Beyond the Crisis: Insights into Disaster Medicine: Q&A Session with an Expert

(Focus - Malaysia)

As we step into the final month of the year, we are delighted to present an interview on an indispensable realm of healthcare: Disaster Medicine. Given the dynamic landscape of healthcare changes, being ready for disasters and knowing how to respond stands paramount.   

Disaster Medicine encompasses a vast spectrum of disciplines, intertwining medical expertise with logistical finesse, community engagement, and rapid decision-making. From natural disasters to pandemics and human-made crises, the ability to anticipate, mitigate, and effectively manage such events remains a cornerstone of public health and safety.    

To learn more about the complexities of disaster medicine, we have interviewed Dr. Shahrul Nizam bin Ahmad Zamzali, a renowned Emergency Physician & General Manager from Malaysia, who emphasizes that the foremost challenge does not solely arise from the severity of individual injuries but from the overwhelming volume of patients coupled with limited resources available for their effective treatment. He says that the only way to tackle such challenges is to have a well-structured disaster plan. 

Dr. Shahrul Nizam bin Ahmad Zamzali is an Emergency Physician & General Manager currently serving at Selcare Clinics Sdn Bhd, Selangor, Malaysia. 

When it comes to the medical team, doctors, and paramedics, our primary involvement lies in the preparedness, response, and recovery phases. To be well-prepared, we undergo extensive training and actively engage with the community, stakeholders, and various agencies. Sharing data plays a crucial role as well. We collect and exchange information because it helps us predict and plan for future emergencies. So, in summary, our preparation for disaster management involves these five stages, and within each stage, we have specific responsibilities and actions to take. 

What are the key principles of disaster medicine, and how do they differ from traditional emergency medicine practices? 

Dr. Zamzali - In the field of disaster medicine, the main goal is to save as many people as possible, even when resources are limited. The approach taken by doctors and paramedics is to prioritize patients based on their likelihood of survival. It's a bit different from regular hospital medicine because in a disaster situation, resources are scarce and there are more patients to treat. So, the key principle of disaster medicine is to do the best we can with whatever we have and save as many lives as possible. 

How do disaster medicine practitioners prepare for and respond to large-scale natural disasters like hurricanes, earthquakes, or floods? 

Dr. Zamzali - In the field of disaster management, we follow a five-stage approach to effectively handle emergencies. It all begins with prevention, where we work to stop problems before they occur. Then comes mitigation, where we aim to reduce the impact of potential disasters. After that, we focus on preparedness, response, and recovery. 

When it comes to the medical team, doctors, and paramedics, our primary involvement lies in the preparedness, response, and recovery phases. To be well-prepared, we undergo extensive training and actively engage with the community, stakeholders, and various agencies. Sharing data plays a crucial role as well. We collect and exchange information because it helps us predict and plan for future emergencies. So, in summary, our preparation for disaster management involves these five stages, and within each stage, we have specific responsibilities and actions to take. 

What are the most common injuries and illnesses that occur during a disaster, and how are they treated in a disaster medicine setting?   

Dr. Zamzali - Typically, the injuries you come across in a disaster setting are primarily physical in nature. Initially, during the early phases of a disaster, most injuries tend to be physical. However, as the situation progresses or lingers, other issues may arise, such as infections and psychological problems. 

As for how these conditions are treated, it largely depends on the resources available. In certain situations, we may have to work with whatever resources we have at hand and make the best use of them. Sometimes, improvisation becomes necessary when the circumstances demand it. 

What is the most unusual or unexpected medical condition or injury you have seen during a disaster, and how did you treat it in that setting? 

Dr. Zamzali - Based on my experience responding to various disasters, the majority of cases I have encountered are relatively common and not unusual. In comparison, cases encountered in emergency departments are usually more severe. The challenge in a disaster setting lies in the scarcity of resources, limited treatment space, and the sheer volume of patients. It's not necessarily the severity of individual injuries that poses the greatest challenge, rather, it's the sheer number of patients and the lack of resources available to effectively treat them. This is the primary problem we face in such situations. 

How do disaster medicine teams triage patients during a crisis, and what factors are considered when determining which patients to prioritize for treatment? 

Dr. Zamzali - When it comes to triage, there are different types depending on the setting. In the emergency department, we have field triage, disaster triage, and hospital triage. In hospital triage, our goal is to identify the most severe cases. These patients are directed to the red zone or critical area, while those with less severe conditions go to the less critical zone or stable area. In the emergency department, we have all the necessary resources, including doctors, nurses, and assistants, to provide focused care to each patient, especially those in the red zone. It's a patient-centered approach, prioritizing their needs. 

