly and cause great injury and/or loss of life, damage and hardship. Disaster planning occurs during the disaster interphase.[4]
Disaster preparation – The act of practicing and implementing the plan for dealing with a disaster event before an event occurs, especially one with the potential to occur suddenly and cause great injury and/or loss of life, damage and hardship. Disaster preparation occurs during the disaster interphase.[5]
Disaster recovery – The restoration or return to the former or better state or condition proceeding a disaster event (i.e., status quo ante, the state of affairs that existed previously). Disaster recovery is the fourth phase of the disaster life cycle.[4]
Disaster response – The ability to answer the intense challenges posed by a disaster event. Disaster response is the third phase of the disaster life cycle.[6]
Medical contingency planning – The act of devising a methodology for meeting the medical requirements of a population affected by a disaster event.[6]
Medical surge – An influx of patients (physical casualties and psychological casualties), bystanders, visitors, family members, media and individuals searching for the missing who present to a hospital or healthcare facility for treatment, information and/or shelter as a result of a disaster.[2]
Surge capacity – The ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system.[7]
Medical triage – The separation of patients based on severity of injury or illness in light of available resources.[8]
Psychosocial triage – The separation of patients based on the severity of psychological injury or impact in light of available resources.[8]
History
The term "disaster medicine" first appeared in the medical lexicon in the post-World War II era. Although coined by former and current military physicians who had served in World War II, the term grow out of a concern for the need to care for military casualties, or nuclear holocaust victims,[citation needed] but out of the need to provide care to the survivors of natural disasters and the not-yet-distant memory of the 1917-1918 Influenza Pandemic.
The term "disaster medicine" continued to appear sporadically in both the medical and popular press[citation needed] until the 1980s, when the first concerted efforts to organize a medical response corps for disasters grew into the National Disaster Medical System. Simultaneous with this was the formation of a disaster and emergency medicine discussion and study group under the American Medical Association (AMA) in the United States as well as groups in Great Britain, Israel and other countries. By the time Hurricane Andrew struck Florida in 1992, the concept of disaster medicine was entrenched in public and governmental consciousness. Although training and fellowships in disaster medicine or related topics began graduating specialists in Europe and the United States as early as the 1980s, it was not until 2003 that the medical community embraced the need for the new specialty.[citation needed]
Throughout this period, incomplete and faltering medical responses to disaster events made it increasingly apparent[citation needed] in the United States of America that federal, state and local emergency management organizations were in need of a mechanism to identify qualified physicians in the face of a global upturn in the rate of disasters.[citation needed] Many physicians who volunteer at disasters have a bare minimum of knowledge in disaster medicine and often pose a hazard to themselves and the response effort because they have little or no field response training. It was against this backdrop that the American Academy of Disaster Medicine (AADM) and the American Board of Disaster Medicine (ABODM) were formed in the United States of America for the purpose of scholarly exchange and education in Disaster Medicine as well as the development of an examination demonstrating excellence towards board certification in this new specialty. In 2008, the United States National Library of Medicine (NLM) formed the Disaster Information Management Research Center (DIMRC) in support of the NLM's history of supporting healthcare professionals and information workers in accessing health information. DIMRC provides a specialized database, Disaster Lit: Database for Disaster Medicine and Public Health, an open access resource of disaster medicine documents, including guidelines, research reports, conference proceedings, fact sheets, training, fact sheets, and similar materials.
Ethics in Disaster Medicine
The Disaster Medicine practitioner must be well-versed in the ethical dilemmas that commonly arise in disaster settings. One of the most common dilemmas occurs when the aggregate medical need exceeds the ability to provide a normal standard of care for all patients.
Triage
In the event of a future pandemic, the number of patients that require additional respiratory support will outnumber the number of available ventilators.[9] Although a hypothetical example, similar natural disasters have occurred in the past. Historically, the influenza pandemic of 1918-19 and the more recent SARS epidemic in 2003 led to resource scarcity and necessitated triage. One paper estimated that in the United States, the need for ventilators would be double the number available in the setting of an influenza pandemic similar to the scale of 1918.[10] In other countries with fewer resources, shortages are postulated to be even more severe.
