SAS 1

DISASTER: “a serious disruption of the functioning of a community or a society at any scale due to
hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or
more of the following: human, material, economic and environmental losses and impacts” (United
Nations International Strategy for Disaster Reduction [UNISDR], 2017).

DISASTER NURSING

The adaptation of professional nursing skills in recognizing & meeting the nursing physical & emotional
needs resulting from a disaster.

“Nursing practiced in a situation where professional supplies, equipment, physical facilities & utilities are
limited or not available”.

GOAL: To achieve the best possible level of health for the people & the community involved in the
disaster.

Nurses’ Roles in Disaster:

1. Determine magnitude of the event

2. Define health needs of the affected groups

3. Establish priorities & objectives

4. Identify actual & potential public health problems

5. Determine resources needed to respond to the needs identified

6. Collaborate with other professional disciplines, governmental & non-governmental agencies

7. Determine magnitude of the event

8. Define health needs of the affected groups

HEALTH DISASTER: is a catastrophic event that results in casualties that overwhelm the healthcare
resources in that community and may result in a sudden unanticipated surge of patients, a change in
standards of care, and a need to allocate scarce resources.

TWO BROAD CATEGORIES OF DISASTER:

1. Natural

2. Man-made or anthropogenic

NATURAL DISASTER

Those caused by natural or environmental forces. WHO defines “natural disaster” as the “result of an
ecological disruption or threat that exceeds the adjustment capacity of the affected community”
(Lechat, 1979). Natural disasters include earthquakes, floods, tornadoes, hurricanes, volcanic eruptions,
ice storms, tsunamis, and other geological or meteorological phenomena. Natural disasters are the
Consequence of the intersection of a natural hazard and human activity.

MAN-MADE OR ANTHROPOGENIC (Human Generated)

Anthropogenic disasters are those in which the principal direct causes are identifiable human actions,
deliberate or otherwise (Jha, 2010). Anthropogenic disasters include biological and biochemical
terrorism, chemical spills, radiological (nuclear) events, fire, explosions, transportation accidents, armed
conflicts, and acts of war.

THREE CATEGORIES OF HUMAN-GENERATED DISASTERS:

1. Complex Emergencies

2. Technological disasters

3. Disasters that are not caused by natural hazards but occur in human settlements

Complex human emergencies involve situations where populations suffer significant casualties as a
result of war, civil strife, or other political conflict. Technological disasters, large numbers of people,
property, community infrastructure, and economic welfare are directly and adversely affected by major
industrial accidents, unplanned release of nuclear energy, and fires or explosions from hazardous
substances such as fuel, chemicals, or nuclear materials. Natural and human-made disasters trigger each
other and the distinctions between the two disaster types may be blurred. A natural and human
generated disaster may trigger a secondary disaster, the result of weaknesses in the human
environment. An example of this is a chemical plant explosion following an earthquake. Disasters are
frequently categorized based on their:

1. Onset

2. Impact

3. Duration

For example:

- Earthquakes and tornadoes are rapid-onset events—short durations but with a sudden impact on
communities.

-Hurricanes and volcanic eruptions have a sudden impact on a community; however, advanced warnings
are issued enabling planners to implement evacuation and early response plans.

- A bioterrorism attack may be sudden and unanticipated and have a rapid and prolonged impact on a
community.

- Incontrast, droughts and famines have a more gradual onset or chronic genesis, the so- called creeping
disasters and generally have a prolonged onset.

Factors that influence Impact of a Disaster on a Community:

1. Nature of the event

2. Time of day and year

3. Health and age characteristics of the population affected

4. Availability of resources

Classification of disasters in the field of disaster science:

1. Hazards (cause) is a potential threat to humans and their welfare (Smith & Petley, 2009)

2. Disasters

3. Risk-- is the actual exposure of something of human value and is often measured as the product of
probability and loss (Smith & Petley, 2009).

Classification of Disasters in hospital and other health care facilities:

1. internal

2. external

External disasters are those that do not affect the hospital infrastructure but tax hospital resources due
to numbers of patients or types of injuries (Burstein, 2014). For example, a tornado that produced
numerous injuries and deaths in a community would be considered an external disaster.

Internal disasters cause disruption of normal hospital function due to injuries or deaths of hospital
personnel or damage to the facility itself, as with a hospital fire, power failure, or chemical spill
(Hendrickson & Horowitz, 2016).

HEALTH EFFECTS OF DISASTERS:

▪ Disasters may cause premature deaths, illnesses, and injuries in the affected community, generally
exceeding the capacity of the local healthcare system.

▪ Disasters may destroy the local healthcare infrastructure, which therefore will be unable to respond to
the emergency. Disruption of routine health and mental healthcare services and prevention initiatives
may lead to long-term consequences in health outcomes in terms of increased morbidity and mortality.

▪ Disasters may create environmental imbalances, increasing the risk of communicable diseases and
environmental air, soil, and water hazards.

▪ Disasters may affect the psychological, emotional, and social well-being of the population in the
affected community. Depending on the specific nature of the disaster, responses may be fear, anxiety,
depression, widespread panic, terror, and exacerbation of preexisting mental health problems. Children,
in particular, may be deeply affected by the impact of a disaster (Save the Children, 2017).

▪ Disasters may cause shortages of food and cause severe nutritional deficiencies.

▪ Disasters may cause large population movements (refugees) creating a burden on other healthcare
systems and communities. Displaced populations and their host communities are at increased risk of
communicable diseases and the health consequences of crowded living conditions (Lam, McCarthy, &
Brennan, 2015).
▪ Disaster frameworks for response are increasingly shaped by globalization, changing world dynamics,
social inequality, and sociodemographic trends (Tierney, 2012; WHO, 2016

2 Major Concerns about Role (Dr. Veenema)

1. Personal safety: “Nurses want to know that they’re safe & that their loved ones & patients are safe.”

2. Clinical competence: “They want to know they can deal with emergencies properly—even less
common ones like massive radiation exposure or SARS outbreaks.”

Nurses’ Roles in Disaster:

1. Determine magnitude of the event

2. Define health needs of the affected groups

3. Establish priorities & objectives

4. Identify actual & potential public health problems

5. Determine resources needed to respond to the needs identified

6. Collaborate with other professional disciplines, governmental & non-governmental agencies

7. Determine magnitude of the event

8. Define health needs of the affected groups

THE DISASTER CONTINUUM – life cycle of a disaster management program.

Three Major Phases

1. Preimpact (before)

2. Impact (during)

3. Postimpact (after)

Basic phases or “life cycle” of a disaster management program: (PMPRR)

1. Preparedness refers to the proactive planning efforts designed to structure the disaster
response prior to its occurrence. Disaster planning encompasses evaluating potential
vulnerabilities (assessment of risk) and the propensity for a disaster to occur.
Warning (also known as “forecasting”) refers to monitoring events to look for indicators that
predict the location, timing, and magnitude of future disasters.

2. Mitigation includes measures taken to reduce the harmful effects of a disaster by attempting to
limit its impact on human health, community function, and economic infrastructure. These are
 all steps that are taken to lessen the impact of a disaster should one occur and can be
considered as prevention measures.

Prevention refers to a broad range of activities, such as attempts to prevent a disaster from
occurring, and any actions taken to prevent further disease, disability, or loss of life. Mitigation
usually requires a significant amount of forethought, planning, and implementation of measures
before the incident occurs.

3. Response phase is the actual implementation of the disaster plan. Disaster response, or
emergency management, is the organization of activities used to address the event.
Traditionally, the emergency management field has organized its activities in sectors, such as
fire, police, hazardous materials management (hazmat), and emergency medical services. The
response phase focuses primarily on emergency relief: saving lives, providing first aid,
minimizing and restoring damaged systems such as communications and transportation,
and providing care and basic life requirements to victims (food, water, and shelter).

4. Recovery ations focus on stabilizing and returning the community (or an organization) to normal
(its preimpact or improved status). This can range from rebuilding damaged buildings and
repairing infrastructure to relocating populations and instituting physical, behavioral, and
mental health interventions. Rehabilitation and reconstruction involve numerous activities.
Goal: “Build, Back, Better”

5. Evaluation is the phase of disaster planning and response that often receives the least attention.
After a disaster, it is essential that evaluations be conducted to determine what worked, what
did not work and what specific problems, issues and challenges were identified.

