DEVELOPMENT, IMPLEMENTATION AND OUTCOMES OF A TRAINING PROGRAM

FOR RESPONDERS TO ACTS OF TERRORISM

Geoffrey T. Miller, NREMT-P, Joseph A. Scott, MD, S. Barry Issenberg, MD, Emil R. Petrusa,PhD, Angel A. Brotons, EMT-P, David Lee Gordon, MD, William C. McGaghie, PhD,

Michael S. Gordon, MD, PhD

ABSTRACT

Introduction. Responding to acts of terrorism requires the ef-fective use of public-safety and medical-response resources.The knowledge, skills and attitudes necessary to respondto future threats is unfamiliar to most emergency respon-ders. Objectives. The purpose of this report to describethe development, implementation and evaluation of a mul-tidisciplinary, interactive and simulation-enhanced courseto prepare responders to acts of terrorism. Methods. Weused a 5-step systematic process to develop a blended-learning, simulation-enhanced training program. Learnerscompleted a self-confidence questionnaire and written ex-amination prior to the course and a self-confidence ques-tionnaire, written examination and course evaluation whenthey finished the course. Results. From July 7, 2003 to March8, 2005, 497 consenting learners completed the course. Af-ter course completion, learners demonstrated significant in-creases in their knowledge of terrorism response (t = −64.3,df = 496, p < 0.05) and their confidence in responding to ter-rorist events (t = −45.5, df = 496, p < 0.05). Learner feedbackabout the course was highly positive. Conclusions. We suc-cessfully implemented a two-day course for professionalslikely to respond to terrorist acts that included scenario-basedperformance training and assessment. Course participants in-creased their knowledge and were more confident in theirability to respond to acts of terrorism after participating inthis course. Key words: disaster; EMS; simulation; terrorism;training.

PREHOSPITAL EMERGENCY CARE 2006;10:239–246

INTRODUCTION

Complex and increasing threats such as terrorism, bio-logical disease outbreaks (Marburg1 and Severe AcuteRespiratory Syndrome [SARS]),2 catastrophic natu-ral disasters (hurricanes, tsunamis, mud slides, earth-quakes) and other emergencies are driving the need fora better prepared and sustainable emergency-response

Received September 9, 2005 from the University of Miami MillerSchool of Medicine, (GTM, JAS, SBI, AAB, DLG, MSG) Duke Univer-sity School of Medicine (ERP), and Northwestern University FeinbergSchool of Medicine (WCM). Accepted October 12, 2005.

Address correspondence and reprint requests to: Geoffrey T. Miller,NREMT-P, Center for Research in Medical Education, University ofMiami Miller School of Medicine, PO Box 016960 (D-41), Miami, FL33101. e-mail: gmiller@med.miami.edu

doi:10.1080/10903120500541191

community. The potential for mass-casualty incidentsthat cross broad geographic areas, and medical, politi-cal, criminal and public-safety issues dictate that train-ing for the emergency-response community be stan-dardized across all disciplines, agencies and regions3−5

All responders must be able to react appropriately tothese events, protect themselves, initiate command,communicate, perform appropriate triage and decon-tamination, and render medical care, in and out of thetraditional healthcare delivery venues.6−9 The rangeof those expected to respond to these events is ex-panding to include many different professionals, allof whom will be required to adapt rapidly to specificincident demands in a unified approach. The knowl-edge, skills and attitudes needed to respond to thesethreats are unfamiliar to most of these populations.In addition, it is unlikely emergency responders willencounter many of these high-impact, low-frequencyevents after their initial training. Studies demonstratethat if providers are not exposed to critical events on aregular basis, their knowledge and skills in respond-ing to such events decline 6–12 months after initialtraining.10

Simulation-based education has been shown to bea practical and valid approach to prepare respondersto these events.11,12 It is generally agreed that a fun-damental core of knowledge and essential skill set isnecessary for anyone involved in response to acts ofterrorism.13−17 Training in this area has increased inthe past few years but continues to vary in content,methods and availability. Most available programs arelecture based and lack skill training and opportunityfor practice.13 Usually, only highly specialized teamsof responders (hazardous materials [HAZMAT], bombdisposal, special response teams, etc.) participate inprograms that include skills practice and simulationtraining.13 Major challenges to the widespread imple-mentation of intensive, hands-on training programs toa larger number of responders include program dura-tion, required prerequisites, high cost and a lack of lit-erature regarding the effectiveness of this type of train-ing. This report describes how the University of MiamiCenter for Research in Medical Education (UM CRME)addressed these challenges through the development,implementation and evaluation of a multidisciplinary,interactive and simulation-enhanced course to prepareresponders to acts of terrorism.