How, then, is a clinician to decide whom to offer this treatment? Examples of common approaches that guide triage include "saving the most lives", calling for care to be provided to "the sickest first" or alternatively a "first come, first served" approach may attempt to sidestep the difficult decision of triage.[9] Emergency services often use their own triaging systems to be able to work through some of these challenging situations; however, these guidelines often assume no resource scarcity, and therefore, different triaging systems must be developed for resource-limited, disaster response settings. Useful ethical approaches to guide the development of such triaging protocols are often based on the principles of the theories of utilitarianism, egalitarianism and proceduralism.[9]
Utilitarian Approach
The Utilitarian theory works on the premise that the responder shall 'maximise collective welfare'; or in other words, 'do the greatest good for the greatest numbers of people[9]'. The utilitarian will necessarily need a measure by which to assess the outcome of the intervention. This could be thought of through various ways, for instance: the number of lives saved, or the number of years of life saved through the intervention. Thus, the utilitarian would prioritize saving the youngest of the patients over the elderly or those who are more likely to die despite an intervention, in order to 'maximise the collective years of life saved'. Commonly used metrics to quantify utility of health interventions include DALYs (Disability Adjusted Life Years) and QALYs (Quality Adjusted Life Years) which take into account the potential number of years of life lost due to disability and the quality of the life that has been saved, respectively, in order to quantify the utility of the intervention.
Egalitarian Approach
Principles of egalitarianism suggest the distribution of scarce resources amongst all those in need irrespective of likely outcome.[11] The egalitarian will place some emphasis on equality, and the way that this is achieved might differ. The guiding factor is need rather than the ultimate benefit or utility of the intervention. Approaches based on egalitarian principles are complex guides in disaster settings. In the words of Eyal (2016) "Depending on the exact variant of egalitarianism, the resulting limited priority may go to patients whose contemporaneous prognosis is dire (because their medical prospects are now poor), to patients who have lived with serious disabilities for years (because their lifetime health is worse), to young patients (because dying now would make them short-lived), to socioeconomically disadvantaged patients (because their welfare prospects and resources are lower), or to those who queued up first (because first-come first-served may be thought to express equal concern."[9]
The inherent difficulties in triage may lead practitioners to attempt to minimize active selection or prioritization of patients in face of scarcity of resources, and instead rely upon guidelines which do not take into account medical need or possibility of positive outcomes. In this approach, known as proceduralism, selection or prioritization may be based on patient's inclusion in a particular group (for example, by citizenship, or membership within an organization such as health insurance group). This approach prioritizes simplification of the triage and transparency, although there are significant ethical drawbacks, especially when procedures favor those who are part of socioeconomically advantaged groups (such as those with health insurance). Procedural systems of triage emphasize certain patterns of decision making based on preferred procedures. This can take place in the form of a fair lottery for instance; or establishing transparent criteria for entry into hospitals - based on non discriminatory conditions. This is not outcome driven; it is a process driven activity aimed at providing consistent frameworks upon which to base decisions.[9]
These are by no means the only systems upon which decisions are made, but provide a basic framework to evaluate the ethical reasoning behind what are often difficult choices during disaster response and management.
Areas of competency
Internationally,[citation needed] disaster medicine specialists must demonstrate competency in areas of disaster healthcare and emergency management including but not limited to:
1812 – Napoleonic wars give rise to the military medical practice of triage in an effort to sort wounded soldiers in those to receive medical treatment and return to battle and those whose injuries are non-survivable. Dominique-Jean Larrey, a surgeon in the French emperor's army, not only conceives of taking care of the wounded on the battlefield, but creates the concept of ambulances, collecting the wounded in horse-drawn wagons and taking them to military hospitals.
1881 – First American Red Cross chapter founded in Dansville, New York.
