??????? Delivery of Medical Care in Natural Disaster

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???????Delivery of Medical Care in Natural
Disaster

• ?????? ??? ??
• Buddhist Dalin TzuChi General Hospital
• Wei-che Lee MD

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Basic Disaster Awareness

• Disasters follow no rules. No one can predict the
  complexity, time, or location of the next
  disaster.
• All disasters, regardless of etiology, have
  similar medical and public health consequences.
• Disasters differ in the degree to which these
  consequences occur and the degree to which they
  disrupt the medical and public health
  infrastructure of the disaster scene.

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Basic Disaster Awareness

• The key principle of disaster care is To Do the
  Greatest Good for the Greatest Number of
  Patients, while the objective of conventional
  medical care is to do the greatest good for the
  individual patient.
• Mass Casualty Incident (MCI) Response.A
  consistent approach to disasters, based on an
  understanding of their common features and the
  response expertise they require.

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Basic Disaster Awareness

• The mass-casualty-incident response has four
  critical medical components Search and
  rescue Triage and initial stabilization
  Definitive medical care Evacuation
• This strategy permits teams from various
  countries to work together to meet
  disaster-related needs, despite language and
  cultural barriers.

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Basic Disaster Awareness

• Disaster Medicine is a severe form of First Aid,
  in which treatment priorities need to be
  reassessed against those usually applied in an
  everyday First Aid emergency.
• Priorities are reassessed because Significant
  numbers of casualties are involved Emergency
  services are overwhelmed Hospital facilities
  are compromised Damaged roads mean
  difficulties with transportation.

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TIMA in Natural Disaster

• El Salvador, Jan 13, 2001
• 7.6-magnitude earthquake struck El Salvador at
  1134 AM, killing at least 844, injuring 4,723
  and damaging or destroying 278,000 dwellings.

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• El Salvador, Jan 13, 2001
• Exactly one month later another quake, with a
  magnitude of 6.6, hit this country, killing at
  least 400, injuring 3,153 and destroying 45,000
  homes. Still recovering from the damage wrought
  by Hurricane Mitch few years ago, this disaster
  maimed the tiny country.

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TIMA in Natural Disaster

• El Salvador, Jan 13, 2001
• The first Tzu Chi medical team, composed of five
  physicians and one nurse from the United States,
  provided medical service for some 2,000 residents
  at four places in three days.
• Tzu Chi distributed food for 35,750 victims to
  last one month and helped 6,729 victims through
  the free clinics.

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TIMA in Natural Disaster

• Back to 921 Earthquake
• 921 earthquake rocked the island at 147 am. By
  3am, TzuChi Taichung Rescue Center was
  established.
• TIMA members established first aids stations in
  11 heavily damaged areas
• Medical teams from Tzu Chi Hospital in Hualien,
  consisted of 40 medical staffs, set up medical
  aids centers in 3 local hospitals.

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TIMA in Natural Disaster

• Iran Earthquake, Dec 26, 2003
• 41,000 people presumed to be dead
• Tens of thousands injured
• Nearly all survivors among the original 100,000
  inhabitants left homeless.

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• Iran Earthquake, Dec 26, 2003

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TIMA in Natural Disaster

• Iran Earthquake, Dec 26, 2003
• Medical aid is not simply coming to the help of
  someone in pain, but should also inspire local
  people to bring their own compassion and kindness
  into play, so that even more people will
  contribute.

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TIMA in Natural Disaster
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Principles of International Relief Work

• Directness We insist on personally distributing
  relief supplies into the hands of victims without
  going through any third party.
• Priority There are too many victims and
  disasters in the world, and our resources are
  very limited. So we are forced to offer our help
  and rebuild homes only for victims in the most
  devastated areas.
• Respect We respect the victims' lifestyles,
  customs, culture and traditions. We distribute
  relief supplies with gratitude and without
  expecting to receive anything in return, so that
  the victims' dignity will be maintained.