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METHODS

The UM CRME convened a curriculum developmentadvisory committee (CDAC) to conduct an extensivereview of existing terrorism, HAZMAT, military anddisaster-response curricula in response to the events ofSeptember 11, 2001. UM CRME faculty members par-ticipated in several existing courses as a prelude to de-veloping the new curriculum. The goal was to create astandardized, interdisciplinary curriculum for targetedlearner groups. The CDAC adopted a modified ADDIE(Analysis, Design, Development, Implementation andEvaluation)18 model for curriculum development andbenefited from the UM CRME’s experience in creatingcourses such as Emergency Management of Acute My-ocardial Infarction19 and Emergency Management ofAcute Stroke.20

Needs Analysis

The CDAC collaborated with subject matter experts(SMEs) from different regions, agencies and municipal-ities that represented our target audiences (emergencymedical technicians, paramedics, firefighters, nursesand physicians) to identify their unique learning needs.The geographic target audience included emergencyresponders in the state of Florida. We reached thisaudience through Florida’s community colleges andvocational-technical schools that provide initial andcontinuing public-safety and medical education.

The CDAC deliberated often to determine the opti-mal duration of the training program. Most existingcurricula for terrorism and disaster response rangedfrom 4 hours to more than 40 hours in length depend-ing on technical specialty. In many cases, the contentfor these curricula was delivered only through lecturesand reading materials, limiting learner time for hands-on skill training and deliberate practice of core com-petencies. Additional curriculum delivery methods in-cluded CD-ROM, web-based eLearning and self-studyprograms. The CDAC felt that lengthy courses incur asignificant financial and workforce burden on agenciesand are often impractical or prohibitive. As a result, theCDAC recommended a course length of 16 hours over2 days to provide a balance between training needs andscheduling constraints in the community.

Design of Course

The curriculum design was based on (1) UM CRMEexpertise19−21; (2) the input of an international con-sortium of experts in medical education and assess-ment from 12 medical centers; and (3) the input ofthe CDAC and SMEs, including emergency physi-cians, trauma surgeons, toxicologists, infectious dis-ease experts, members of the U.S. military, emergencymedical services (EMS) and fire-rescue experts in haz-

TABLE 1. UM Emergency Response to Terrorism GlobalLearning Outcomes

(1) Recognize a potential terrorist incident and initiate incidentoperations.

(2) Implement personal and public safety protective measures.(3) Perform appropriate decontamination procedures.(4) Implement the Incident- and Unified-Command systems and

perform effective intra- and interagency communication.(5) Provide triage and emergency medical care specific to incident

type(s).

ardous materials and urban search and rescue, andlaw-enforcement officers. Global learning outcomes(Table 1) were established focusing on desired compe-tencies that all learners should master by the end ofthe course. We then adapted specific learning objec-tives from existing curricula and ensured they werein congruence with existing state and federal guide-lines. Redundancies and omissions of content for thecore competencies were noted and modified. These corecompetencies provided the framework for a curriculumand evaluation process that adhered to the principlesof Instructional System Design.22 These include: pro-viding clear goals and instructions, keeping individu-als motivated to learn, and providing opportunities forself-assessment and immediate and constructive feed-back. All adopted strategies were guided by evidence-based literature.23−25

We introduced each topic in an interactive, case-based, lecture format that contains embedded videosand questions to engage learners and provides themwith opportunities to respond and receive instructorfeedback. Some lectures are followed by interactive ses-sions, such as a game show, large-group tabletop, andtriage exercises, which allow learners to quickly ap-ply and practice the material. During afternoon ses-sions, learners practice hands-on emergency-responseskills that were presented in the lectures while work-ing in their personal protective equipment. Learnerspractice skills with manikins, task trainers (airwaymanagement, antidote administration, IV therapy) andstandardized patients (ambulatory decontamination,triage, communication). Multidisciplinary team build-ing concepts are practiced by having the learners partic-ipate in team-based scenario exercises. These exercisesallow learners to recognize and analyze the incident,communicate information, evaluate the patient, prac-tice team and individual skills, and receive specific, im-mediate feedback that corrects omissions and errors.

