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Disaster Medicine

Authors

Joshua W. Loyd, MD, NRP
Emergency Medical Services Fellow
Carolinas Medical Center

Seth M. Kelly, MD, MBA, FF/EMT
Chair, EMRA Prehospital and Disaster Medicine Committee 2018-2019
Emergency Medicine Resident
University of Maryland Medical Center

David Comstock, MD, MS, NREMT
St. George’s University School of Medicine

Randall Beaupre II, MS3
University of Louisville School of Medicine
Louisville, KY

Faculty Editor

Luis E. Rios, Jr., MD, MPH, FACEP
Assistant Professor
Department of Emergency Medicine, Division of Field Operations
UF Health Jacksonville

Special thanks to our 1st edition writing team

Loui Alsulimani, MD, MBBS
Jeremy Maggin, MD
Ritu R. Sarin, MD, EMDM

INTRODUCTION

Description of the specialty
The specialty of disaster medicine represents an exciting and fast-growing opportunity for emergency physicians. In the 1980s, the slowly escalating presence of disaster needs caught the attention of various domains and specialties. Disaster medicine emerged as a combination of acute care medicine, public health, and emergency management (formerly known as disaster management).1 This resulted in a specialty that incorporates principles from different disciplines, including emergency medicine and its associated acute care specialties, public health, emergency management, humanitarian services, non-medical genres, and prehospital emergency medical services (EMS). 

Disaster medicine provides care for the victims of natural and man-made disasters with specific consideration given to timeliness and availability of resources. This often means expanding scopes of practice to allow dynamic operations with partners from other jurisdictions. The role of a disaster medicine-specialized physician is not limited to responding to the disaster; it should also be integrated into the full disaster cycle, including the areas of preparedness, recovery, and mitigation.

History of the specialty/fellowship pathway
It is difficult to track a linear chronological progress for the development of disaster medicine as a specialty. It evolved to fulfill the need for an organized management structure for health and human issues arising from disasters around the world. By 1990, the first core textbook for disaster medicine training was written.Since then, the paradigm of the domain of disaster response has slowly and heterogeneously moved toward more formal, interoperable, and consensus-based training. 

Events such as the 1993 World Trade Center bombing, the 1995 Oklahoma City bombing, the September 11 attacks of 2001, the 2004 Indian Ocean earthquake and tsunami, Hurricane Katrina in 2005, the Haiti earthquake of 2010, and the rise of domestic and international terrorist attacks have shaped the specialty. In 1976, the American College of Emergency Physicians developed a policy statement describing the role of emergency physicians during disasters. The University Association of Emergency Medicine (now the Society of Academic Emergency Medicine) called for the establishment of fellowship training in disaster medicine. In 2005, after decades of asynchronous growth, the American Board of Physician Specialties (ABPS) determined that a new board of certification in disaster medicine should exist as a unique part of the national disaster preparedness strategy. In response, the American Board of Disaster Medicine (ABODM) was created as the first medical board certification in disaster medicine in the U.S. (http://www.abpsus.org/disaster-medicine).

Why residents choose to follow this career path
Residents choose this career path when they desire to be disaster medicine specialists engaged in leadership roles in disaster management through the whole spectrum of the disaster cycle. 

How do I know if this path is right for me?
If you are the kind of person who wants to break from routine and go beyond traditional boundaries to save lives during disasters, then this is the perfect specialty for you. Envision yourself in the role of a leader: sorting causalities, managing hyper-acute injuries, and leading domestic field and hospital operations or deploying with medical teams overseas. You should also imagine yourself in meetings, sitting around a table surrounded by leaders from different disciplines, discussing matters that affect your hospital, region or state, nation, and the international community. You may find yourself in another part of the world, helping people recover from a recent disaster. However, if the idea of frequent meetings, committee brainstorming sessions, and hours-long discussions of non-clinical issues doesn’t appeal to you, reconsider such a fellowship. 