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Principles of International Relief Work

• Timeliness We provide victims with what they
  need when they need it the most. Though our
  resources are limited, their hearts will be
  warmed.
• Conservation We fully utilize every single
  dollar that people have donated.
• "Three No's" principles during relief
  distribution
• No politics
• No propaganda
• No religion, especially in mainland china.

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Notes on International Relief Work

• Medical intelligence is an essential part of an
  international disaster response.
• Data on endemic and epidemic illnesses are
  critical, but an understanding of the cultural
  and social norms is of equal importance in
  meeting disaster-related needs.
• Trained specialists, however well-intentioned, do
  not by themselves constitute an effective medical
  team for a response to international disasters.
• Critical to a successful medical response to a
  mass casualty incident are important non-medical
  elements such as communication, safety,
  sanitation, and security.

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Acute Injuries and Illnesses in the Aftermath of
a Natural Disaster

• Open and closed fractures
• Foreign-body eye injuries
• Crush-related injury and contaminated lacerations
• Drowning
• Heart attacks and other stress- and
  exertion-related conditions
• Injury and exacerbation of illness related to the
  evacuation and transferring
• Electrocutions
• Shock

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Disruption of Medical and Public Health
Infrastructure

• Local clinics
• Drugstores
• Hemodialysis center
• Psycotherapy service
• Home care nursing
• IV medication
• Parenteral nutrition
• Ventilator
• Dialysis
• Oxygen

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Needs Of The VictimsDuring the Immediate Phase

• Whether they are injured, survivors, disaster
  victims, evacuees or people involved, the victims
  all have the same needs

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Needs Of The VictimsDuring the Immediate Phase

• Physical Needs
• Survival
• To be looked after (somatic care and
  medico-psychological care)
• Shelter (tent, gymnasium, caravan, housing)
• Bedding (bed, blankets)
• Food and drink
• Hygiene (washing, toilets)
• Clothing, grants

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Needs Of The VictimsDuring the Immediate Phase

• Cognitive needs
• Information (about the disaster)
• Information on aid, help and grants
• Information on legal advice

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Needs Of The VictimsDuring the Immediate Phase

• Emotional needs
• Need not to feel abandoned or excluded
• Need to verbalize the experience lived through
• Need to be listened to
• Need for empathy and understanding
• Need to return to (or be accepted in) the
  community of the living
• Need to restore autonomy

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Disaster Medical Assistant Team (DMAT)

• DMAT teams normally consist of approximately 35
  members
• 4 or 5 physicians
• 10 to 12 nurses and paramedics
• 8 to 12 EMTs
• The remainder of the team made up of support
  personnel
• There are still controversies about role of the
  volunteers attending in the DMATs.
• Most of the volunteers lack in medical training
  such as basic and advanced life support and lack
  clinical experiences.

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Disaster Medical Assistant Team (DMAT)

• 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.
• In mass casualty incidents, Triaging
  patients Providing austere medical care
  Preparing patients for evacuation
• May provide primary health care and/or may serve
  to augment overloaded local health care staffs.

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Disaster Medical Assistant Team (DMAT)

• DMAT is an independent, self-sufficient team that
  can be deployed within a matter of hours and can
  set up and continue operations at the disaster
  site for up to 72 hours with no additional
  supplies or personnel.
• The 72-hour period allows national/international
  support, including medical supplies, food, water
  and any other commodity required by the DMAT,
  to arrive.

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Operations Plan of the Medical Disaster-response

• The model organizes surviving health care
  providers into teams capable of delivering
  medical care immediately.
• Stabilize the condition of victims in the field
  and then facilitate their transport.
• The plan is divided into three phases according
  to the time elapsed and the location of
  treatment Hour 0 to 1? Solo-treatment period
  Hours 1 to 12 ? Disaster-medical-aid period
  Hours 12 to 72? Casualty-collection period.

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Phase 1 Solo-Treatment Areas

• Immediately after an earthquake, physicians would
  assess their surroundings.
• If patients in critical condition were present,
  solo-treatment locations would be established
  where patients could be evaluated and their
  condition stabilized with resources from a
  medical backpack.
• Patients would be moved to a disaster-medical-aid
  center as soon as possible.