Development of Course

With the assistance of the CDAC, we adopted educa-tional strategies intended to facilitate learner masteryof curricular objectives. Content and delivery meth-ods included the development of modular, interactivePowerPoint presentations to present core knowledge,

Miller et al. TRAINING PROGRAM FOR RESPONDERS TO ACTS OF TERRORISM 241

TABLE 2. University of Miami Emergency Response to Terrorism Course Agenda

Day 1 Day 2

Topic Time Format Topic Time Format

Precourse Assessments 30 min. MCE, SRF Chemical Agents 60 min. CBLTerrorism Response Concepts 30 min. CBL Biological Agents 45 min. CBLIncident Operations 45 min. CBL Radiological and Explosive Agents 45 min. CBLPersonal Protective Equipment (PPE) 50 min. EGE Managing the Incident 45 min. TTEMass Decontamination 60 min. CBL Triage 45 min. VBEIncident and Unified Command 45 min. CBL Team-Based Scenario ExercisesPPE Donning Exercise 45 min. SE • Case 1 (Nerve Agent) 45 min. OSCESkills Stations • Case 2 (Vesicant Agent) 45 min. OSCE

• Ambulatory Decontamination 45 min. SE • Case 3 (Cyanide) 45 min. OSCE• Incapacitated Decontamination 45 min. SE • Case 4 (Radiological Device) 45 min. OSCE• Medical Management 45 min. SE Postcourse Assessments 30 min. MCE, SRF, CE• Specialized Equipment 45 min. SE

CBL: Case-Based Lecture; CE: Course Evaluation; EGE: Educational Gaming Exercise; MCE: Multiple-Choice Examination; OSCE: Objective Structured ClinicalEvaluation; SE: Skills Exercise; SRF: Self-Rating Form; TTE: Tabletop Exercise; VBE: Video-Based Exercise.

reinforced with case presentations, instructional games,video demonstrations, large- and small-group exer-cises, scenario-based skill stations, and discussion andfeedback sessions. We then developed a student learn-ing manual that included a course syllabus and agenda,explicit learning objectives for each module, and writ-ten curricular materials such as slides, case studies,skills checklists, and resources for additional learningand reference. We also developed an instructor man-ual and comprehensive curricular training materialsthat included annotated instructor slide sets empha-sizing key teaching points, detailed instructional ma-terials for teaching skills, checklists, teaching posters(Figure 1), scripted scenarios, team building projectsand learner evaluation forms. Finally, we developedcurricular evaluation tools: pre- and postcourse learnerexaminations, pre- and postcourse annotated instruc-tor evaluations, formative psychomotor skills check-lists, affective (behaviors and attitudes) evaluations andcourse effectiveness surveys.

We developed course content to be delivered via avariety of instructional methods. These include lec-tures, small-group sessions, independent study, skill-building exercises and team training. We incorporateda high degree of realism into the skills stations to repre-sent actual working conditions including the use of spe-cialized equipment and medical simulators (Figure 2).Significant course time was devoted to hands-on skilltraining and simulation exercises (Table 2). This al-

TABLE 3. Study Population Demographics

Group N (%) Age Male Female Years of experience

Paramedic 313 (63.0%) 39.1 (23–58) 268 (85.6%) 45 (14.4%) 9.4 (1–30)EMT 137 (27.6%) 40.8 (24–58) 122 (89.1%) 15 (10.9%) 7.7 (1–31)RN 24 (4.8%) 40.4 (25–59) 7 (29.2%) 17 (70.8%) 13.3 (1–27)Other∗ 16 (3.2%) 34.7 (26–49) 9 (56.3%) 7 (43.7%) Not ReportedMD 7 (1.4%) 35.1 (28–50) 4 (57.1%) 3 (42.9%) 6.0 (2–12)Total 497 39.4 (23–59) 410 (82.5%) 87 (17.5%) 9.1 (1–31)

∗Law enforcement, first responder, ER technician, dispatcher, physician assistant.

lowed for deliberate practice26 of core competencieswith the intent to promote transfer of knowledge andskill.