1937 – President Franklin Roosevelt makes a public request by commercial radio for medical aid following a natural gas explosion in New London, Texas. This is the first presidential request for disaster medical assistance in United States history.[12]
1955 – Col. Karl H. Houghton, M.D. addresses a convention of military surgeons and introduces the concept of "disaster medicine."[13]
1959 – Col. Joseph R. Schaeffer, M.D., reflecting the growing national concern over nuclear attacks on the United States civilian population, initiates training for civilian physicians in the treatment of mass casualties for the effects of weapons of mass destruction creating the concept of medical surge capacity.[14]
1986 – A disaster medical response discussion group is created by NDMS team members and emergency medicine organizations in the United States. Healthcare professionals worldwide join the discussion group of the years to come. dd 1989 – The University of New Mexico creates the Center for Disaster Medicine, the first such medical center of excellence in the United States. Elsewhere in the world, similar centers are created at universities in London, Paris, Brussels and Bordeaux.[17]
1992 – Hurricane Andrew, a Category 5 hurricane, strikes south Florida, destroying the city of Homestead, Florida and initiating the largest disaster healthcare response to date.[citation needed]
1993 – On February 26, 1993, at 12:17 pm, a terrorist attack on the North Tower of the World Trade Center (the first such attack on United States soil since World War II) increases interest in specialized education and training on disaster response for civilian physicians.[citation needed]
2001 – The September 11, 2001 attacks on the World Trade Center and the Pentagon cause the largest loss of life resulting from an attack on American targets on United States soil since Pearl Harbor. As a result, the need for disaster medicine is galvanized.[citation needed]
2003 – The American Medical Association, in conjunction with the Medical College of Georgia and the University of Texas, debuts the National Disaster Life Support (NDLS) training program, providing the first national certification in disaster medicine skills and education. NDLS training would later be referred to as "the CPR of the 21st century."
2003 – In February 2003, the American Association of Physician Specialists (AAPS) appoints an expert panel to explore the question of whether disaster medicine qualifies as a medical specialty.
2003 – On February 28, 2003, President Bush issues HSPD-5 outlining the system for management of domestic incidents (man-made and natural disasters). HSPD-5 mandates the creation and adoption of the National Response Plan (NRP).[1]
2003 – On September 30, 2003, the National Response Plan is published and adopted by all Federal agencies.[1]
2003 – On December 17, 2003, President Bush issues HSPD-8, outlining the new framework for national preparedness and creating the National Incident Management System (NIMS).[1]
2004 – In February, 2004 the AAPS reports to the American Board of Physician Specialties (ABPS) that the expert panel, supported by the available literature and recent HSPDs, has determined that there is a sufficient body of unique knowledge in disaster medicine to designate the field as a discrete specialty. ABPS empanels a board of certification to determine if board certification is appropriate in this new specialty.
2004 – On April 28, 2004, President Bush issues HSPD-10, also known as the plan for Biodefense for the 21st Century which calls for healthcare to implement surveillance and response capabilities to combat the threat of terrorism.[1]
2004 – Hurricanes Charlie, Francis, Ivan and Jeanne batter the state of Florida, resulting in the largest disaster medical response since Hurricane Andrew.
2005 – Hurricane Katrina batters the Gulf Coast of the United States, destroying multiple coastal cities. For the first time in NDMS history, the entire NDMS system is deployed for a single disaster medical response. Among the many lessons learned in field operations following Hurricane Katrina are the need for cellular autonomy under a central incident command structure and the creation of continuous integrated triage for the management of massive patient surge. The lessons learned in the Hurricane Katrina response would be applied less than a month later following Hurricane Rita and again following Hurricane Wilma and the Indonesian tsunami.
2006 – In June 2006, the Institute of Medicine publishes three reports on the state of emergency Health care in the United States. Among the condemnations of emergency care is the lack of substantial improvement in disaster preparedness, or "cross-silo" coordination.