DISASTER PLANNING
• Addressing the problems posed by various potential events.
• Participation by nurses in all phases of disaster planning is critical to ensure that nurses are
aware of and prepared to deal with whatever these numerous other factors may turn out to be.
• Individuals and organizations responsible for disaster plans should consider all possible
eventualities from the sanitation needs to the crowd, psychosocial needs of vulnerable
populations, to evacuation procedure.
• Completion of the disaster planning process should result in the production of a
comprehensive disaster or “emergency operations plan”.

DISASTER PLAN- a formal plan of action of coordinating the responsive of health care agency
staff in the event of a disaster.
AIM: to provide prompt & effective medical care to the maximum possible in order to minimize
morbidity and mortality.
Objectives:
• To optimally prepare the staff and institutional resources for effective performance in disaster
situation. • To make the community aware of the sequential steps that could be taken at
individual and organizational levels.
Types of Disaster Planning:
1. Agent specific approach – focus their preparedness activities on the most likely threats to
occur based on their geographic location (Hurricanes in Florida)
2. All -hazards approach- conceptual model for disaster preparedness that incorporates disaster
management component that are consistent across all major events to maximize resources,
expenditures and planning efforts.

Nurses’ Roles in Disaster Planning:

1. Personal and professional preparedness
2. Make a personal and family preparedness.
3. Be aware of the disaster plan at the workplace and community.
4. Maintain certification in disaster training and CPR
5. Participate in Mock disaster drills.

Problems, Issues and Challenges in Disaster Planning:

1. Anticipate communication problems.
2. Address operational issues related to effective triages, transportation and evacuation.
3. Accommodate the management, security of and distribution of resources at the disaster
sides.
4. Implement advanced warning systems and increase the effectiveness of warning messages
5.Enhance coordination of search and response efforts.
6. Effective triage of patients (prioritization for care and transport of patients).
7. Establish plans for the distribution of patients to hospitals in an equitable.
8. Patient identification and tracking.
9. Damage or destruction of the health care infrastructure.
10. Management of volunteers, donations and other large numbers of resources.
11. Organized improvisational response to the disruption of major systems.
12. Encountering overall resistance (apathy) to planning efforts.

HAZARD IDENTIFICATION, VULNERABILITY ANALYSIS,

AND RISK ASSESSMENT
Methods for Data Collection for Disaster Planning:
1. Hazard identification is used to determine which events are most likely to affect a community
and to make decisions about whom or what to protect.
2. Vulnerability analysis is used to determine who is most likely to be affected, the property
most likely to be damaged or destroyed, and the capacity of the community to deal with the
effects of the disaster. Data are collected regarding the susceptibility of individuals, property
and the environmento potential hazards in order to develop prevention strategies. A separate
vulnerability analysis should be conducted for each identified hazard.
3. Risk assessment uses the results of the hazard identification And nerability analysis to
determine the probability of a specified outcome from a given hazard that affects a community
with known vulnerabilities and coping mechanisms (risk equals hazard times vulnerability).
Disaster Planning and Public Health Preparedness:
Six Domains:
1. Community resilience
2. Incident management
3. Information management
4. Countermeasure and mitigation
5. Surge management
6. Biosurveillance

EVALUATING CAPACITY TO RESPOND

Resource identification is an essential feature of disaster planning. A community’s capacity to
withstand a disaster is directly related to the type and scope of resources available, the
presence of adequate communication systems, the structural integrity of its buildings and
utilities (e.g., water, electricity), and the size and sophistication of its healthcare system
(Burstein, 2014; Cuny, 1998). Resources include both human and physical elements, such as
organizations with specialized personnel and equipment. Disaster preparedness includes
assembling lists of healthcare facilities; medical, nursing, and emergency responder groups;
public works and other civic departments; and volunteer agencies, along with phone numbers
and key contact personnel for each.

CORE PREPAREDNESS ACTIVITIES

1. Prepare a theoretical foundation for disaster planning
2. Disaster planning is only as effective as the assumptions upon which it is based.
3. Core preparedness activities must go beyond the routine
4. Have a community needs assessment.
5. Identify leadership and command post.
6. Design a local response for the first 72 hours.
7. Identify and accommodate vulnerable populations.
8. Know about state and federal assistance.
9. Identify training and educational needs, resources, and personal protective equipment (PPE).
10. Plan for the early conduction of damage assessment.

EVALUATION OF A DISASTER PLAN

An essential step in disaster planning and preparedness is the evaluation of the disaster
response plan for its effectiveness and completeness by key personnel involved in the response.
The comprehension of people expected to execute the plan and their ability to perform duties
must be assessed. The availability and functioning of any equipment called for by the disaster
plan needs to be evaluated and reviewed on a systematic basis. Several methods may be used
to exercise the disaster plan, the most comprehensive of which would be its full implementation
in an actual disaster.
Disaster drills may also provide an excellent means of testing plans for their completeness and
effectiveness. Drills can be staged as large, full-scale exercises, using triaged victims and
requiring vast resources of supplies and personnel, or they may be limited to a small segment of
 the disaster response, such as drills that assess the effectiveness of communications protocols
or notification procedure.

SAS 2

DISASTER RISK REDUCTION and MANAGEMENT (DRRM)

It is a systematic process of using administrative decisions, organization and operational skills and
capacities to implement strategies, policies and improved coping capacities of the society and
community in order to lessen the adverse impacts of hazards and the possibility of a disaster.

2 ASSUMPTIONS: disaster risk is endemic & it is within the power of the state to reduce disaster risk
(Source: IRR of RA10121)

DRRMC ORGANIZATIONAL NETWORK

❖ National Disaster Risk Reduction & Management Council

❖ 12 Regional Disaster Risk Reduction & Management Councils

❖ 80 Provincial Disaster Risk Reduction and Management Councils

❖ 122 City Disaster Risk Reduction and Management Councils

❖ 1,512 Municipal Disaster Risk Reduction and Management Councils

❖ 42,026 Barangay Disaster Risk Reduction and Management Committees

THE NATIONAL DISASTER RISK REDUCTION MANAGEMENT COUNCIL (NDRRMC)

The National Disaster Risk Reduction and Management Council (NDRRMC), formerly known as the
National Disaster Coordinating Council (NDCC), is a working group of various government, non-
government, civil sector and private sector organizations of the Government of the Republic of the
Philippines established by Republic Act 10121 of 2010.

THE NATIONAL DISASTER RESPONSE PLAN

The NDRP is the Government of the Philippines’ “multi-hazard” response plan. Emergency management
as defined in the NDRRM Act of 2010 (RA10121), is the organization and management of resources to
address all aspects or phases of the emergency, mitigation of, preparedness for, response to and
recovery from a disaster or emergency

The NDRP is also built on the following understanding:

• All government agencies and instrumentalities have their own respective Disaster Preparedness Plans
for Terrorism related incidents;

• All Local Government Units (LGUs) have prepared their Contingency Plans for Terrorism related
incidents and implemented their Local Disaster Risk Reduction and Management Plans (LDRRMPs)
within the DRRM Framework of Prevention/Mitigation, Preparedness, programs and activities that are
directly connected to response like prepositioning of key assets and resources; and

• The Cluster Approach System and Incident Command System in response operations have been
cascaded to all levels of government both national and local.

National Disaster Risk Reduction and Management Plan 2011-2028.

The NDRRMP sets down the expected outcomes, outputs, key activities, indicators, lead agencies,
implementing partners and timelines under each of the four distinct yet mutually reinforcing thematic
areas. The goals of each thematic area lead to the attainment of the country’s overall DRRM vision, as
graphically shown below.

The NDDRMP goals are to be achieved by 2028 through 14 objectives, 24 outcomes, 56 outputs, and 93
activities. The 24 outcomes, with their respective overall responsible agencies, are summarized below.
COORDINATION AND EMERGENCY AND DISASTER

Challenges in Managing Emergencies related to Coordination and Communication

• No identifiable leader or incident manager

• No basic organizational structure for chain of command and span of control

• No common terminology

• No unified communications system

• No system for allocating resources

• Lack of integration, due to competition

• Lack or loss of resources, due to failures in planning and lack of resource allocation

• Lack of planning, due to absence of commitment

• failures in risk and crisis communications

INCIDENT MANAGEMENT SYSTEM (IMS)

❑ Is a standardized, all hazards incident management concept.