Prior to implementing the new course, we pilot-tested all classroom presentation materials, the learnermanual, skills station instructional posters and check-lists, scenario/Objective Structured Clinical Examina-tion (OSCE)27 guides and assessment materials, and acomprehensive instructor training manual. We elicitedinstructor, learner and CDAC feedback to refine thesematerials. The SMEs reviewed and approved all finalcurricular materials.

IMPLEMENTATION OF COURSE

Participants

We first implemented the course at the UM CRME. Apilot phase allowed the CDAC to determine the nec-essary administrative structure and support. We setthe class size at 24-30 students to allow for optimalinstructor-learner ratios and hands-on time for the stu-dents to practice skills. Course registrants were fromSouth Florida fire-rescue departments, hospitals andother healthcare agencies (Table 3). Although most ofthe fire-rescue department personnel receive manda-tory training while on-duty, a small percentage at-tended courses on their own time. All of the nursesand physicians attended the course voluntarily. None

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Miller et al. TRAINING PROGRAM FOR RESPONDERS TO ACTS OF TERRORISM 243

FIGURE 2. Learners practice incapacitated victim decontamination in level C personal protective gear.

of the learners received any compensation for their par-ticipation in the course. EMTs, paramedics and nursesreceived continuing professional education credit to-wards their re-licensure.

Instructors

All of the instructors attended a training course andparticipated in the pilot program. Full- and part-timefaculty from the UM CRME presented lectures, facil-itated group discussions and skills development ex-ercises, and gave feedback to the instructor-learners.The instructor course included delivery of comprehen-sive training materials and individual instructor train-ing. To facilitate statewide dissemination, we repli-cated the instructor-development process at partnerEMS training centers throughout the state of Florida,resulting in more than 200 trained instructors at29 locations.

Implementation Plan

From the beginning, we involved stakeholders fromkey state organizations to ensure that the training wasappropriate for their constituents and that the evalua-tion data addressed their needs.28 Prior to wide-scaleimplementation of our curriculum, we met with thesegroups to minimize potential barriers such as compet-ing demands, nonsupportive attitudes, and scheduling

concerns. Sixty days prior to each planned course, theUM CRME identified local agencies, training officers,medical directors, coordinators and managers to advisethem of the program and provide them information forrecruitment purposes. We also maintained a websitethat publicized the course and allowed for on-line reg-istration.

Course Evaluation

A course-evaluation process is essential to demonstrateneed for the course and how it contributes to the goalsand objectives of agencies, departments and individ-uals who participate. Program evaluation typically in-cludes feedback from instructors, learners and otherstakeholders. This information may be collected duringthe development of the program (formative), when a fi-nal program is delivered (summative) or both. For thisstudy, we evaluated learners’ attitudes (confidence),cognitive knowledge gain and learners’ perception ofcourse effectiveness.

Design

This was a prospective, cross-sectional, before-and-after study designed to measure the effectiveness of theERT training program. The study was approved by theUniversity of Miami Miller School of Medicine HumanSubjects Research Office (IRB Protocol #03/300).

244 PREHOSPITAL EMERGENCY CARE APRIL / JUNE 2006 VOLUME 10 / NUMBER 2

TABLE 4. Results of Self- and Cognitive Assessments

Group N (%) Pre-self Post-self Change Pre-cog Post-cog Change

Paramedic 313 (63.0%) 3.0 (± 0.7) 4.5 (± 0.5) 1.5 (± 0.7) 54.4 (± 10.2) 88.5 (± 7.9) 34.1 (± 11.4)p < 0.001 p < 0.001

EMT 137 (27.6%) 2.7 (± 0.8) 4.2 (± 0.5) 1.5 (± 0.8) 49.7 (± 9.5) 82.5 (± 9.5) 32.8 (± 11.9)p < 0.001 p < 0.001

RN 24 (4.8%) 2.4 (± 0.9) 4.5 (± 0.5) 2.1 (± 0.9) 49.0 (± 12.4) 91.5 (± 6.2) 42.5 (± 13.2)p < 0.001 p < 0.001

Other 16 (3.2%) 2.1 (± 0.8) 4.1 (± 0.5) 2.0 (± 0.8) 42.8 (± 11.4) 78.0 (± 10.4) 35.3 (± 16.2)p < 0.001 p < 0.001