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Medical Emergencies and First Aid

• Most field medical situations you encounter are
  not immediately life threatening. The few that
  are can generally be addressed by anyone with
  basic first aid skills and a rational approach.
• Maintain a calm, thoughtful manner. Panic will
  cause or contribute to a shock response in the
  victim and may cause others to act irrationally
  as well.

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Medical Emergencies and First Aid

• When confronted by a medical emergency, your
  first step is to determine whether or not you can
  safely and effectively render assistance.
• Do not move the victim unless you have to for
  your safety or his or hers.
• Once you have determined that you are not
  endangering yourself and that the victim is in a
  relatively safe position, get help if you are
  able to do so.

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Medical Emergencies and First Aid

• WARNING
• There is a definite risk to the first aid
  responder from the bodily fluids of the patient.
  These include blood, mucus, urine, and other
  secretions.
• You should take the steps necessary to protect
  yourself before attempting to treat the patient.
• Use surgical gloves if you have them. Also, it is
  strongly advised that you use a cardiopulmonary
  resuscitation (CPR) barrier device if giving
  mouth to mouth.
• A facemask will also reduce the potential for
  rescuer infection.

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Medical Emergencies and First Aid

• Try to do the most good for the greatest number
  in the shortest possible time but always ensure
  your own safety first!
• Do not attempt CPR (heart massage) unless you
  have received instruction in the technique.
• Do not give a casualty any food or drink if they
  are badly injured, suspected of having broken
  bones, or are likely to require surgical
  treatment.

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Medical Emergencies and First Aid
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Medical Emergencies and First Aid

• Primary Survey
• Ensure your own safety first.
• Assess the hazards and remove or secure them
  where possible.
• Sort mobile casualties from immobile ones.
• Assess the consciousness of any silent, immobile
  casualties by use of voice and/or tapping
  collarbone.

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Medical Emergencies and First Aid

• Primary Survey
• Use your voice first - "Can you hear me?".
• If casualty responds, place in a comfortable
  position and monitor.
• If casualty does not respond, tap their
  collarbone to check response to pain.
• If casualty responds to tap, place in recovery
  position and arrange transfer to hospital.

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Medical Emergencies and First Aid

• Primary Survey
• If patient does not respond, assess their
  breathing and circulation.
• If breathing and pulse detected, place in
  recovery position, cover and arrange urgent
  transfer to hospital (advanced life support
  facility).
• Where there are many casualties, if there is no
  breathing or pulse, move on to others.

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Phase 2 Disaster-Medical-Aid Centers

• Evenly spaced in a community, set up no more than
  an hour's walk from any location even if the
  transportation system failed.
• 3 physicians per site to provide coverage for
  alternating 12-hour shifts and 1 backup.
• Sites might include schools, fire stations, and
  hospitals.
• Adjacent open area to serve as a helicopter
  landing zone for patient evacuation and the
  resupply of equipment.

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Medical-aid Centers

• The principal sites for the delivery of medical
  care.
• An initial triage area immediately outside the
  center, in accordance with the Simple Triage and
  Rapid Treatment system
• The walking wounded would be identified first.
• The remaining patients would then be divided into
  three categories Those requiring immediate
  care Those for whom care might be delayed
  The dead or dying

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Medical-aid Centers

• Patients assigned to the immediate-care and
  delayed-care categories would receive further
  evaluation and treatment.
• The dead would be sent to the morgue area and
  those facing imminent death segregated.
• The walking wounded might be used as volunteers
  to assist health care workers.
• Patients would be periodically reevaluated.

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Medical-aid Centers
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Medical-aid Centers
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Medical-aid Centers
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Phase 3 Casualty-Collection Points

• Performs two functions
• First, it serves as a staging area for the
  arrival of medical supplies and personnel and the
  evacuation of patients.
• Second, it contains a medical area for triage and
  treatment.
• Once stabilized, patients would be transported
  either to newly established field hospitals or to
  functioning hospitals outside the disaster zone.

