From the Department of Emergency Medicine(Chen CC, Chang H, Wang TL), Shin-Kong Wu Ho-Su Memorial Hospital.

Correspondence to Dr. Tzong-Luen Wang, Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Road, Taipei, Taiwan. E-mail M002183@ms.skh.org.tw

The objectives of this study were tried to evaluate the effectiveness of the standardization of training and uniform certification by making comparisons among Taiwan Society of Disaster Medicine (TSDM) and other Societies, to analyze the composition of the students joined in the examination of certification and to help further modification of DMAT set-up. We invited ten specialists of disaster medicine to establish an examination database for certification. Fifty questions were randomly selected as the final test of certification within the following four months. Totally 517 students joined in the examination of certification. Of 400 students attending the basic training course of TSDM, 10 students (2.5%) failed to pass, whereas 12 students (10%) failed (P<0.05 vs. TSDM group) among another 117 students joined in the training course of other Societies. The mean scores were 74.67 and 69.15 in TSDM and other Societies respectively (P<0.05). The effectiveness of the standardization of training and uniform certification has been proven in our study. Further policies may be needed to direct the standardization of training course, appropriate certifications and licensure of DMAT members and the engagement of emergency medical technicians in the DMATs. (Ann Disaster Med. 2003;1:70-77)
Key words: Standardization; Uniform Certification; Disaster Medicine

The natural energy contains infinite lives, however, it sometimes brings calamity as well. In this high-density society, the centralization of population increases calamity level to thousand times than past. A scientific research reveals that the natural calamity is growing by geometric progression in recent decades. In these few years, wars and terror attacks have been caused severe damages to human society. Hence, how to take precautions against natural and man make calamities has become a “Not a moment is to be lost” matter. Historically the government has relied on the military as a source of manpower and supplies during disasters.¹ Military personnel are well trained and prepared to establish and maintain essential services in areas that have had infrastructures destroyed by warfare. As a result of restructuring and downsizing, the military does not represent the labor pool that it once did. This results in a decrease in the military's ability to respond to disaster relief situations. The new role of the military during disasters will be to transport supplies, equipment, and volunteer disaster workers to, and within, a stricken area.¹ In Taiwan, so-called volunteer disaster workers has always conjured up images of the Tzu Chi Foundation aiding disaster victims. Its resources to act as providers of food, shelter, and emergency living areas, rather than providers of expert medical care. This void between Tzu Chi Foundation involvement and the traditional military role of providing disaster health care workers is currently filled by disaster medical assistance teams (DMATs). Staffed by volunteers, DMATs provide medical care both at the scene of a disaster and at transfer points and reception sites associated with patient evacuation.
According to the definition from National Disaster Medical Team (NDMS) in the United States,² DMATs are organized as a division of the federal government through the NDMS. NDMS is a joint effort of the Department of Health and Human Services, the Department of Defense, the Department of Veterans Affairs, the Federal Emergency Management Agency (FEMA), state and local governments, and private organizations. NDMS was developed to provide for mutual aid among different parts of the nation in the event of a catastrophic disaster that overwhelms the health care resources in the locally affected area. Its main objectives are to (1) provide direct medical assistance to the disaster area in the form of DMATs, (2) evacuate patients who cannot be cared for locally, and (3) provide hospitalization through a nationwide network of pre-allocated hospital beds.
After Chi-Chi earthquake, our government has been engaged in the establishment of a good disaster response system including DMATs since July 2000.^3,4 However, the compositions of our DMATs (either national or local) individualized, depending upon different policies and different guidance in each team, so the ability of emergency response and action are different in each team. The phenomenon elucidated that our disaster response system is still lacking in uniform policies and consistent planning. Taiwan Society of Disaster Medicine has been established in 2001, and engaged in the standardization of training and uniform certification of local disaster medical assistance team. The objectives of this study are tried to 1) evaluate the effectiveness of the standardization of training and uniform certification by making comparisons between Taiwan Society of Disaster Medicine and other Societies; 2) analyze the composition of the students joined in the examination of certification; and 3) help further modification of DMAT set-up.

All the data were processed and analyzed with Microsoft Excel 2000 for Windows. The techniques applied to data analysis included descriptive statistics generating and independent samples t-test and chi-square test. We compared the percentage of failure between the students from Taiwan Society of Disaster Medicine and those from other Societies by chi-square test. The differences in the performance of students were examined by an independent samples t-test. A P value less than 0.05 was considered as statistically significant.

