A simulation-based biodefense and disaster preparedness curriculum for internal medicine residents

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Practice points

Internists are poorly trained to recognize and respond to bioterrorism and other natural and man-made disasters. A disaster preparedness training curriculum that included an active, experiential learning component significantly improved Internal Medicine residents’ knowledge regarding the epidemiology and clinical manifestations of specific biologic agents and effective utilization of PPE. However, without internal reinforcement, this effect was not long-lasting. Participants also reported improved teamwork ability and increased confidence regarding critical care skills and procedures. In a number of small studies, experiential learning through simulation training has been shown to be more efficacious in the teaching of critical thinking, clinical management, teamwork, and psychomotor skills. As the cost and logistics of simulation based education are important considerations, additional research is needed in order to further define the most effective applications of simulation-based medical education.

Table 1.  Instructional and evaluative methodology for biodefense and disaster preparedness curriculum

Topics	Instructional Methods	Time Allotted	Location	Staffing	Evaluation/Feedback
• Introduction to disaster medicine	• Didactic lecture	1 hour	Classroom	1 Physician faculty	Objective testing
• Public health infrastructure and resources	• Supplemental reading materials			1 Public Health Administrator
• Overall risk assessment
• Psychologic consequences
• Biologic agents	• Didactic lecture	1 hour	Classroom	1 Physician faculty	Objective testing
	• Supplemental reading materials
	Scenario 1: Smallpox	30 ;min	High-fidelity simulation center	2 Physician faculty	Videotaped with debriefing and feedback
	• Experiential learning			3 Support staff
	Scenario 2: Tularemia	30 ;min	High-fidelity simulation center	2 Physician faculty	Videotaped with debriefing and feedback
	• Experiential learning			3 Support staff
• Chemical agents	• Didactic lecture	1 hour	Classroom	1 Physician faculty	Objective testing
	• Supplemental reading materials
	Scenario 3: Sarin	30 ;min	High-fidelity simulation center	2 Physician faculty	Videotaped with debriefing and feedback
	• Experiential learning			3 Support staff
• Radiologic agents	• Didactic lecture	1 hour	Classroom	1 Physician faculty
• Bombs
• Blast injuries
• PPE	• Didactic Lecture	30 ;min	Classroom	1 Physician faculty	Debriefing and feedback
	• Practicum	30 ;min	High-fidelity simulation center	2 Physician faculty	Debriefing and feedback
				3 Support staff

Table 2.  High fidelity simulation scenarios

Scenario	Case presentation	Set-up	Educational Goals/Interventions
1: Biologic agent (Smallpox)	• 25 year-old woman following syncopal episode while shopping	• Emergency room patient bay	• Recognition of clinical presentation of smallpox
	• Notes two day history of malaise, fever, sore throat, lightheadedness, and nausea	• Mannequin with maquillage, interactive capability	• Know treatment and prevention guidelines
	• On physical exam numerous discrete erythematous papular lesions on posterior pharynx, face, proximal upper and lower extremities		• Understand transmission routes
			• Initiation of appropriate infection control measures
			• Recognize need for and initiate public health reporting
2: Aerosolized biologic agent (Tularemia)	• 55 year old male journalist	• ICU patient room	• Recognition of the possibility of a weaponized biologic agent
	• Acute onset fever, chills, headache, sore throat, non-productive cough, shortness of breath and pleuritic chest pain	• Interactive capability	• Know treatment guidelines
	• Chest radiograph shows bilateral hilar adenopathy and infiltrates	• Hemodynamic/ECG monitoring	• Understand transmission routes
	• Condition deteriorates; subsequent reporting of two similar cases		• Initiation of appropriate infection control measures
			• Recognize need for and initiate public health reporting
			• Practice skills:
			• Intubation, ventilator management
			• Resuscitation, hemodynamic management
			• Chest tube, central line placement
3: Inhalational agent (Sarin)	• Explosion in public shopping area	• Emergency room	• Recognize signs and symptoms of nerve agent exposure
	• Five victims, one dies at scene	• Decontamination chamber	• Decontamination outside of the ER
	• Four arrive via EMS with rapid development of combinations of the following: miosis, rhinorrhea, chest tightness, sweating, abdominal pain, vomiting, fasiculations, and seizure activity	• Interactive capability	• Don and demonstrate use of appropriate PPE
		• Hemodynamic/ECG monitoring	• Triage and initiate appropriate specific treatment as well as the ‘ABC's’–airway, breathing, and circulation
			• Recognize the important of teamwork and crew resource management
			• Practice skills:
			• Intubation
			• Resuscitation, hemodynamic management

Figure 1. Biodefense and disaster preparedness knowledge in the participant group immediately following training compared to that of the control group (expressed as mean percentage correct ;+ ;1 SD).

Figure 2. Comparison of knowledge based upon postgraduate year (PGY) training level (expressed as mean percentage correct ;+ ;1 SD).