Career options after fellowship
Many exciting opportunities await the disaster medicine specialist. Burnout leads many emergency physicians to look for an area of interest outside the doors of emergency departments. Whether you want to spend most of your time in the ED, disaster administration, or both, all options are available. Many factors can affect your career pathway. This includes the hospital’s view of and demand for emergency management, as well as your qualifications and intentions. Many hospitals are in need of someone who can help them prepare for and sail through the waves of disasters toward safer shores after a crisis. You may need to gather more information about the disaster management system before applying for a job and see what suits your goals the most. It is not only hospitals that employ disaster specialists. There are many non-hospital opportunities, including the military, city, state, and federal government, public health departments including the Centers for Disease Control and Prevention (CDC), academic research centers and universities, and private small and international agencies. Humanitarian disaster relief work is another great opportunity for those who are interested in being in the field, and career paths can lead you to work with various non-governmental organizations (NGOs), the World Health Organization (WHO) or foreign governments. If you prefer domestic operations, you can also join a DMAT (Disaster Medical Assistance Team) in your region to be part of a federally sponsored deployment team or (create) a hospital system or university-based disaster medical team. Mentors in the field are available for you to seek advice and to make suggestions that will help satisfy your career goals. It is projected that every large, tertiary, and private academic center will need a DM specialist on staff. Another projection among disaster faculty is aligned with moderate size cities. 

Splitting time between departments
The graduate of a disaster medicine fellowship is expected to participate actively in hospital emergency management. Splitting time between the ED and your hospital’s emergency management team is not uncommon. Some graduates will pursue a full-time job in emergency management but splitting the time with ED shifts is more common. Taking the responsibility of hospital disaster management is not an easy job as it requires a lot of time and effort. The best way to figure out what is expected from you is to discuss it with your hiring institution. Ask about their expectations from you and working hours for both (ED and disaster management). The same approach applies if you want to work for institutions other than hospitals, whether local, federal or international. Fortunately, the flexible nature of ED shift work will help you to save time for other duties. In the end, it is up to you to plan how to manage your time and to maintain balance in your life, income and career. 

Academic vs. community positions
The earlier you plan for your future, the greater the chance you will get the position you seek. Think about lifestyle, family and income bracket when planning. It is important to decide early if you want an academic or community position. If you are passionate about teaching, research, and academic titles, then you may want to pursue an academic position. Positions are available for disaster medicine fellows in many universities and university-affiliated hospitals. Many faculty members of fellowships hold academic titles in well-known academic institutions, not only in the United States, but all over the world. Working in a community hospital will most likely lead to more involvement in emergency management with less teaching and research opportunities. Disaster medicine is a relatively new and rapidly growing specialty. As such, the demand for more research and education is high. This fellowship can help you build bridges to connect with many academic staff from different disciplines, which may help you in your future career. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Currently there are at least 17 programs that address disaster medicine, although some combine it with an EMS fellowship. Programs include:

Differences between programs
Most have the same core content. Some programs are older than others, and better established. Some are fast-growing, while others are almost in a steady state. Programs may have a particular emphasis on a specific aspect of disaster medicine and management. Many programs still combine EMS and/or International Medicine with disaster medicine which may bridge some of the need to work ED shifts for income. The location of some programs may be advantageous. For example, a few programs are concentrated in distinct geographical areas, which allow them to share resources and experiences together in an enriching environment. The intensity of the curriculum and the level of hands-on training provided can vary between programs. The strength of research activities is also variable between programs. 

Length of time required to complete fellowship
Disaster medicine fellowships are generally 1-2 years in length. Some programs may be combined with another subspecialty and/or an MPH degree for a total of 3 years.

Skills acquired during fellowship
As a disaster medicine fellow, you are expected to grasp the principles of operations and disaster management and to gain the skills to manage disasters both clinically and administratively. Through didactic sessions and clinical training, the fellow will learn to triage, manage, and evaluate a multitude of disaster-related injuries, including blast injuries, hazardous material casualties, mass casualty incidents (MCI), and more. Fellows will develop the requisite administrative skills needed for success, including planning, allocating resources, utilizing data, maximizing surge capacity, conducting drills, and improving research. You will gain experience in prehospital disaster-related operations, Hospital Incident Command System (HICS), and the development of hospital disaster-related protocols. You will also learn about field disaster response on the domestic level using Incident Command and on the international level, including coordinating with the UN, WHO, and basic deployment field skills and principles.

Typical rotations/curriculum
Most fellowships have a common core content, which includes mandatory and elective rotations. Usually, the curriculum is a mixture of didactics, meetings, clinical sessions, courses (both online and in person), field experience, and research activities. Core content will include things like Federal Emergency Management Agency Incident Command System (ICS) courses, mass casualty incident (MCI) triage, and management of CBRNE (Chemical-Biological-Radiological-Nuclear and Hazardous Materials) events. 