However, things work differently in a disaster scenario. In a disaster, our primary objective is to save as many people as possible. So, a key difference is that we prioritize resources based on the likelihood of survival. If a patient has a low chance of surviving, we allocate our resources to those with a higher chance of survival. This means that in a disaster setting, we have to relegate the severely ill patients to a lower priority. Our focus shifts towards saving as many lives as we can, rather than solely concentrating on the most critically ill patients like we do in a hospital setting. 

When it comes to providing psychological support during disaster response, the current approach is to ensure that all responders, whether they're medical professionals or part of the rescue team, receive what's known as PFA or psychology plus aid. The aim of PFA is not to provide treatment right away, but rather to identify individuals who may require further psychological intervention or support. 

What are some of the ethical considerations that arise in disaster medicine, such as rationing of medical supplies or prioritizing treatment for certain groups over others? 

Dr. Zamzali - Let's talk about Cardiopulmonary Resuscitation (CPR) as an example. In a normal situation, if someone is not breathing and has no pulse, we perform CPR to try and revive them. However, in a disaster scenario, things can be different. If we come across a patient without a pulse and not breathing, but there's another person nearby who is conscious and in need of immediate help, we prioritize saving the conscious person first. It's not that we're neglecting the first patient who is critically ill. It's just that their chances of survival are lower. Ethically, it's a challenging decision because we have to go against our natural instinct and focus on those who have a higher likelihood of being saved. If you ask me, this is one of the most difficult ethical dilemmas I face in such situations. 

Doctor, you mentioned that disaster medicine teams also offer psychological support to survivors of disasters. Could you please explain how these teams provide such support, and what are some of the enduring mental health effects that people may experience after going through a disaster? 

Dr. Zamzali - When it comes to providing psychological support during disaster response, the current approach is to ensure that all responders, whether they're medical professionals or part of the rescue team, receive what's known as PFA or psychology plus aid. The aim of PFA is not to provide treatment right away, but rather to identify individuals who may require further psychological intervention or support. 

While most people tend to focus on the well-being of the victims, it's equally important to look inward and pay attention to the mental health of the response team itself. When we face calamities and witness immense suffering, it can take a toll on the responders. That's why we need to consider conditions like post-traumatic stress disorder (PTSD) as a top concern. 

These psychological challenges can affect not only the victims but also the well-being of the responders. They may struggle to return to their normal lives, experiencing symptoms of depression, anxiety, or even issues related to intimacy. It's crucial, in a disaster response scenario, to recognize not just the needs of the victims but also those of our teammates who may require additional psychological support. This is where PFA plays a vital role. It acts as a form of first aid, helping us identify and acknowledge the need for further psychological support without providing immediate treatment. 

How do disaster medicine teams collaborate with other emergency responders, such as firefighters, police, and public health officials? 

Dr. Zamzali - It is a part of our work, and I always emphasize collaborating with various stakeholders in disaster response. These stakeholders include the medical team, the police for security control, and the rescue team, which includes firefighters and those specialized in heavy rescue with equipment. We also have policymakers and decision-makers who contribute to the planning process. The challenge arises from the fact that each of these groups speak a different language, metaphorically speaking. 

For example, when I mention fractures, I am referring to bone breaks from a medical standpoint. However, engineers might interpret fractures in a different context. That's why I emphasize the importance of effective communication and harmonizing our language to ensure we understand each other and can respond collectively. This becomes especially crucial when collaborating with other agencies, which is known as the inter-agency approach. 

An insightful concept I learned from my Japanese mentor is the transdisciplinary approach. It means that when we design a disaster program together, we go beyond our specific domains. Medical professionals consider health, police focus on safety, and rescue teams concentrate on patient extraction. Through collaboration, the boundaries between these agencies become blurred. We all need each other's expertise. In this way, when we build a disaster plan or program, the approach becomes transdisciplinary. Nobody individually owns the disaster. It becomes a collective responsibility shared by everyone involved. 

What role do telemedicine and other technologies play in disaster medicine, and how have they been used in recent disasters? 

Dr. Zamzali - The challenge with implementing telemedicine in a disaster setting primarily revolves around logistics. In such situations, we not only lack the necessary computer infrastructure, but we also face difficulties in establishing reliable communication lines. Often, we have to rely on phones, walkie talkies, or other makeshift methods to stay connected.  