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Casualty Collection Sites

• Casualty collection sites for Levels 1 and 2
  triage should be located close enough to a
  disaster site to offer quick treatment, but far
  enough away to be safe. Important features are
• Proximity to the disaster site
• Safety from hazards and upwind location from
  contaminated environments
• Protection from climactic conditions
• Easy visibility for disaster victims
• Convenient exit routes for air and land
  evacuation

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Follow-up Trauma and Medical Care

• gtfirst 48 hours,the health services progressively
  overwhelmed by the need for secondary or
  maintenance care for the trauma victims as well
  as the demand resulting from the rapid emergence
  of normal emergencies or routine medical care.
• The health facilities may not be fully
  operational and staff will urgently need some
  rest and time to care for possible personal
  losses.

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Long-term Medical Sequelae of Natural Disasters

• Clean-up and rebuilding-related injury
• Food- and water-borne disease
• Carbon monoxide (CO) poisoning with
  gasoline-powered electricity generators
• Snake and rodents bite
• Arboviral infection

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Common Diseases

• The most common symptoms and diseases among
  displaced people are those normally to be
  expected in a developing country Diarrhea
  Measles Nutrition Deficiencies Respiratory
  Infections Malaria Parasites Anemia.
• However, crowded conditions among the displaced
  people are likely to increase the occurrence of
  these diseases, in particular diarrhea.

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Long-term Medical Sequelae

• Diarrhea, due to the new environment,
  overcrowding, and poor environmental services,
  usually poses the major threat to displaced
  peoples health in the first weeks of living in a
  camp.
• It remains a major health risk should there be a
  sudden deterioration in some aspect of the
  communal services, such as contamination of the
  water supply.

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Long-term Medical Sequelae

• An important point to note is that among the
  diseases listed, 80- 90 of all deaths in
  displaced populations are caused by five killer
  conditions Malnutrition Measles
  Acute Respiratory Infections Diarrheal
  Diseases Malaria.
• Most of these diseases are caused byprotozoa,
  bacteria, or viruses.

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Notes on Caring for the Victims

• Protect the victims from further stress such as
  the press, curiosity seekers, gory sights and
  sounds, or additional unnecessary exposures to
  the horror of the incident.
• Mobilize the resources necessary to assist the
  victims such as the Red Cross or other disaster
  services.
• Help the victims to find missing family members
  and friends.
• Regroup families.

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Notes on Caring for the Victims

• Regroup people who come from the same areas.
• Listen carefully to the victims. They need
  opportunities to express themselves.
• Accurate, current and timely information is
  extremely important to the well being of victims.
  
• Reassure people that they are safe.
• Establish private quarters for the victims as
  soon a possible.

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Notes on Caring for the Victims

• Provide for medical, social, religious,
  psychological, shelter and other needs as they
  arise.
• Do not tell victims that they are lucky because
  it could have been worse. Those sorts of
  statements almost never console and usually anger
  a distressed person.
• Keep yourself calm and your voice smoothing and
  reassuring.
• Gently touch a distressed person on the shoulder
  or hand if they seem receptive to such contact.

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Notes on Caring for the Victims

• A shocked, very silent and withdrawn person
  should be evacuated from the scene immediately.
• Noisy, hysterical or acting out victims are
  actually a secondary priority.
• Those who seem to be doing fine at the scene are
  the third priority for evacuation. However, it
  does not imply that they should be ignored. They
  can get worse if they are unattended.
• Children are the most vulnerable to
  psychological harm during a disaster. Special
  care should be afforded for children.

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Effects on Children

• Children, in particular, in the three to ten age
  group, may be adversely affected by the disaster,
  even if not affected physically.
• It is extremely difficult for children to
  understand what has happened to their home and
  family, following the impact of a major disaster.
• Intense feelings and emotional trauma may result
  directly and immediately for some children,
  while for others it may occur at a later time.