2007 – On January 31, 2007, President Bush issues HSPD-18, calling for the development and deployment of medical countermeasures against weapons of mass destruction.[1]
2007 – On September 30, 2007, the NIMS Implementation Plan for Hospitals and Healthcare Facilities compliance deadline passes with fewer than nine percent of all United States hospitals fully compliant and fewer than half of hospitals and healthcare facilities having made substantial progress towards compliance.
2007 – On October 18, 2007, President Bush issues HSPD-21, outlining an augmented plan for public health and disaster medical preparedness. HSPD-21 specifically calls for the creation of the discipline of "disaster healthcare" using the accepted definition of "disaster medicine." HSPD-21 also calls on the Secretary of Health and Human Services (HHS) to use "economic incentives" including the Center for Medicare Services (CMS) to induce private medical organizations, hospitals and healthcare facilities to implement disaster healthcare programs and medical disaster preparedness programs.[1] Establishment of the National Center for Disaster Medicine and Public Health (NCDMPH) with Founding Partners, Department of Homeland Security, Department of Defense, Department of Health and Human Services, Department of Veterans' Affairs, and Department of Transportation.
Board certification
Physicians who hold board certification in disaster medicine have demonstrated by written and simulator-based examination that through training and field experience, they have mastered the spectrum of knowledge and skills which defines the specialty of disaster medicine. As with all medical specialties, this body of knowledge and skills is contained in the core competencies document created and maintained by the American Board of Disaster Medicine and the American Academy of Disaster Medicine. As with all core competencies documents, the specific knowledge and skills required for certification are subject to constant refinement and evolution. This statement cannot be more true than for a specialty like disaster medicine where the nature of the threats faced, the responses undertaken, and the lessons learned become more complex with each event.
Related Research Articles
In medicine, triage is a practice invoked when acute care cannot be provided for lack of resources. The process rations care towards those who are most in need of immediate care, and who benefit most from it. More generally it refers to prioritisation of medical care as a whole. In its acute form it is most often required on the battlefield, or at peacetime when an accident results in a mass casualty which swamps nearby healthcare facilities' capacity.
Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians continuously learn to care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with Emergency Medical Services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency physicians generally practise in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.
An emergency department (ED), also known as an accident & emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.
A first responder is a person with specialized training who is among the first to arrive and provide assistance at the scene of an emergency, such as an accident, natural disaster, or terrorism. First responders typically include law enforcement officers, paramedics, EMT's and firefighters. In some areas, emergency department personnel, such as nurses and doctors, are also required to respond to disasters and critical situations, designating them first responders.
International emergency medicine is a subspecialty of emergency medicine that focuses not only on the global practice of emergency medicine but also on efforts to promote the growth of emergency care as a branch of medicine throughout the world. The term international emergency medicine generally refers to the transfer of skills and knowledge—including knowledge of ambulance operations and other aspects of prehospital care—from developed emergency medical systems (EMSs) to those systems which are less developed. However, this definition has been criticized as oxymoronic, given the international nature of medicine and the number of physicians working internationally. From this point of view, international emergency medicine is better described as the training required for and the reality of practicing the specialty outside of one's native country.
The United States Public Health Service Commissioned Corps (PHSCC), also referred to as the Commissioned Corps of the United States Public Health Service, is the federal uniformed service of the U.S. Public Health Service (PHS), and is one of the eight uniformed services of the United States. The commissioned corps' primary mission is the protection, promotion, and advancement of health and safety of the general public.
A field hospital is a temporary hospital or mobile medical unit that takes care of casualties on-site before they can be safely transported to more permanent facilities. This term was initially used in military medicine, but it is inherited to be used in disasters and other emergency situations.
Disaster response is the second phase of the disaster management cycle. It consists of a number of elements, for example; warning/evacuation, search and rescue, providing immediate assistance, assessing damage, continuing assistance and the immediate restoration or construction of infrastructure. The aim of emergency response is to provide immediate assistance to maintain life, improve health and support the morale of the affected population. Such assistance may range from providing specific but limited aid, such as assisting refugees with transport, temporary shelter, and food, to establishing semi-permanent settlement in camps and other locations. It also may involve initial repairs to damaged or diversion to infrastructure.