❑ It can be composed of several levels

• ICP (INCIDENT COMMAND POST)

• EOC (EMERGENCY OPERATIONS CENTER)

• ECC (EMERGENCY COORDINATION CENTER)

❑ Allows its users to adopt an integrated organization structure to match the complexities and demands
of single

or multiple incidents without hindered by jurisdictional boundaries

Emergency Response Management Systems: Core Principles

• Based on an all-hazards approach

• Modular, scalable or adaptable organization

• Support for joint engagement of multiple institutions / organizations in management decisions

• Clear lines of accountability and authority

• Clearly defined roles and responsibilities, consistent with normal roles and supported by training

• Clearly articulated procedures for activation, escalation, and demobilization of emergency capacities.

• Common functional groupings and consistent terminology

• Integrated with stakeholder agencies

• Mechanisms for the involvement of all stakeholders and users of the EOC in its design, operational
planning and evaluation.

• Provision of capacity to manage public communications opportunities as part of the response to

emergencies

Core Components of the System

• integrated communications

• modular organization

• unified command structure

• manageable span of control

• consolidated incident action plans

• comprehensive resource management

• pre-designated incident facilities

The essence of the system 5 functions (in many countries)

1. Incident management (manager who coordinates)

2. Operations

3. Planning

4. Logistics

5. Administration and finance

Management: provides overall direction of the response through the establishment of objectives for the
system. This functional area usually includes other activities that are critical to providing adequate
management:

– Public Information manages information released to media and public;

– Safety assesses hazardous and unsafe conditions and develops measures to ensure responder safety;
and

– Liaison provides coordination with agencies outside the response system. For the purposes of this
discussion, the terms Operations: achieves management’s objectives through directed strategies and
developed tactics.

Logistics: supports management and operations with personnel, supplies, communications equipment,
and facilities.

Plans/Information: supports management and operations with information processing and the
documentation of prospective plans of actions (also known as action plans, or APs). Critical components
include:

Administration/Finance: supports management and operations through tracking of such issues as

reimbursement and regulatory compliance.

Incident Management System (IMS)

The IMS (or Incident Command System) refers to the combination of facilities, equipment, personnel,
procedures, and communications operating within a common organizational structure and designed to
aid in the management of resources during incident response. The MCM Management System
emphasizes management rather than command because no inherent “line authority” exists in a
multidisciplinary response by which assets can be commanded.

Levels of command

Level 1: using emergency response plans of the hospitals; developing operational plans to respond to a
crisis

Level 2: information sharing; systems: mutual aid

Level 3: there are several command and coordination mechanisms: at the site (Incident Command Post);
the Emergency Operations Centre (EOC) at the local authority level (multi-sectoral). Depending upon the
organization of the country (it size; level of development, resources available) the EOC can be at District
level or even at Provincial level

Level 4: in some countries level 3 is assumed by level 4 in this diagram. The notion of Emergency
Coordination Centre is important when the size of the incident justify the activation of national (or
provincial in some countries) plans. In some particular circumstances the national level has not only a
coordination function but also a “managerial function of the response” (it can be in the case of a
pandemic; for managing the international donations, etc.)

Incident Command Post (ICP)

• Site

• tactical resources directly applied to address emergency problems

• responders may come from one agency, or many

• the on-site response is directed by one agency by jurisdiction or agreement

• operates from an ad-hoc site command post

• utilizes standard functions

• Advise incoming units of what’s going on. What does it contain?

• Be part of solution, not the problem. May have to wait for special resources to arrive. Does a problem
still exist?

• Do not rush to a scene. Gather info before entering a scene. Is the area safe to be in? If not, make it
safe with your capabilities or wait for trained resource to arrive

• Expect chaos & confusion

• Careless heroics can injure or kill you

• First priority is personal safety, then team safety, then by standers safety and last is patient safety

EOP (Emergency Operation Center) requires much preparatory work, especially a plan describing the
core elements: The plan usually is composed of:

• purpose of the plan

• concept of operations, management structure, roles of personnel and how the components work
together

• Activation procedures and levels, and who has authority

• Escalation and de-escalation plan

• Call-out list and notification procedures

• Checklists of the roles and responsibilities of EOC functions

• Checklists of standard operating procedures

• floor plan, with inventory and locations of equipment and supplies

• Electronic information management processes (including a layout plan of phone, fax, data lines,
cables, switches and outlets)

• Communication resources and procedures, especially mobile phones and radios

• Public information and warning processes

• Procedures for engaging levels of government and/or a superior authority/ jurisdiction

• Standard forms and instructions for documenting EOC activities

• Maps of the area of the event

• Guidelines for worker care and safety

• agency and position responsible for maintaining and updating the plan

• Training and exercise schedule to ensure staff and procedures are up-to-date.

Role of Health Emergency Manager in IMS

• Protect response personnel and resources

• Minimize loss of life, disability and suffering

• Protect public health

• Protect civil infrastructure

• Protect environmental and economic assets, including property

• Reduce economic losses

Risk Communication

- purposeful exchange of information about the existence, nature and form severity or acceptability of
health risks between policymakers, health care providers and the public/media aimed at changing
behavior and inducing action to minimize/reduce risks.

- The process of bringing together various stakeholders to come to a common understanding aboutthe
risks, their acceptability, and actions needed to reduce the risks

Risk Communication Activities

Pre Crisis

◼ Development of a

communication plan
◼ Fostering alliances/

networking

◼ Formative evaluation of the Plan

CRISIS

◼ Implementation of the

communication plan

◼ Process evaluation/monitoring

◼ Impact evaluation of immediate effects

◼ Networking/advocacy

◼ Revision of plan based on monitoring results

POST CRISIS

◼ Impact/summative evaluation

◼ Documentation of lessons learned

◼ Revision of plans

Nurses’ Responsibility in Risk Communication

• Identifying/ verifying sources of information

• Protecting patients’ rights to privacy and confidentiality

• Advocating for the public’s right to know

• Following institution’s chain of command or flow of communication

• Supporting institution’s official statements about public health risk and safety

SAS 3
Disaster Preparedness: Understanding the Psychosocial Impact of Disasters

Disasters, by their very nature, are stressful, life-altering experiences, and living through such an
experience can cause serious psychological effects and social disruption. Disasters affect every aspect of
the life of an individual, family, and community. Depending on the nature and scope of the disaster, the
degree of disruption can range from mild anxiety and family dysfunction (e.g., marital discord or parent–
child relational problems) to separation anxiety, posttraumatic stress disorder (PTSD), engagement in
high-risk behaviors, addictive behaviors, severe depression, and even suicidality

While there are common mental health effects across different types of disasters, each disaster is
unique and many factors can determine a given disaster’s effect on survivors. Natural disasters, such as
floods, hurricanes, forest fires, and tornadoes most often result in property loss and dislocation. When
physical injury and loss of life are minimal, the incidence of psychiatric sequelae may be reduced

The mental health effects of any type of disaster, mass violence, or terror attack are well documented in
the literature to be related to the intensity of exposure to the event. Documented potential indicators of
mental health problems following the event are: sustaining personal injury, death of a loved one due to
the disaster, disaster-related displacement, relocation, and loss of property and personal finances (Neria
& Shultz, 2012).

BIOTERRORISM AND TOXIC EXPOSURES

“bioterrorism is an act of human malice intended to injure and kill civilians and is associated with higher
rate of psychiatric morbidity than are ‘Acts of God’”

Common psychological reactions to bioterrorism

• Horror, anger, or panic

• Magical thinking about microbes and viruses

• Fear of invisible agents or fear of contagion

• Attribution of arousal symptoms to infection

• Anger at terrorists, the government, or both

• Scapegoating, loss of faith in social institutions

• Paranoia, social isolation, or demoralization

The following are recommended interventions to minimize the potential psychological and social
consequences of suspected or actual biological exposures:

1. Provide information on the believed likelihood of such an attack and of possible impact.

2. Communicate what the individual risk is.

3. Clarify that negative health behaviors, which may increase during time of stress (i.e., smoking,
unhealthy eating, excessive drinking), constitute a greater health hazard than the hazards likely to stem
from bioterrorism.