There is a large variety of available elective rotations, some of which can entail a second year. Examples of elective rotations include EMS (if not already integrated in the program), tactical medicine, visits to federal agencies, CDC, international emergency medicine, disaster relief/humanitarian aid, and disaster simulation. Those who want to do a 2-year fellowship often have the opportunity to obtain advanced degrees related to disaster medicine. For instance, fellows may be able to obtain a Master’s of Public Health (MPH), Health Care Emergency Management (HEM), or the European Master of Disaster Medicine (EMDM).

Board certification afterwards?
The ABODM provides medical board certification in disaster medicine. 

Average salary during fellowship
Salary will vary, but it is usually based on that of a PGY-4/5 trainee but in some cases may be commensurate to that of a junior faculty/attending.

PREPARING TO APPLY

How competitive is the fellowship application process?
Competition is variable between centers. Some may have difficulty filling slots due to proximity to other similar fellowships. As the number of fellowship programs increases, so does the number of candidates. 

Requirements to apply
Applicants must be board-certified (or eligible) emergency physicians. 

Research requirements
It is always advantageous to have prior experience in research, but it is not mandatory. Having a research project in mind before starting the fellowship is a good idea, since you will be asked to conduct research during fellowship. The more research experience you have during residency, the stronger your application will be from an academic point of view. Ideally it is related to disaster medicine, and specifically your area of interest. If possible, present your work as an oral or poster presentation at a conference if you cannot publish it before applying. 

Suggested elective rotations to take during residency
Disaster medicine education during residency training is usually quite limited but may be growing as experts raise awareness of the need for education. However, some related content will be covered during the usual required residency rotations in the ED, EMS, intensive care units, and trauma care. Take advantage of elective training in disaster medicine. Look for opportunities to work with and learn from emergency management personnel at your hospital. 

Suggestions on how to excel during these elective rotations
Start with a disaster medicine textbook or National Disaster Life Support (NDLS®) courses. Share your interest with those who can help you early in residency. Actively participating in hospital emergency management is a strong indicator of your interest. This includes involvement in meetings, table-top exercises, planning processes, and disaster drills. 

Should I complete an away rotation?
An away rotation is not mandatory, but it can be significantly beneficial. Also, deploy whenever possible for a disaster, whether local or international. Disaster relief work will be a strong point in your application. Deploy with a professional organization to get the maximum benefit. International emergency medicine is a subspecialty of emergency medicine, with a significant overlap with disaster medicine. Participation in international activities will help you in your fellowship and your career after the fellowship. It is reasonable to look for such experience in your local area (whether your city or state) before traveling far away to get a similar experience. 

What can I do to stand out from the crowd?
Demonstrate a strong desire toward disaster medicine in your application. Your education, research, and training should display that interest. Focus early on disaster medicine-related activities to strengthen your application. You should also show the administrative skills needed to manage critical operations during disasters. Your reputation during your work in the ED is very important; excel in your primary job as an emergency physician from the beginning. Obtain a mentor with sound experience in disaster medicine. 

Should I join a hospital committee?
Yes! Active participation, ideally in your institution’s emergency management group, includes attending meetings, participating in drill development, and showing up on time. Try to leave a positive impact on any committee in which you participate. If possible, participate in committees on larger scales, such as on a city or state level. These can potentially expose you to leaders in disaster medicine within your region.

Publications other than research
There are plenty of opportunities for writing other than research that include, but are not limited to, book chapters, blogs, magazine articles, and scientific material for disaster courses. 

How many recommendations should I get? Who should write these recommendations?
Most programs will ask for three letters of recommendation, with at least one from either your program director or chair of the emergency department. You will likely need two additional letters, and it is recommended that both of these are from physicians who work in the field of disaster medicine and emergency management. Getting the letters from hospital emergency management and a disaster medicine fellowship director is ideal. These letter writers should have worked with you on a project, in the field, or in the ED, as the letters should be strong, well-written, and specific to you. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
You can still be competitive after working as an attending, but you will need to show your dedication to learning disaster medicine. Most of the things aforementioned apply here, like joining the emergency management committee at your hospital and being actively involved. Being involved completely in another subspecialty of emergency medicine may make others question your interest in disaster medicine as a future career path. However, working as an attending by itself will enhance your clinical, administrative, communication and leadership skills. Make sure you have a disaster medicine mentor who will help ensure that you make this time productive and demonstrate your interest in disaster medicine. 