However, if these logistical hurdles can be overcome, telemedicine can play a vital role in disaster response. It can enable us to consult, review patients, and monitor their progress without physically being present in the affected area. This can be particularly beneficial when our medical team is unable to reach the disaster site due to various constraints. In such cases, we can leverage telemedicine to seek input and guidance from specialists located outside the immediate vicinity. This allows us to access crucial expertise and provide specialized consultations for patients in need. 

When it comes to dealing with disasters, one key aspect is the need for effective planning. We must have a solid plan in place that includes preparedness, mitigation strategies, and more. Having a well-thought-out plan is crucial because it's challenging to make on-the-spot decisions during a disaster. That's why I always emphasize the importance of planning your work and then working your plan. 

Doctor, in addition to the resource constraints you mentioned, what are some of the other challenges that practitioners of disaster medicine face in such settings? 

Dr. Zamzali - I would say one of the main challenges we face is communication. In disaster settings, we often encounter difficulties in effectively communicating with different stakeholders. It's crucial for us to ensure that moving forward, we all speak the same language, metaphorically speaking. This means not only the act of talking and conveying information but also aligning expectations. 

Sometimes, various agencies may have different expectations from the medical team, and vice versa. It's important for us to have clear and open communication to address these expectations and clarify our respective roles. The goal is to achieve a unified response where everyone understands their responsibilities and works together seamlessly. 

If you were to ask me what the primary challenge is, I would say that if we can address the communication issues, it would go a long way in resolving many other problems that arise in disaster medicine. Clear and effective communication holds the key to overcoming various obstacles we face in these challenging situations. 

What are some best practices for disaster preparedness and response, and how can individuals and communities better prepare for future disasters? 

Dr. Zamzali - Certainly, if you were to ask me about the best approach in terms of training and preparation, I would emphasize the importance of community resilience. So, how do we go about developing resilience? Essentially, it refers to the ability to withstand the impact of a disaster. Let's take an example: imagine two families living by a river. One is a wealthy family in a sturdy brick house, while the other is a less affluent family. If a flood occurs, it may destroy the house of the latter family but not significantly affect the house of the wealthier family. Furthermore, although the flood may cause the less affluent family to lose their means of livelihood, the wealthier family has resources to sustain themselves. This highlights the need to focus on making communities more resilient, even if we can't entirely prevent disasters from occurring. 

Another aspect to consider is the concept of Public-Private Partnerships (PPP). This approach involves engaging private companies, utilizing their technology, assets, and financial resources, to collaborate with the government and relevant agencies in managing disasters alongside the community. It's beneficial when the community itself can respond to its own disaster, rather than solely relying on external assistance. Waiting for help to arrive can sometimes be time-consuming, but if the community is resilient and adequately prepared, they can take action and respond effectively to the situation. 

In summary, promoting community resilience and fostering public-private partnerships are vital aspects of disaster management, ensuring that communities are prepared to withstand and respond to disasters on their own, while also utilizing external resources when needed. 

To conclude our session, in your opinion, what is the most important skill or attribute for a disaster medicine practitioner to possess, and how can it be developed and cultivated? 

Dr. Zamzali - When it comes to dealing with disasters, one key aspect is the need for effective planning. We must have a solid plan in place that includes preparedness, mitigation strategies, and more. Having a well-thought-out plan is crucial because it's challenging to make on-the-spot decisions during a disaster. That's why I always emphasize the importance of planning your work and then working your plan. 

In fact, it's essential to have multiple plans ready. Plan A, Plan B, Plan C, and so on, all the way to Plan Z, or even having a backup plan for your backup plan. This allows you to be prepared for various scenarios and contingencies. Looking ahead, you anticipate what could go wrong and prepare accordingly. It's a matter of being proactive rather than reactive. 

As I often say, it's best to prepare for the worst while hoping for the best. By doing so, we ensure that we have the necessary strategies in place to handle the challenges that may arise during a disaster. 

The way we can foster this is through what I consider disaster medicine. When we talk about medicine, it's a combination of science and art. It's a field where we need to be trained and continuously learn. For me, the training process involved accompanying my mentors and teachers to actual disasters. I observed how they managed the situations and would ask them questions like, "Why did you handle it this way? Can I do the same?" As I gained more confidence, I started managing my own disasters while maintaining contact with my mentors. I would consult them by asking, "Is it okay if I do this? What do you think about this?" And they would provide valuable input. 

To me, the key characteristics here are continuous learning and the mentor-mentee relationship. It's about creating an environment where learning is encouraged and cultivated. This not only helps us improve our skills in disaster medicine but also as individuals. By embracing this learning mindset and fostering relationships with experienced mentors, we can constantly evolve and enhance our abilities. 

Thank you so much for your valuable insights!