A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include children (paediatrics), cancer (oncology), laboratory medicine (pathology), or primary care. After completing medical school, physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple-year residency to become a specialist.
The National Disaster Medical System (NDMS) is a federally coordinated healthcare system and partnership of the United States Departments of Health and Human Services (HHS), Homeland Security (DHS), Defense (DOD), and Veterans Affairs (VA). The purpose of the NDMS is to support State, local, Tribal and Territorial authorities following disasters and emergencies by supplementing health and medical systems and response capabilities. NDMS would also support the military and the Department of Veterans Affairs health care systems in caring for combat casualties, should requirements exceed their capacity.
Hospital emergency codes are coded messages often announced over a public address system of a hospital to alert staff to various classes of on-site emergencies. The use of codes is intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors to the hospital. Such codes are sometimes posted on placards throughout the hospital or are printed on employee identification badges for ready reference.
Emergency medical services in France are provided by a mix of organizations under public health control. The central organizations that provide these services are known as a SAMU, which stands for Service d'Aide Médicale Urgente. Local SAMU organisations operate the control rooms that answer emergency calls and dispatch medical responders. They also operate the SMUR, which refers to the ambulances and response vehicles that provide advanced medical care. Other ambulances and response vehicles are provided by the fire services and private ambulance services.
In the United States, the hospital incident command system (HICS) is an incident command system (ICS) designed for hospitals and intended for use in both emergency and non-emergency situations. It provides hospitals of all sizes with tools needed to advance their emergency preparedness and response capability—both individually and as members of the broader response community.
Disaster medicine as a specialty and mindset was not only a reaction from September 11, 2001, but to the numerous subsequent events that seemed to all too quickly follow: random anthrax attacks, the SARS outbreak, the New York City blackout in the summer of 2003, the December 26, 2004 Indian Ocean earthquake and tsunami, the Pakistan earthquake of 2005, tumultuous hurricane seasons in 2004 and 2005 and, of course, terrorist attacks throughout the world — all against a backdrop of conflict in Afghanistan and Iraq.
The medical establishment in North America and the United Kingdom began forming study and discussion groups in disaster medicine. In some cases, the medical schools were on the front lines of this movement. Meanwhile, courses and fellowships in disaster medicine related fields at universities in London, Paris, Brussels, Bordeaux and the United States have been in existence since the early 1980s.
Throughout this period, incomplete and faltering medical responses to disaster events made it increasingly apparent that federal, state and local emergency management organizations were in need of a mechanism to identify qualified physicians in the face of a global upturn in the rate of natural and man-made disasters. Many physicians who volunteer at disasters have a bare minimum of knowledge in disaster medicine and often pose a hazard to themselves and the response effort because they have little or no field response training. It was against this backdrop that the American Academy of Disaster Medicine (AADM) and the American Board of Disaster Medicine (ABODM) were formed for the purpose of scholarly exchange and education in Disaster Medicine as well as the development of an examination demonstrating excellence towards Board Certification in this new specialty.
A mass casualty incident describes an incident in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties. For example, an incident where a two-person crew is responding to a motor vehicle collision with three severely injured people could be considered a mass casualty incident. The general public more commonly recognizes events such as building collapses, train and bus collisions, plane crashes, earthquakes and other large-scale emergencies as mass casualty incidents. Events such as the Oklahoma City bombing in 1995 and the September 11 attacks in 2001 are well-publicized examples of mass casualty incidents. The most common types of MCIs are generally caused by terrorism, mass-transportation accidents, fires or natural disasters. A multiple casualty incident is one in which there are multiple casualties. However the key difference from a mass casualty incident is that in a multiple casualty incident the resources available are sufficient to manage the needs of the victims. The issue of resource availability is therefore critical to the understanding of these concepts. One crosses over from a multiple to a mass casualty incident when resources are exceeded and the systems are overwhelmed
Homeland Security Presidential Directive (HSPD)-8, National Preparedness, describes the way United States Federal agencies will prepare for an incident. It requires Department of Homeland Security to coordinate with other Federal agencies and with State, local, and Tribal governments to develop a National Preparedness Goal with Emergency management. Congressional laws enacted, following the wake of 9/11, which resulted in new developments in the way security was assessed and addressed in the United States, to prevent and respond to threatened or actual domestic terrorist attacks, disasters, and other emergencies by requiring a national domestic all-hazards preparedness goal. HSPD 5, HSPD-7, HSPD-8, and HSPD-8 Annex 1 are directives that deal with the preparedness goals.