4. Emphasize that the only necessary action against terrorism on the individual level is increased
vigilance of suspicious actions, which should be reported to authorities.

5. Clearly communicate the meaning of different levels of warning systems when such warnings are
issued

6. When issuing a warning, specify the type of threat, the type of place threatened, and indicate specific
actions to be taken.

7. Make the public aware of steps being taken to prevent bioterrorism without inundating people with
unnecessary information.

8. Provide the public with follow-up information after periods of heightened alert.

NORMAL REACTIONS TO ABNORMAL EVENTS

Normal reactions to stress and bereavement can and do vary— sometimes even among members of the
same family.

Factors that affect expressions of stress and bereavement include age, gender, ethnicity, religious
background, personality traits, coping skills, and previous experience with loss, especially traumatic loss.
Stress symptoms can occur due to secondary exposure, meaning that those experiencing distress need
not have been present at the site of the disaster but may have witnessed it secondhand either via media
coverage or through retelling of the event by a person who was present. As these reactions can be quite
startling and overwhelming to those who have not experienced them before, it is helpful for survivors to
hear that their experiences are entirely normal, given the tremendous stress to which they have been
exposed.

COMMON REACTIONS OF DISASTER SURVIVORS

Emotional

Shock, feeling numb

Fear

Grief, sadness

Anger

Guilt, shame

Feelings of helplessness
Interpersonal

Distrust

Conflict

Withdrawal

Work or school problems

Irritability

Loss of intimacy

Feeling rejected or abandoned

Cognitive

Confusion

Indecisiveness

Worry

Shortened attention span

Trouble concentrating

Physical

Tension, edginess

Fatigue, insomnia

Body aches, pain, nausea

Startling easily

Racing heartbeat

Change in appetite

Change in sex drive

SPECIAL NEEDS POPULATION

Certain populations affected by disasters may be more vulnerable and therefore require special
consideration both in disaster planning and response. In particular, women, older people, children and
young people, people with disabilities, and people marginalized by ethnicity are more vulnerable (Sim &
Cui, 2015).
1. Children and Youth - while most children are resilient, many children do experience some significant
degree of distress. Poverty and parents with mental health challenges put children at higher risk for
long-term impairments (McLaughlin et al., 2009).

2. Older Adults - Older adults are particularly vulnerable to loss. Factors such as age and disability affect
vulnerability to a disaster. Both of these vulnerability traits are apparent in the elderly population. They
are often lacking in social supports, may be financially disadvantaged, and are traditionally reluctant to
accept offers of help. Older adults are also more likely to have preexisting medical conditions that may
be exacerbated, either directly because of the emotional and psychological stress, or because of
disruptions to their care, such as loss of medications or needed medical equipment, changes in primary
care providers, lack of continuity of care, or lack of consistency in self-care routines due to relocation.

3. The Seriously Mentally Ill - According to Austin and Godleski (1999), the most psychologically
vulnerable people are those with a prior history of psychiatric disturbances. Although previous
psychiatric history does not significantly raise the risk of PTSD, exacerbations of preexisting chronic
mental disorders, such as bipolar and depressive disorders, are often increased in the aftermath of a
disaster. Those with a chronic mental illness are particularly susceptible to the effects of severe stress,
as they may be marginally stable and may lack adequate social support to buffer the effects of the
terror, bereavement, or dislocation.

4. Cultural and Ethnic Groups - Sensitivity to the cultural and ethnic needs of survivors and the bereaved
is key not only in understanding reactions to stress and grief but also in implementing effective
interventions. Mental health outreach teams need to include bilingual, multicultural staff and translators
who are able to interact effectively with survivors and the bereaved.

5. Disaster Relief Personnel - The list of those vulnerable to the psychosocial impact of a disaster does
not end with the survivors and the bereaved. Often victims can include emergency personnel: police
officers, firefighters, military personnel, Red Cross mass care and shelter workers, cleanup and
sanitation crews, the press corps, body handlers, funeral directors, staff at receiving hospitals, and crisis
counselors.

COMMON STRESS REACTIONS BY DISASTER WORKERS

Psychological

Denial

Anxiety and fear

Worry about the safety of self or others

Anger

Irritability and restlessness

Sadness, moodiness, grief, depression

Distressing dreams
Guilt or “survivor guilt”

Feeling overwhelmed, hopeless

Feeling isolated, lost, or abandoned Apathy

Behavioral

Change in activity level

Decreased efficiency and effectiveness

Difficulty communicating

Outbursts of anger, frequent arguments, irritability

Inability to rest or “let down”

Change in eating habits

Change in sleeping patterns

Change in patterns of intimacy, sexuality

Change in job performance

Periods of crying

Increased use of alcohol, tobacco, and drugs

Social withdrawal/silence

Vigilance about safety of environment

Avoidance of activities/places that trigger memories

Cognitive

Memory problems

Disorientation

Confusion

Slowness of thinking and comprehension

Difficulty calculating, prioritizing

Poor concentration

Limited attention span

Loss of objectivity
Unable to stop thinking about disaster

Blaming

Physical

Increased heart/respiratory rate/blood pressure

Upset stomach, nausea, diarrhea

Change in appetite, change in weight

Sweating or chills

Tremor (hands/lips)

Muscle twitching

“Muffled” hearing

Tunnel vision

Feeling uncoordinated

Proneness to accidents

Headaches

Muscle soreness, lower back pain

“Lump” in the throat

Exaggerated startle reaction

Fatigue

Menstrual cycle changes

Change in sexual desire

Decreased resistance to infection

COMMUNITY REACTIONS AND RESPONSES

It is important to understand common responses and needs after a disaster, regardless of the type of
disaster. It is important to recognize:

1. Everyone who sees or experiences a disaster is affected by it in some way.

2. It is normal to feel anxious about your own safety and that of your family and close friends.

3. Profound sadness, grief, and anger are normal reactions to an abnormal event.
4. Acknowledging your feelings helps you recover.

5. Focusing on your strengths and abilities helps you heal.

6. Accepting help from community programs and resources is healthy.

7. Everyone has different needs and different ways of coping.

8. It is common to want to strike back at people who have caused great pain.

Large-group preventive techniques for children have been used for some time in California during the
aftermath of community-wide trauma (Eth, 1992). This type of school-based intervention occurs as soon
after the event as possible, and follows three phases:

1. Preconsultation—identifying the need; preparing the intervention with school authorities

2. Consultation in class—introduction, open discussion (fantasy), focused discussion (fact), free drawing
task, drawing or story exploration, reassurance and redirection, recap, sharing of common themes, and
return to school activities

3. Postconsultation—follow-up with school personnel and triage/referrals, as needed

MOURNING, MILESTONES, AND ANNIVERSARIES

The normal process of mourning is often facilitated by the use of rituals, such as funerals, memorials,
and events marking key time intervals, such as anniversaries. It is important to include the community in
the services, as well as the immediate family members. Community-wide ceremonies can serve to
mobilize the supportive network of friends, neighbors, and caring citizens and provide a sense of
belonging, remembrance, and letting go.

Websites and social media groups link the bereaved and can also provide special support during
important anniversaries or milestones. Ceremonies or memorials in schools should be developmentally
appropriate and involve students in the planning process. Websites and pages to be created in the
aftermath of a disaster serve as a place for people, both directly and indirectly impacted, to express
their condolences and offer support.

The phases of the mourning process have much in common with the emotional phases of disaster
recovery, and Worden (1982) has identified specific tasks that need to be accomplished at each phase of
mourning for successful resolution:

- Period of shock, or “numbness.” The task is to accept the reality of the loss (as opposed to denying the
reality of the loss).

- Reality, or “yearning,” and “disorganization and despair.” The tasks are to accept the pain of grief (as
opposed to not feeling the pain of the loss) and to adjust to an environment in which the deceased is
missing (as opposed to not adapting to the loss).