What if I’m a DO applicant?
In general, there has been an increase in the number of fellowships that accept graduates of DO residencies. Contact each fellowship to see if they accept DO candidates and what additional requirements for ACGME certification they have. In most situations, though, inclusiveness is the rule.

What if I am an international applicant?
In general, the requirements are almost the same, but you need to know if passing USMLE exams is mandated by the program or not. You need to work on your application even earlier, at least 6 months ahead. Allot time for your visa application. It would be best to ask programs about this prior to applying. 

APPLICATION PROCESS

How many applications should I submit?
There are many factors to consider. Which programs offer guidance and educational programs in the specific areas of disaster medicine you are interested in? Are there certain geographic areas of the country you want or more importantly don’t want to be? Do you want to be in a program close to your family or friends? Do you have an idea of what you want to do post-fellowship, and will a particular program or a program in a particular area help you achieve those goals? Is university affiliation important to you, or are you going to be happy in any program as long as you obtain a fellowship position? Whether coming straight out of residency or taking a short hiatus from the clinical duties in an already established professional practice, the important factors in choosing the right program are going to be different for everybody. Apply to all the programs fit your criteria. 

How do I pick the right program for me?
The most common mistake people make when applying is assuming all programs have the same curriculum. Disaster medicine is not, as of yet, an ACGME-accredited specialty. This has advantages and disadvantages; While you are given considerable latitude and flexibility in designing an educational experience that fits your specific interests, there is no standardized core curriculum, so understanding opportunities at specific programs is critical. Nearly all disaster fellowship programs have websites explaining their mission, the programs they offer, the specialties and interests of their faculty and what their graduates are doing post-fellowship. You’re going to be overwhelmed by all the amazing and cool opportunities out there, and you will probably change your mind about what interests you in disaster medicine several times during this process. 

Common mistakes during the application process
The biggest mistake one could make during the application process is not doing enough research about the different programs and faculty. This is critical in designing an attractive CV as well as planning for the interview – the two most important pieces of the application process. Exaggeration or embellishment of experience, previous positions, or professional roles on the CV or during the interview is a significant mistake an applicant can make. Your integrity matters. Have confidence in your experiences and sell yourself truthfully. 

Application deadlines
Fellowship schedules typically follow the academic year (July - June) so the best time to apply, particularly for senior residents, is the summer at the beginning of your final residency year. Interviews will typically take place October-November, and fellowship acceptance notifications will be sent out in November. Most programs accept applications on a rolling basis, but each program is different. Contact the programs you are interested in early to get application materials and guidance regarding deadlines. 

Tips for writing your personal statement
Keep it simple. Depending on the fellowship program, you may be asked to write a full 1- to 2-page statement or just a single paragraph, placed at the top of your CV. In either case, you want to be succinct and hit a few important points:

  • Identify your personal career goals and what experiences have led you to identify those particular goals.
  • Explain why you think a fellowship in disaster medicine will help you reach those goals.
  • Explain both why the program is the right fit for you and why you are the right fit for the program.

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
Contact the programs who have not contacted you and see if there are any openings. If all of your desired positions have been filled, secure a clinical position for the following year, and then re-evaluate a fellowship. The greatest benefits of a disaster medicine fellowship are the networking potential with others in the field and the opportunity to learn about the various aspects of the specialty in an environment where the education is paramount and clinical duties are important, but secondary. While these benefits offer certain advantages when developing your career in the specialty, completing a disaster medicine fellowship is not a requirement. There are many resources available for self-learning, or you may take an entirely different structured academic approach to the field by seeking a master’s in emergency management or public health. If you still strongly believe that fellowship is your path and you are willing to wait the extra year (or two, depending on your clinical responsibilities), take the time to strengthen your application. Participate in your hospital’s emergency management committee, take online and in-person courses offered by the Federal Emergency Management Agency and other disaster-associated organizations, or join your local medical reserve corps. There are many opportunities if you are willing to do the research and find them.

INTERVIEW PROCESS

How do I stand out from the crowd?
There are many tips on good interviewing practices, but the most critical thing to do is be yourself. Play up your strengths, but do not stretch or exaggerate the truth to make yourself look better, and NEVER lie on your CV. You would not have been asked to interview if the program did not see something special in your application, so be confident in yourself and your accomplishments.