The Emergency Care Coordination Center (ECCC) is the policy home for the emergency care community within the federal government. It is charged with strengthening the U.S. response systems to better prepare for times of crisis. It was established in January 2009.
A sobering center is a facility or setting providing short-term recovery and recuperation from the effects of acute alcohol or drug intoxication. Sobering centers, instead, are fully staffed facilities providing oversight and ongoing monitoring throughout the sobering process. Sobering centers include alternatives to jail and emergency departments, as well as drop-in centers”. There are small numbers of sobering centers around the world. There are over 40 sobering centers in the United States, with dozens more in development.
A medical surge occurs when "patient volumes challenge or exceed a hospital's servicing capacity"—often but not always tied to high volume of patients in a hospital's emergency room. Medical surges can occur after a mass casualty incident. In a poll by the American College of Emergency Physicians (ACEP) in May 2018, 93% of doctors said their US emergency rooms were not fully prepared for medical surges. 6% said their emergency departments were fully prepared.
The impact of the COVID-19 pandemic on hospitals became severe for some hospital systems of the United States in the spring of 2020, a few months after the COVID-19 pandemic began. Some had started to run out of beds, along with having shortages of nurses and doctors. By November 2020, with 13 million cases so far, hospitals throughout the country had been overwhelmed with record numbers of COVID-19 patients. Nursing students had to fill in on an emergency basis, and field hospitals were set up to handle the overflow.
1 2 Shultz et al. 2006. Surge, Sort, Support: Disaster Behavioral Health for Healthcare Professionals. Orlando: Disaster Life Support Publishing, Inc.
1 2 Ramirez, M. National Strategies for Medical Contingency Planning seminar, September, 2007
1 2 Marghella, P. National Strategies for Medical Contingency Planning seminar, September, 2007
↑ Marghella, P. National Strategies for Medical Contingency Planning Seminar, September 2007
1 2 Marghella, P. National Strategies for Medical Contingency Planning Seminar, September, 2007
↑ Barbera JA, McIntyre AG. (2003). Jane’s Mass Casualty Handbook: Hospital. Emergency Preparedness and Response. Surrey, UK: Jane’s’ Information Group, Ltd.
1 2 Ramirez & Shultz. 2006. Surge, Sort, Support Lecture Series. University of Miami and the Florida Department of Health
1 2 3 4 5 6 7 Eyal, N. (2016) Chapter 11: Ethical Issues in Disaster Medicine. In Ciottone’s Disaster Medicine, Second Edition. Pages 27-34. Philadelphia: Elsevier Mosby.
↑ Bartlett J, Borio L. The current status of planning for pandemic influenza and implications for the health care planning in the United States. Clin Infec Dis. 2008;46(6):919–925.
↑ Hanfling D, Altevogt BM, Viswanathan K, et al. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: Institute of Medicine; 2012.
↑ Associated Press. "670 Children, Teachers, Feared Dead in Terrific Texas School Explosion." The Galveston Daily News. March 19, 1937. Pages 1 and 19.
↑ United Press. "Hard Role for Doctor Seen in Atomic War." Reno Evening Gazette. November 10, 1955. Page 30.
↑ "Public Doesn't Realize Dire Need for C-D" (Civil Defense) The Kerrville Times. April 4, 1959. Page 6.
↑ Associated Press article with no headline, mentioning Schaeffer's death and referring to him as an authority in "disaster medicine." The Gettysburg Times, August 12, 1966. Page 14
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