MD 7 (1.4%) 2.7 (± 0.8) 4.6 (± 0.4) 1.9 (± 0.8) 60.0 (± 15.0) 90.9 (± 5.5) 30.9 (± 13.6)p < 0.001 p < 0.001

Total 497 (100%) 2.9 (± 0.8) 4.4 (± 0.5) 1.5 (± 0.8) 52.7 (± 10.6) 86.7 (± 8.9) 34.0 (± 11.8)

Outcome Measures

Demographic Data

We developed a database (Microsoft Access 2000;Microsoft Corp., Redmond, WA) to document eachtrainee’s contact information, professional classifica-tion, current position and employer, primary jobfunction, experience in the position, previous expe-rience/education and performance on evaluations.Learners completed a registration form at the begin-ning of each course. Learners also read and signeda consent form that permitted us to use their in-formation for quality improvement and academicpurposes.25

Knowledge

Participants completed a 25-question multiple-choiceexamination before and after the course that measuredlearners’ knowledge in responding to terrorist events.25

All examination items were linked to course objectivesand reviewed by the CDAC and SME groups followinga rigorous 8-step process to ensure item reliability andvalidity.29

Confidence

Participants completed a 10-item survey regardingtheir confidence in responding to a terrorist event. Par-ticipants indicated their confidence for each questionusing a five-point scale (1 = not confident, 5 = very con-fident). If a participant ranked themselves low (1 or 2),they were asked to explain in an open-ended responsearea. The same ten questions and scale were used at theend of the course. This provided data on participants’achievement of affective outcomes.25

Learner Satisfaction

A 22-item program-evaluation questionnaire solicitedfeedback from learners regarding the effectiveness ofthe course and suggestions for improving the curricu-lum. Learners ranked each component of the courseon a five-point scale (1 = strongly disagree, 5 = strongly

agree). Learners were also invited to provide additionalcomments.

Analytical Methods

Data were extracted from the database and enteredinto SPSS (Ver. 12; SPSS Inc., Chicago, IL) for analysis.We analyzed pre- and postcourse written tests and theself-confidence questionnaires with a t-test for pairedgroups. We used a probability of 0.05 to determine sta-tistical significance.

RESULTS

From July 7, 2003 to March 8, 2005 we conducted 33courses involving 497 consenting study participants(829 total course registrants). Most learners were maleand the majority was either paramedics or EMTs.Learners gained a significant amount of new infor-mation by the end of the course (52.7% to 86.7%,t = −64.3, df = 496, p < 0.05) (Table 4). A pass mark of84% was used for cognitive pre- and postcourse ex-aminations, modeled after the standards of the Ameri-can Heart Association(AHA).30 This has been our typ-ical pass score and used for the past decade with morethan 50,000 learners. Seventy-three percent of learnersscored greater than or equal to the pass mark. Learnerswho did not achieve the pass mark completed manda-tory remediation. All learners received feedback on allitems of the assessment. Learners also demonstrated asignificantly higher confidence in responding to terror-ist events after the course (2.9 to 4.4 out of 5), (t = −45.5,df = 496, p < 0.05) (Table 4). Course evaluation washighly positive, with an average rating of 4.51 of 5. Themost highly rated component was the hands-on skillstation for emergency personal protective equipmentdonning. Learners highly agreed with the followingstatements:

• “I would recommend this course to others,”• “this program is useful for me in my occupation,”

and• “a positive learning environment was maintained

during the course.”

Miller et al. TRAINING PROGRAM FOR RESPONDERS TO ACTS OF TERRORISM 245

Written comments supported the positive ratings—no items were rated less than 4.3.

DISCUSSION

We successfully incorporated the latest scientificknowledge related to disaster and terrorism events intoa dynamic and interactive 2-day, sixteen-hour coursefor emergency responders caring for victims of disas-ters and terrorism. We adopted a standardized yet flexi-ble, hands-on, competency-based curriculum for a widerange of healthcare and public-service providers. Par-ticipants who attended the course demonstrated im-proved knowledge on a 25-item written examinationand improved selfconfidence on an affective question-naire. Since its inception, the course has been imple-mented statewide through a grant and partnership withthe State of Florida Department of Health. As of Au-gust 2005, we have trained more than 2,200 learnersin the ERT course, demonstrating the practicality of itswidespread implementation.