- Recovery, or “reorganized behavior.” The task is to reinvest in new relationships (as opposed to not
loving).
NORMAL MANIFESTATIONS OF GRIEF

Feelings

Sadness

Anger

Guilt and self-reproach

Anxiety

Loneliness

Fatigue

Helplessness

Shock (most often after sudden death)

Yearning (for the deceased person)

Emancipation

Relief

Numbness

Physical Sensations

Hollowness in stomach

Tightness in chest

Tightness in throat

Oversensitivity to noise

Sense of depersonalization/derealization

Breathlessness, shortness of breath

Weakness in muscles

Lack of energy

Dry mouth

Behaviors

Sleep disturbance

Appetite disturbance
Absentmindedness

Social withdrawal

Avoiding reminders (of deceased)

Dreams of deceased

Searching, calling out

Restless overactivity

Crying Treasuring objects

Visiting places/carrying objects of remembrance

Thoughts

Disbelief

Confusion

Preoccupation

Sense of presence

Hallucination

SAS 4

LEGAL AND ETHICAL ISSUE IN DISASTER RESPONSE

Law – are the rules and regulations under which nurses must carry out their professional duties—can
come from many different sources. What most people commonly think of as “law” are what lawyers call
“statutes.”

All of these sources of law can affect nurses in many different ways. For example, laws may require them
to do some affirmative act, such as report new cases of certain diseases to the local or state health
department. There may be criminal penalties for those who fail to comply with these requirements.
Laws may also give the authority to certain governmental officers to require nurses to either do or
refrain from doing something in a particular circumstance. Law can also create certain responsibilities
for nurses, such as laws that impose civil liability for the failure to provide professionally adequate care.

Civil liability is when an individual may be required to pay monetary damages to another individual, or in
some cases to the government, for failure to comply with a legal obligation.

Good Samaritan law – is a law that the nurses and other healthcare provider from liabilities for their
good deeds during a sudden emergency, but not always during a disaster.
RELATIONSHIP BETWEEN ETHICAL AND LEGAL OBLIGATIONS

Ethics – refers to the examination of what it means to live a moral life.

Morality – encompasses the norms people adopt to direct right and wrong conduct

Nurses’ ethical obligations come from many different sources, but one formal source is the professional
code of ethics.

The ANA Code of Ethics for Nurses proscribes the ethical obligations of nurses, and expresses the
profession’s commitment to society (ANA, 2015). Studying the potential issues in advance is key to this
preparation.

LAW AND ETHICS

Typical disaster-related issues that challenge traditional legal and ethical thinking include the privacy
issues of reporting diseases of epidemic or pandemic proportions, maintaining confidentiality, and issues
surrounding a potential quarantine. Mandatory vaccination, treatment refusal, resource allocation, and
duty to treat also legally and ethically challenge nurses working in disaster situations.

It is important for nurses to think about ethical and legal issues in advance of disasters because
sometimes it is the fear of handling these ethical issues that keep healthcare providers from offering
their services during disasters. Public health events quickly transform resource-rich environments into
settings of austerity and as a consequence produce unique and challenging ethical and legal issues.
Healthcare providers are often conflicted between their moral duty to serve disaster victims and their
moral duty to safeguard their own health, as well as their family’s and even their pet’s health (Rutkow et
al., 2017). Research studies reveal that healthcare providers are more likely to respond to disasters with
appropriate knowledge, sense of role importance, and trust in their organizations (Connor, 2014).

Dilemma - is a circumstance in which a person finds himself or herself choosing between two or more
actions he or she is morally required to perform, but the actions are actually incompatible with one
another

SPECIFIC ETHICAL AND LEGAL ISSUES

Privacy Issue Case Example: An outbreak of an infectious disease leads public health officials to believe
that a bioterrorist attack has occurred. To avoid panic of the public, however, the officials have made no
public announcement of their suspicions. They have requested, however, that nurses be on the alert for
new cases of the infectious disease and to report them immediately, along with certain information
about the patient. A nurse asks her supervisor if she can legally make such reports.

Reporting of Diseases

Nurses should already be aware of the reporting requirements of the state and local governments in the
areas where they currently practice. In the event of a public health crisis resulting from a terrorist attack,
nurses will need to keep current on any additional reporting requirements that may be imposed by state
and local health authorities. If the reporting is anonymous, then there is not concern for confidentiality
of the individual. Where the reporting requires the naming of a particular individual, however, this raises
both legal and ethical concerns surrounding the privacy and confidentiality of
medical information, which will be discussed in the next section.

Disclosure of Health Information

When health information contains information that would identify the individual, issues are raised
concerning both privacy and confidentiality. Frequently, these two terms are used interchangeably, but
there are technical distinctions between the two.

Privacy - is an individual’s claim to limit access by others to some aspect of his or her life

Confidentiality - is a type of privacy aimed at preserving a special relationship of trust, such as the
relationship between medical care provider and patient.

Examples:

A person who gains access to a patient’s electronic medical record without authorization violates patient
privacy but does not violate confidentiality (Beauchamp & Childress, 2013).

A nurse who discloses to a neighbor or colleague that a particular patient told her or him about past
drug abuse violates confidentiality.

Generally, disclosure of health information could not be made without the consent of the individual.
Five exceptions are:

Disclosure directly to the individual

2. Disclosure to the individual’s immediate family members or representative

3. Disclosure to appropriate federal agencies or authorities pursuant to federal law

4. Disclosure pursuant to a court order to avert a clear danger to an individual or the public’s health

5. Disclosure to identify a deceased individual or to determine the manner or cause of death.

Quarantine, Isolation, and Civil Commitment

Quarantine - is usually considered to be the restriction of the activities of a healthy person who has been
exposed to a communicable disease, usually for the period of time necessary for the disease to reveal
itself through physical symptoms

Isolation - is usually defined to mean the separation of a person known to have a communicable disease
for the period of time in which the disease remains communicable.

Civil commitment - is often associated today with proceedings in the mental health system to forcibly
confine persons who are mentally ill and a danger either to themselves or to others. More broadly in
public health, civil commitment “is the confinement (usually in a hospital or other specially designated
institution) for the purposes of care and treatment”.
Vaccination

Under their police powers, states have the governmental authority to require citizens to be vaccinated
against disease. The U.S. Supreme Court, early in the last century, upheld the authority of states to
compel vaccination, even when an individual refused to comply with the mandatory vaccination laws
(Jacobson v. Massachusetts, 1905). All states currently have laws that require school children to obtain
vaccinations against certain diseases, such as measles, rubella, and polio, before attending school. In a
public health crisis, however, the question may arise whether the state (or local) government could
require an individual to be vaccinated against an infectious agent released into the general population.

The state or local government must have the authority to do so. This may arise from a specific grant of
authority by the state legislature to mandate vaccinations in the wake of a public health crisis, or the
authority may be found in more general grants of authority given specific governmental agencies to
protect the public’s health.

Treatment for Disease

The U.S. Supreme Court affirmed the right of adults to select the course of treatment for their disease,
including the right of adults to refuse treatment. This right is not absolute, however. For example, when
children are involved, the courts have consistently upheld the power of the state to step in and require
treatment, even in the face of religious objections by the parents to medical treatment (Prince v.
Massachusetts, 1944).

Screening and Testing

Case Example: Because public health officials suspect a “stealth” bioterror attack, they request that
hospitals secretly test all of their new patients for the suspected contagious disease. The patient is to be
notified only if he or she tests positively for the disease, and he or she will be offered standard medical
treatment. Reports are to go directly to public health officials. Can a nurse legally or ethically participate
in such a program?

Screening and testing are two related, yet distinct, public health tools. “Testing” usually refers to a
medical procedure to test whether an individual has a disease. “Screening,” on the other hand, might be
thought of as testing all the members of a particular population. Although this distinction is important to
public health officials, public health laws often use the terms interchangeably or make no sharp
distinction between the two.

Professional Licensing

Case Example: In the immediate aftermath of the release of a biological agent in a large city, the city’s
health professionals are overwhelmed with the number of people they must treat. Nurses from a nearby
city, which is in another state, offer to help. In addition, it is proposed that nurses carry out duties
normally performed solely by physicians. Can nurses without a current state license “help out” in a
public health crisis? Can nurses perform duties and procedures normally outside the scope of their field?

All states require licenses in order for an individual to engage in the practice of nursing. Most states, in
addition, recognize different types of nurses such as professional nurses, licensed practical nurses, and
nurse practitioners.
Nurse licensing laws have two effects. The first is to limit the geographical area in which a nurse may
practice to the state in which he or she holds a license. The second is to define the scope of practice.
State statutes make illegal the practice of nursing within the state by one not licensed to practice in the
state , including the practice by an individual licensed to practice in another state.