Disaster medicine programs may have an extensive network of faculty, but the core faculty that will be interviewing you is a small group. Know each program’s strengths, the opportunities that they provide and the research interests of the faculty, particularly the core faculty. These will give you talking points throughout the interview to bring up and show that you are truly interested.

This interview may be different from others. While it is still very important to sell yourself, your previous accomplishments, and the experience you have garnered over the years leading to this point in your life, remember that you are interviewing the program at the same time they are interviewing you. For the sake of your own future career, you want to do your fellowship at the program that best fits your needs and interests, so come prepared to ask a lot of questions.

What types of questions are typically asked?

  • Why do you want to go into disaster medicine?
  • What aspects of the specialty interest you?
  • What are your goals for future?
  • Why do you want to attend our program?
  • Do you see yourself in academic or community medicine?

*These interviews tend to be pretty informal compared to residency interviews. Most programs are just trying to get a sense of what you want to accomplish so they know if you would be a good fit.

How many interviews should I go on?
Revisit the advice from the application section. If you chose to apply only to positions that met the criteria for programs that would allow you to achieve your goals, accept every interview you are offered. The more interviews you go on, the better you will become at them – and the better your ability will be to discern key differences between programs. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Antosia RE, Cahill JD. Handbook of bioterrorism and disaster medicine. New York, NY: Springer; 2006.
  • Ciottone GR. Disaster medicine. 2nd ed. Philadelphia, PA: Elsevier; 2016.
  • Koenig KL, Schultz CH. Koenig and Schultz's Disaster Medicine: comprehensive principles and practices. Cambridge, MA: Cambridge University Press; 2010.
  • Partridge RA. Oxford American handbook of disaster medicine. Oxford: Oxford University Press; 2012.
  • Schwartz RB, McManus JG, Swienton RE. Tactical emergency medicine. Philadelphia, PA, and London: Wolters Kluwer/Lippincott Williams & Wilkins; 2012.

Beyond the textbooks, there is a wealth of disaster-related research literature available.

Important skills to practice while in residency to prepare for fellowship
Try to expand your disaster medicine knowledge base as much as possible prior to starting fellowship. Take advantage of the opportunities provided by your residency program in the various areas that disaster medicine encompasses. Get involved with opportunities for global health (whether that be humanitarian aid missions with your hospital group or formal international rotations through your residency). Volunteer at the main medical tent for large city marathons or Ironman events. Go on EMS and air medical ride-alongs or spend some time with local EMS medical directors and agencies.

Tips on how to succeed as a fellow
When the fellowship year starts, you want to do all in your power to make it as worthwhile as possible. Do your reading. Complete as much of the available online and classroom training as you are able up front. Participate in your hospital’s emergency management meetings. Take every available opportunity to meet key people in the field by going to conferences and joining the ACEP Disaster Medicine Section group and the SAEM Disaster Medicine Interest Group. Some medical schools are encouraging their students to become involved in disaster medicine training so seek out opportunities to teach when available. Become active in your local Medical Reserve Corp and participate in disaster simulation exercises in your area. Wherever you end up, opportunities will be numerous. Be flexible with your schedule and get involved with as many as you can. You will have some of the foremost experts in the field at your disposal so use their guidance, but you should also take an active role in developing your own self-directed educational experience.

CONCLUSION

Additional resources

Online and classroom training

Journals

Clinical Resources/Websites/Blogs

National organizations

  • EMRA Prehospital & Disaster Medicine Division
  • ACEP Disaster Medicine Section
  • SAEM Disaster Medicine Interest Group
  • World Association of Disaster and Emergency Medicine
  • Society of Disaster Medicine and Public Health

Conferences

How to find a mentor
Reach out to any faculty in your residency who may have an interest in disaster medicine or emergency management. Physicians who sit on the emergency management committee have already identified themselves as someone interested in the field and will be able to network you with other physicians on a hospital, city and state level. Reach out to local EMS agencies as they are also often linked in with people who work in disaster medicine on a larger scale and can help find you mentors in your area of interest. Do not be afraid to use email as a way to find mentors. It never hurts to ask, as most senior members in the field are eager to help interested newcomers find their way.

References

  • Ciottone, Gregory R. 2016. Disaster medicine. Second edition. ed. Philadelphia, PA: Elsevier.
  • Noji EK. Core content development project. American College of Emergency Physicians, Disaster Medicine Section News. 1990;l:S-6.