We provided learners not only with the opportunityto learn new principles regarding an effective responseto acts of terrorism, but also the opportunity to engagein deliberate practice26 of core skills necessary for such aresponse. Deliberate practice involves (a) repetitive per-formance of psychomotor skills in a focused domain,coupled with (b) rigorous skill assessment, that pro-vides learners (c) specific, informative feedback, thatresults in (d) better skills performance in a controlledsetting.

The use of standardized patients as victims of multi-ple types of terrorism events facilitated the training andpractice of critical skills. Learners actually practiced theproper technique for ambulatory decontamination andburn-victim care and demonstrated their competence.The use of a wide range of task trainers and simulatormanikins enhanced the “psychological fidelity”31 of allskills stations and scenarios for training and testing. In-teractive, multimedia video exercises portrayed a widerange of causalities, enabling learners to practice triage.Throughout the course, we repeatedly emphasized andevaluated crisis-resource-management principles32

with emphasis on cross-disciplinary communication.Perhaps the most important process that led to the

course’s success was establishing the necessary rela-tionships with local, state and federal organizations tofacilitate the dissemination of this training. The UMCRME currently trains more than 10,000 course reg-istrants annually in a variety of acute clinical carecourses through our Division of Emergency MedicalSkills Training. Participants in these courses come froma variety of fire-rescue, emergency-medical-services,hospital, and public-health departments and agencies.We disseminate programs throughout Florida and thesoutheastern United States, primarily via communitycolleges and vocational technical centers that provide

primary and continuing education for emergency med-ical services, allied-health professionals, and public-safety officers.

The primary limitation of the study is the lack ofdemonstrated skill acquisition by the learner popu-lation. This, however, is being addressed in a sepa-rate study that evaluates both individual and team ac-quisition of the core skills necessary for a terrorismresponse. A limitation to the successful implementa-tion of this course is the constant need to train morefirst-time learners while also providing refresher train-ing 12 months or more postcourse. Another challengeto its implementation is the lack of sufficient trainingtime provided by departments and agencies. To ad-dress these challenges, we plan to develop an onlineprecourse program followed by a 1-day, eight-hour,hands-on course. We will convert the present courseinto individual modules that will be large enough tosupport learning, but flexible and free-standing enoughfor re-use in different contexts for different populations.We will convert all existing learning and testing ma-terials (lectures, tabletop exercises, skills stations andscenario-based exercises) to digital resources for effi-cient and quick online delivery. We will develop a web-site to provide a single location for all e-learning coursematerial that will be accessible to all registrants for bothinitial cognitive-based training and refresher training.Our goal is to reduce the time responders are away fromtheir active duties and reduce the training-time bur-den on departments, agencies and municipalities. Wewill measure the time saved for faculty instruction andlearner training and establish a continuous quality im-provement process that includes evaluating outcomesand modifying the course to achieve our performancegoals.

CONCLUSIONS

We successfully integrated didactic and performancesessions into a two-day course for professionals likelyto respond to terrorist acts. We integrated state-of-the-art training with objective assessments of all learners infour terrorism scenarios. Results from the pre- and post-course self-assessments and examinations indicate thatcourse participants are more confident in their ability torespond to acts of terrorism and increase their knowl-edge as a result of their participation in this course.This project demonstrated that it is possible to developand implement a successful terrorism-response train-ing program using a five-step, systematic approach(ADDIE) with special attention to cultivating essen-tial resources such as personnel; time; facilities; politi-cal and financial support; and community, regional andstate support.

The authors would like to thank Robert B. Tober, MD, Nabil El Sanadi,MD, members of the Curriculum Development Advisory Committee,

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and the Miami International Alliance for Medical-education Innova-tion (“the M.I.A.M.I. Group”) for their expert input; Eva Blanco, JillHershbein, Maria Lorenzo, Dori McLean, Obed Frometa, EMT-P andthe paramedic-instructor staff of the University of Miami Center forResearch in Medical Education for their valuable contributions; theFlorida Department of Health for financial support and the expertguidance of Sandra Schoenfisch, RN, PhD, and Mark O’Neill, PhD;the Miami Urban Area Security Initiative, Florida Department of Ed-ucation, Friends For Life nonprofit volunteer organization, W. Georgeand Ethel M. Kennedy Family Foundation, and Health Foundationof South Florida for their financial support; and the U.S. Army forproviding invaluable educational resources.

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