Resource Allocation

Despite preparation, a bioterrorist attack or a disaster involving a large number of casualties or

casualties in excess of personnel and resources will challenge providers to justly allocate resources. In
this case, resources might be medical supplies, antibiotics, antitoxins, pain medications, vaccines, and/or
personnel. One aspect of justice in healthcare is the concept of “distributive justice.” Distributive justice
involves such issues as the fair and equitable allocation of scarce resources.

Triage - is one mechanism for allocating scarce resources in emergency situations. “biog” is a French
word meaning “to sort.” Emergency room and military personnel use triage to prioritize treatments of
wounded persons.

For example, in the military, the practice of triage is to sort the wounded into three groups—the walking
wounded, the seriously wounded, and the fatally wounded. The walking and seriously wounded receive
immediate attention, the walking wounded so that they may be returned to fight in battle, the seriously
wounded to save their lives. Those deemed fatally wounded are given narcotics to be kept comfortable,
but their wounds are not treated.

In emergency departments and at disaster sites, the wounded are also sorted into categories according
to medical need and medical utility. Treated first (triage level 1) are those people who have major
injuries and will die without immediate help; second are those whose treatment can be delayed without
immediate danger (triage level 2). The third group treated is those with minor injuries (triage level 3),
and the last group is those for whom treatment will not be effective. In emergency rooms, treatment for
those with minor injuries tends to be delayed because the order of treatment is based only on medical
need and medical utility.

Professional Liability

All healthcare professionals, including nurses, are subject to civil liability for providing substandard
healthcare. Malpractice liability is generally a matter of state law, although the law of malpractice
liability is very similar in all of the states. A nurse may be held liable, that is, have to pay monetary
damages, for providing professional care that is below the standard followed by the profession. Absent
special legislation, liability for medical professionals continues, even when they are performing medical
care in an emergency situation Some states have enacted special legislation, often called “Good
Samaritan” laws, which may provide immunity from civil liability for persons when they render care in
emergency situations. It is important for nurses to know the Good Samaritan laws in their own states in
order to avoid being held liable for negligence for intending to perform a good deed during an
emergency or disaster. A nurse can be held liable for negligence if he or she deviates from the accepted
standard of care, resulting in injury.
Provision of Adequate Care

Case Example: The local television news carries a story that a rash of human-to-human transmission
cases of avian flu has occurred in the region, resulting in five deaths to date. Nurses and other staff
begin calling in “sick.” When contacted by supervisors, the nurses admit they are afraid to come in to
work because of fears of a possible pandemic and the danger of spreading flu to their families (as
healthcare workers they received vaccinations, but their families were not similarly protected). What
legal recourse does a hospital have if staff refuse to work during a public health crisis? What liability
does the institution face if it operates in the absence of adequate staff? What ethical issues does calling
in sick raise for the nurse and the institution?

The relationship between nurses and hospitals legally is the same as between any other employer and
employee. Aside from the exceptions discussed in the following, the relationship is viewed as an “at-will
contract.” This means that the hospital can set the terms and conditions of employment and is free to
dismiss an employee for any reason (except as this right is modified by state or federal statutes, e.g.,
laws against racial discrimination). Likewise, the employee, here the nurse, is free to leave the
employment to go elsewhere for any reason, and technically without even giving notice, although
custom usually prevails here

In dealing with staffing requirements during a public health crisis, nurses and nurse administrators will
need to seek advice about the exact legal nature of the relationship between the nurses and the hospital
or other employing agency.

Employee policies regarding hours of work and refusals to work should be reviewed, and this is
particularly critical if there is a contract (either individual or a collective union contract) governing the
conditions of employment. In addition, legal advice will be needed concerning any state requirements
about mandatory work and the hours of employment.

A second legal issue surrounding staffing is liability for failing to maintain adequate nursing staff during a
public health crisis. Generally, all hospitals may be held civilly liable if they fail to maintain adequate
staffing and an individual is injured as a result of the inadequate staffing (Pozgar, 1999, p. 265). There is
no hard-and-fast standard as to what constitutes adequate staffing, and the courts are likely to allow
hospitals a large degree of discretion in determining whether staffing is adequate, particularly in the
event of a public health crisis. Nonetheless, if at some point sufficient numbers of nursing staff fail to
report for work, administrators will need to consider whether the staffing is so insufficient that the
quality of care will suffer.
SAS 5

MAIN LESSON (40 minutes)

Common Terms Used in Emergency Care

• Trauma :Intentional or unintentional wounds/injuries on the human body from particular mechanical
mechanism that exceeds the body’s ability to protect itself from injury

• Emergency Management: traditionally refers to care given to patients with urgent and critical needs

• Triage: process of assessing patients to determine management priorities.

• First Aid: an immediate or emergency treatment given to a person who has been injured before
complete medical and surgical treatment can be secured.

• BLS: level of medical care which is used for patient with illness or injury until full medical care can be
given.

• ACLS: Set of clinical interventions for the urgent treatment of cardiac arrest and often life threatening
medical emergencies as well as the knowledge and skills to deploy those interventions.

• Defibrillation: Restoration of normal rhythm to the heart in ventricular or atrial fibrillation

• Disaster: Any catastrophic situation in which the normal patterns of life (or ecosystems) have been
disrupted and extraordinary, emergency interventions are required to save and preserve human lives
and/or the environment

• Mass Casualty Incident: situation in which the number of casualties exceeds the number of resources

• Post Traumatic Stress Syndrome: characteristic of symptoms after a psychologically stressful event was
out of range of an normal human experience

Principles of Emergency Care

First aid is the initial emergency care given immediately upon arrival at the scene to an ill or injured
person. The first aider and people who are assisting should continue with assistance until the
professional medical assistance takes over the care of the casualty. Medical professionals may include
paramedics, doctors, or ambulance officers. First aiders should always make notes or fill out a casualty
report for any event attended, no matter how minor. Proper records will help you to recall the incident
if you are ever asked about it at a later stage.

Records may be used in a court, so ensure your reports or notes are legible, accurate, factual, contain all
relevant information and are based on observations rather than opinions.

Treatment
The last step is to actually provide care to the limits of the first aider's training, but never beyond. In
some jurisdictions, you open yourself to liability if you attempt treatment beyond your level of training.
Treatment should always be guided by

the 3Ps:

• Preserve life

• Prevent further injury

• Promote recovery

Treatment will obviously depend on the specific situation, but some situations will always require
treatment (such as shock). The level of injury determines the level of treatment required. The principles
first, do no harm and life over limb is essential parts of the practice of first aid. Do nothing that causes
unnecessary pain or further injury unless to do otherwise would result in death.

Aims

Although the 3Ps are outlined above, we will also include two more areas that needs attention when
conducting primary emergency care:

• Protection against further injury.

• Preservation of life.

• Promotion of recovery.

• Prevention of injuries for people at any age.

• Promotion of healthy lifestyles.

Protection against further injury

No injured person should be moved if his or her life is not in danger. If a person is not breathing and has
no pulse, his or her life is in danger. Life threatening situations exist where there is significant risk of loss
of life.

Preservation of Life

In order to stay alive, all persons need to have an open airway—a clear passage where air can move in
through the mouth or nose through the pharynx (part of the throat) and down in to the lungs, without
obstruction.

Conscious people will maintain their own airway automatically, but those who are unconscious may be
unable to maintain a patent airway, as the part of the brain which automatically controls breathing in
normal situations may not be functioning.

Once the airway has been opened, the first aider would assess to see if the patient is breathing. If there
is no breathing, or the patient is not breathing normally, such as agonal breathing (abnormal pattern of
breathing), the first aider would undertake what is probably the most recognized first aid procedure,
called cardiopulmonary resuscitation or CPR, which involves breathing for the patient, and manually
massaging the heart to promote blood flow around the body.

Promoting Recovery

The first aider is also likely to be trained in dealing with injuries such as cuts, grazes or bone fracture.
They may be able to deal with the situation in its entirety (a small adhesive bandage on a paper cut), or
may be required to maintain the condition of something like a broken bone, until the next stage of
definitive care (usually an ambulance) arrives.