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Children in Disaster

• Most children will be confused by the sudden
  interruption of the normality of life. Some
  children may become very restless and unable to
  sleep, others quiet and withdrawn and not willing
  to discuss the experience.
• It is very important for parents and teachers to
  help the children work out their problems so that
  there will be no lasting emotional trauma.
• Proper communication with the children,encouragin
  g them to talk and listening to their fears.

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Children in Disaster

• Adults should explain as well as they can the
  disaster, and should let children know that their
  fears are normal and are shared by all.
• Efforts should be made to reduce the children's
  anxiety by returning to as normal a routine as
  possible.
• Children should be involved in the recovery
  efforts and should be encouraged to participate
  in the clean-up activities.
• Parents and teachers should assure the kids that
  they are not going to leave them alone.

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Screening for and Managing Psychological Sequelae

• Posttraumatic stress disorder can be found in
  both the victims and the responders.
• The elderly and children are especially
  vulnerable to the sequelae of disaster-related
  mental trauma
• Special teams called Crisis Intervention Stress
  Management Teams are often deployed to the site
  of a disaster.

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Facilitate Rapid and Complete Physical and
Emotional Recovery

• Rapid rebuilding of homes, communities
• Early resumption of school and work
• Every effort should be taken to maintain and
  strengthen families and support systems.

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Psychological Sequelae of Disasters

• Disaster characteristics that seem to have the
  most significant mental health impact are the
  following
• Little or no warning
• Serious threat to personal safety
• Potential unknown health effects
• Uncertain duration of the event
• Human error and/or malicious intent
• Symbolism related to terrorist target

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Psychological Sequelae of Disasters

• Post-disaster responses are wide-ranging, from
  mild stress responses to full blown
  post-traumatic stress disorder (PTSD), major
  depression, or acute stress disorder.
• While many people may exhibit signs of
  psychological stress, relatively few (typically
  1525) of those most directly impacted will
  subsequently develop a diagnosable mental
  disorder.

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Psychological Sequelae of Disasters

• Worker Stress
• Disaster workers who choose to be involved in
  this type of work gain great reward and
  satisfaction, but can also become secondary
  victims of stress and other psychological
  sequelae.
• This can adversely affect their functioning
  during and after an event. It can also adversely
  impact their personal well-being as well as their
  family and work relationships.

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How Team Members May Be Affected by Stress

• They may experience physical symptoms associated
  with stress, such as headaches, upset stomach,
  diarrhea, poor concentration, and feelings of
  irritability and restlessness.
• They may become tired of the disaster and prefer
  not to talk about it, think about it, or even
  associate with coworkers during time off.
• They may become tired of continual interaction
  with victims and may want to isolate themselves
  during time off.

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Signs of Stress in Workers

• Physiological signs of stress
• Fatigue, even after rest
• Nausea
• Fine motor tremors
• Tics
• Paresthesias
• Dizziness
• GI upset
• Heart palpitations
• Choking or smothering sensations

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Signs of Stress in Workers

• Emotional signs of stress
• Anxiety
• Irritability
• Feeling overwhelmed
• Unrealistic anticipation of harm to self or
  others

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Signs of Stress in Workers

• Cognitive signs of stress such as
• Memory loss
• Decision-making difficulties
• Anomia (the inability to name common objects or
  familiar people)
• Concentration problems or distractibility
• Reduced attention span
• Calculation difficulties

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Signs of Stress in Workers

• Behavioral signs of stress such as
• Insomnia
• Hypervigilance
• Crying easily
• Inappropriate humor
• Ritualistic behavior

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Coping Methods for Rescue Workers

• Avoid humanization of the bodies
• Do not look at the faces
• Do not learn the names of the victims
• Concentrate on the tasks at hand
• Concentrate on the benefit to society

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Managing Worker Stress On-Site

• Limited exposure to traumatic stimuli
• Reasonable hours
• Adequate rest/sleep
• Reasonable diet
• Regular exercise program
• Private time
• Talking to somebody who understands
• Monitoring signs of stress
• Identifiable endpoint for involvement

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