These 228 questions consisted of the categories such as NDMS, incident command system, public health, mass evacuation, logistics, and mass casualty. We picked up 50 questions for final examination. Of all 400 students attending the basic training course of Taiwan Society of Disaster Medicine, 390 students passed and 10 failed. Among another 117 students attending the training course of other Societies, 105 passed and 12 failed. The percentages of failure were 2.5% and 10% in Taiwan Society of Disaster Medicine and other Society, respectively (P<0.05) (Table 1). The mean scores were 74.67 and 69.15 in Taiwan Society of Disaster Medicine and other Society respectively (P<0.05)(Table 3).
Table 2 depicts the composition of the students attended in the training course of Taiwan Society of Disaster Medicine and joined in the examination of certification. The nurses, doctors, EMTs and volunteers comprised around 58.25%，12.75%，2.5% and 4.75% respectively. Table 2 depicts the composition of the students attended in the training course of other Societies and joined in examination of certification. The nurses, doctor EMTs and volunteers comprised around 29.06%, 9.4%, 3.42% and 52.14% respectively. The comparison between Table 2 revealed that the volunteers comprised around 4.75% in Taiwan Society of Disaster Medicine whereas they consisted 52.14% in other Societies. Few EMTs joined in the examination of certification in Taiwan Society of Disaster Medicine and other societies.

DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site.^1-2 In mass casualty incidents, their responsibilities include triaging patients, providing austere medical care, and preparing patients for evacuation. In other types of situations, DMATs may provide primary health care and/or may serve to augment overloaded local health care staffs. Under the rare circumstance that disaster victims are evacuated to a different locale to receive definitive medical care, DMATs may be activated to support patient reception and disposition of patients to hospitals. DMATs are designed to be a rapid-response element to supplement local medical care until other contract resources can be mobilized, or the situation is resolved.
There are two national disaster medical assistance teams (NCKU、NTU) and 12 local disaster medical assistance teams in Taiwan at present. However, the compositions of our DMATs (either National or local) varied significantly, depending upon different policies and different guidance in each team, so the ability of emergency response and action are different in each team.⁵ The phenomenon elucidated that our disaster response system is still lacking in uniform policies and consistent planning.⁵ Taiwan Society of Disaster Medicine has therefore been engaged in the standardization of training and uniform certification of local disaster medical assistance team. We found out that the scoring and success rate of the students attending the training courses of Taiwan Society of Disaster Medicine were both better than other students (P<0.05). Therefore, the training course needed to been standardized and DMAT members are required to maintain appropriate certifications and licensure within their disciplines.
As mentioned previously, a general DMAT teams normally consist of approximately 35 members - 4 or 5 physicians, 10 to 12 nurses and paramedics, 8 to 12 EMTs, with the remainder of the team made up of support personnel.¹ In Taiwan, however, EMT accounts for only 6.4% of DMAT members,5 which is different from the observations in the United States (28.7%).^5-10 In our study, the EMT comprised only 2.5% of all the students attending examination of certification. It may also explain the fact that there is a greater need for physically strong persons with the ability of first aid rather than for highly trained medical specialists during a disaster. The immediate situation will require more tasks such as stretcher carrying than technical surgeries or procedures.¹ Besides primary first aid and emergency care, the paramedics and EMT always have accepted the training of “disaster medicine” and have some clinical experiences, so the attendance of them should be a crucial step in setting up a good DMAT.⁵ In other words, more EMT should be encouraged to join DMAT.
Another issue is concerning about the role of the volunteers attending in the DMATs. There are still controversies about the role of volunteers. In one of our DMATs, there are more than 60% of the members to be volunteers.⁵ The volunteers attended in training course of other Society joined in the examination of certification comprised 52.14%. It is different from the DMATs in the United States (< 5%).^9-12 As we know, most of the volunteers lack in medical training such as basic and advanced life support and lack clinical experiences. The roles of the volunteers in real disaster situations may be limited. Instead, the paramedics on EMT should play a better role than the volunteers do.
An important limitation of this study is that the compositions of two groups were different; the students attending Taiwan Society of Disaster Medicine have higher percentage of medical education background that those in other societies. It may explain the better performance in certification from those in Taiwan Society of Disaster Medicine. Other limitations include limited students in other societies attending the certifications, and lack of consistent certification in all national DMATs and local DMATs.
In conclusion, the effectiveness of the standardization of training and uniform certification has proven to be good. The uniform policies need to be direct to the standardization of training course, appropriate certifications and licensure of DMAT members and encourage the EMTs to attend the DMAT training.