Prevention of Injuries for people at any Age

The first aider must prevent injuries for all age groups. Age groups are categorised as follow:

1. Infant: For purposes of first aid, an infant is defined as being younger than 1 year of age.

2. Child: A child is categorised as being above 1 year of age

3. Adult: For purposes of first aid, adults are defined as people about age 12 (adolescents) or older.

You need parental permission to give care to a child or an infant, even if it is an emergency. The only
reasons for which you could give care without permission are if the parent is not present or is injured
and unable to respond.

Promoting of Healthy Lifestyles

The upside to living healthy is that there are many different ways to go about doing it. So many ways
that there is no reason why you can't find a plan which suits you well. But no matter which way you
decide works best for you, here are some general guidelines you are probably going to want to adhere
to:

• Be a role model.

• Encourage healthy eating

• Encourage physical activity.

TRIAGE

The word triage comes from the French word trier, meaning “to sort.” In the daily routine of the ED,
triage is used to sort patients into groups based on the severity of their health problems and the
immediacy with which these problems must be treated.

• What were the circumstances, precipitating events, location, and time of the injury or illness?

• When did the symptoms appear?

• Was the patient unconscious after the injury or onset of illness?

• How did the patient get to the hospital?

• What was the health status of the patient before the injury or illness?
• Is there a medical or surgical history? A history of admissions to the hospital?

• Is the patient currently taking any medications, especially hormones, insulin, digitalis, anticoagulants?

• Does the patient have any allergies? If so, what are they?

• Does the patient have any bleeding tendencies?

• When was the last meal eaten? (This is important if general anesthesia is to be given or if the patient is

unconscious.)

• Is the patient under a physician’s care? What are the name and location of the physician?

• What was the date of the patient’s most recent tetanus immunization?

ASSESS AND INTERVENE

For the patient with an emergent or urgent health problem, stabilization, provision of critical
treatments, and prompt transfer to the appropriate setting (intensive care unit, operating room, general
care unit) are the priorities of emergency care. Although treatment is initiated in the ED, ongoing
definitive treatment of the underlying problem is provided in other settings, and the sooner the patient
is stabilized and moved to that area, the better.

The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively
and follow the ABCD (airway, breathing, circulation, disability) method:

• Establish a patent airway.

• Provide adequate ventilation, employing resuscitation measures when necessary. (Trauma patients
must have

the cervical spine protected and chest injuries assessed first.)

• Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and
maintaining or restoring effective circulation.

• Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale.

• After these priorities have been addressed, the ED team proceeds with the secondary survey. This
includes

• A complete health history and head-to-toe assessment

• Diagnostic and laboratory testing

• Insertion or application of monitoring devices such as electrocardiogram (ECG) electrodes, arterial

lines, or urinary catheters

• Splinting of suspected fractures

• Cleaning and dressing of wounds

• Performance of other necessary interventions based on the individual patient’s condition

Once the patient has been assessed, stabilized, and tested, appropriate medical and nursing diagnoses
are formulated, initial important treatment is started, and plans for the proper disposition of the patient
are made.

SAS 6

MAIN LESSON (40 minutes)

SCOPE AND PRACTICE OF EMERGENCY NURSING

• The emergency nurse has had specialized education, training, and experience.

• The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured
patients, supports and attends to families, supervises allied health personnel, and teaches patients and
families within a time-limited, high-pressured care environment.

• Nursing interventions are accomplished interdependently, in consultation with or under the direction
of a licensed physician.

• Appropriate nursing and medical interventions are anticipated based on assessment data.

• The emergency health care staff members work as a team in performing the highly technical, hands-on
skills required to care for patients in an emergency situation.

• Patients in the ED have a wide variety of actual or potential problems, and their condition may change
constantly.

• Although a patient may have several diagnosis at a given time, the focus is on the most life-
threatening ones

ISSUES IN EMERGENCY NURSING CARE

• Emergency nursing is demanding because of the diversity of conditions and situations which are
unique in the ER.

• Issues include legal issues, occupational health and safety risks for ED staff, and the challenge of
providing holistic care in the context of a fast-paced, technology-driven environment in which serious
illness and death are confronted on a daily basis.

• The emergency nurse must expand his or her knowledge base to encompass recognizing and treating
patients and anticipate nursing care in the event of a mass casualty incident.

• Legal Issues Includes:

o Actual Consent

o Implied Consent

o Parental Consent
“Good Samaritan Law”

- Gives legal protection to the rescuer who act in good faith and are not guilty of gross negligence or
willful misconduct.

Focus of Emergency Care

• Preserve or Prolong Life

• Alleviate Suffering

• Do No Further Harm

• Restore to Optimal Function

Golden Rules of Emergency Care

 Do’s

- Obtain Consent

- Think of the Worst

- Respect Victim’s Modesty & Privacy

 Don’ts

- let the patient see his own injury

- Make any unrealistic promises

Guidelines in Giving Emergency Care

A – Ask for help

I – Intervene

D – Do no Further Harm

Stages of Crisis

1. Anxiety and Denial

• encouraged to recognize and talk about their feelings.

• asking questions is encouraged.

• honest answers given

• prolonged denial is not encouraged or supported

2. Remorse and Guilt

• verbalize their feelings

3. Anger

• way of handling anxiety and fear

• allow the anger to be ventilated

4. Grief

• help family members work through their grief

• letting them know that it is normal and acceptable

Core Competencies in Emergency Nursing

• Assessment

• Priority Setting/Critical Thinking Skills

• Knowledge of Emergency Care

• Technical Skills

• Communication

Assess and Intervene

Check for ABCs of life

A – Airway

B – Breathing

C - Circulation

Team Members

• Rescuer

• Emergency Medical Technician

• Paramedics

• Emergency Medicine Physicians

• Incident Commander

• Support Staff

• Inpatient Unit Staff

Emergency Action Principle

I. Survey the Scene

• Is the Scene Safe?

• What Happened?

• Are there any bystanders who can help?

• Identify as a trained first aider!

II. Do a Primary Survey

organization of approach so that immediate threats

to life are rapidly identified and effectively manage.

Primary Survey

A - Airway/Cervical Spine

- Establish Patent Airway

- Maintain Alignment

- GCS ≤ 8 = Prepare Intubation

B – Breathing

- Assess Breath Sounds

- Observe for Chest Wall Trauma

- Prepare for chest decompression

C – Circulation

- Monitor VS

- Maintain Vascular Access

- Direct Pressure

Estimated Blood Pressure

SITE SBP

Radial ≥ 80

Femoral ≥ 70

Carotid ≥ 60

D – Disability

- Evaluate LOC

- Re-evaluate clients LOC

- Use AVPU mnemonics

E – Exposure

- Remove clothing

- Maintain Privacy

- Prevent Hypothermia

III. Activate Medical Assistance

Information to be Relayed:

- What Happened?

- Number of Persons Injured

- Extent of Injury and First Aid given

- Telephone number from where you’re calling

IV. Do Secondary Survey

Interview the Patient (SAMPLE)

S – Symptoms

A – Allergies

M – Medication

P – Previous/Present Illness

L – Last Meal Taken

E – Events Prior to Accident

Check Vital Signs

V. Triage

 comes from the French word ”trier”, meaning to sort

 process of assessing patients to determine management prioritieS

Categories:

1. Emergent - highest priority, conditions are life threatening and need immediate attention

- Airway obstruction, sucking chest wound, shock, unstable chest and abdominal wounds, open fractures
of long bones

2. Urgent – have serious health problems but not immediately life threatening ones. Must be seen
within 1 hour

- Maxillofacial wounds without airway compromise, eye injuries, stable abdominal wounds without
evidence of significant hemorrhage, fractures

3. Non-urgent – patients have episodic illness than can be addressed within 24 hours without increased
morbidity

- Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding,
behavioral disorders or psychological disturbance.

FIRST AID

Role of First Aid

• Bridge the Gap Between the Victim and the Physician

• Immediately start giving interventions in pre-hospital setting

Value of First Aid Training

• Self-help

• Health for Others

• Preparation for Disaster

• Safety Awareness
BASIC LIFE SUPPORT

Artificial Respiration - a way of breathing air to person’s lungs when breathing ceased or stopped
function.

Respiratory Arrest - a condition when the respiration or breathing pattern of an individual stops to
function, while the pulse and circulation may continue.

Causes: Choking, Electrocution, strangulation, drowning and suffocation.

Methods:

• mouth to mouth

• mouth to nose

• mouth to stoma

• mouth to mouth and nose

• mouth to barrier device

To perform rescue breathing perform the following steps:

1. Check the mouth for obstructions, lift the neck and tilt the head back.

2. Pinch the nostrils and seal the mouth, and exhale directly into the victim's mouth.

3. Release the nostrils and the seal around the mouth.

4. Watch for the victim's chest to rise by itself.

5. Feel for a pulse on the victim's neck.

6. If the victim's chest does not start to rise on its own, repeat this process from number 1, until
professional help arrives.

When to Stop AR:

✓ when the patient has spontaneous breathing

✓ when the first aider is too exhausted to continue

✓ when another first aider takes over

✓ when EMS arrives and takes over

Cardiopulmonary Resuscitation (CPR)

Cardiac Arrest - a condition when the persons breathing and circulation/pulse stop at the same time

Causes: Cardiovascular Disease, Heart Attack, MI

Management:
External Chest Compression

- consist of rhythmic application of pressure over the lower portion of the sternum just in between the
nipple

Cardiopulmonary Resuscitation = AR + ECC

Goal: Rapid return of pulse, BP and consciousness

Check that the area is safe, then perform the following basic CPR steps:

1. Call 911 or ask someone else to.

2. Lay the person on their back and open their airway.

3. Check for breathing. If they are not breathing, start CPR.

4. Perform 30 chest compressions.

5. Perform two rescue breaths.

6. Repeat until an ambulance or automated external defibrillator (AED) arrives.

When to STOP CPR:

S – SPONTANEOUS BREATH RESTORED

T – TURNED OVER THE MEDICAL SERVICES

O – OPERATOR IS EXHAUSTED TO CONTINUE

P – PHYSICIAN ASSUMES RESPONSIBILITY

COMPLICATIONS OF CPR:

• Rib Fracture

• Sternum Fracture

• Laceration of the liver or spleen

• Pneumothorax, hemothorax

CHAIN OF SURVIVAL

EARLY ACCESS – early recognition of cardiac arrest, prompt activation of emergency services

EARLY BLS – prevent brain damage, buy time for the arrival of defibrillator

EARLY DEFIBRILLATION - 7-10% decrease per minute without defibrillation

EARLY ACLS – technique that attempts to stabilize patient

SAS 7

BASIC PRINCIPLES OF DISASTER TRIAGING

“Triage is a process which places the right patient in the right place at the right time to receive the right
level of care” (Rice & Abel, 1992). The word “triage” is derived from the French word trier, which means,
“to sort out or choose.”

Triage is the process of prioritizing which patients are to be treated first and is the cornerstone of good
disaster management in terms of judicious use of medical resources.

Personal abilities that are essential to be an effective triage officer during a disaster:

1. Clinically experienced

2. Good judgment and leadership

3. Calm and cool under stress

4. Decisive

5. Knowledgeable of available resources

6. Sense of humor

7. Creative problem solver

8. Available

9. Experienced and knowledgeable regarding anticipated casualties

Most Common Terminologies

Daily triage - is performed by nurses on a routine basis in the ED, often utilizing a standardized approach,
augmented by clinical judgment. The goal is to identify the sickest patients to assess and treat them first,
before providing treatment to others who are less ill and whose outcome is unlikely to be affected by a
longer wait. The highest intensity of care is provided to the most seriously ill or injured patients, even if
those patients have a low probability of survival.

Incident triage - occurs when the ED is stressed by a large number of patients due to an acute incident
or an ongoing medical crisis such as pandemic influenza, but is still able to provide care to all patients
utilizing existing agency resources. Additional resources (on-call staff, alternative care areas) may be
used, but disaster plans are not activated and treatment priorities are not changed. The highest intensity
of care is still provided to the most critically ill patients. ED delays may be longer than usual, but
eventually everyone who presents for care is attended to.

Disaster triage - is a general term employed when local EMS and hospital emergency services are
overwhelmed to the point that immediate care cannot be provided to everyone who needs it because
sufficient resources are not immediately available. The terms “multiple casualty/multicasualty” and
“mass casualty” triage (both also known as “MCI triage”) are often used interchangeably with “disaster
triage.” The distinction between “multiple” and “mass” casualties is principally in the number of victims
and the degree of restriction of resources.
During a disaster, patients are usually sorted into one of the following categories:

1. Minimal or minor (green)

2. Delayed (yellow)

3. Immediate (red)

4. Deceased (black)

5. Expectant (gray)

Special conditions during triage: Incidents involving chemical, biological, or radioactive agents may be
intentional or unintentional (e.g., a truck crash involving the release of hazardous materials). These
triage situations require personal protective equipment for all responders coming into contact with
potentially contaminated patients and decontamination capabilities both in the field and at receiving
facilities. During any disaster, triage personnel must ensure that they themselves do not become
victims. One enters the scene for field triage only when scene safety has been assured.

Population-based Triage:

Main goal of population-based triage is to prevent secondary illness or injury such as disease
transmission from infectious individuals or foodborne illness from contaminated or poorly refrigerated
supplies. The messages and directions sent during population-based triage will depend on the type(s) of
illness or injury that is trying to be contained. Depending on the severity, lethality, and/or
transmissibility of the illness or injury being prevented, these events can be very serious and have a
huge impact on a community.

SEIRV CLASSIFICATION:

1. Susceptible individuals—those individuals who are unexposed but susceptible.

2. Exposed individuals—susceptible individuals who have been in contact with the disease and may be
infected and incubating but still noncontagious.

3. Infectious individuals—persons who are symptomatic and contagious.

4. Removed individuals—persons who no longer can pass the disease to others because they have
survived and developed immunity or died from the illness.

5. Vaccinated or on prophylactic antibiotics—persons in this group are a critical resource for the
essential workforce

PHASES OF DISASTER TRIAGE: FROM THE FIELD TO THE HOSPITAL

Primary Triage: The goal of primary triage is usually to sort patients into five triage categories:
Immediate, Delayed, Minimal, Expectant, and Dead.

Secondary Triage: Additional information about each patient is obtained through a more thorough
physical assessment and history. This is similar to the traditional trauma secondary survey, in which
physiology is reassessed and obvious injuries are identified. When secondary triage is done in the field,
one of the goals is to determine which patients have conditions that can be temporarily but effectively
treated on-scene using available personnel and resources and identify those whose immediate needs
can be met only in a hospital setting.

Tertiary Triage: Hospital personnel determine if the facility can provide appropriate care or if the patient
will require stabilization and transfer to a facility capable of a higher level of care.

IN-HOSPITAL TRIAGE SYSTEM FOR DAILY OPERATIONS

Typical Data Elements Gathered at ED Triage During Normal Operations

• Name

• Age

• Gender

• Chief complaint (CC)

• History of present illness (HPI)

• Mechanism of injury (MOI)

• Past medical or surgical history (PM/SHx.)

• Allergies to food or medication (Allergies)

• Current medications (Meds)

• Date of last tetanus immunization

• Last menstrual period (for females between the ages of 11 and 60) (LMP)

• Vital signs: temperature, pulse, blood pressure, respiratory rate, oxygen saturation (VS)

• Level of consciousness (LOC)

• Skin vital signs (Skin vitals): temperature, color, moisture

• Visual inspection for obvious injuries

• Height and weight (pediatric patients) (Ht./Wt.)

• Mode of arrival (MOA)

• Private medical provider (PMD)

• Other

Most hospitals utilize a triage system that has three to five categories. The three main categories are
emergent (Class 1), urgent (Class 2), and nonurgent (Class 3). Where four or five levels are used,
subcategories are added to either end of the spectrum.

Three-tier System

Emergent signifies a condition that requires treatment immediately or within 15 to 30 minutes.

Urgent category is assigned to patients with serious illness or injury that must be attended to as soon as
possible, but for whom a wait of up to 2 hours would probably not add to morbidity or mortality.

Nonurgent status is used for any patient who can wait more than 2 hours to be seen without the
likelihood of deterioration.

In a four-tier system, the Emergent category is usually subcategorized to identify those conditions that
must be treated immediately (STAT or 1A) versus rapidly (within a few minutes, 1B). STAT conditions
would include cardiac arrest, respiratory failure/arrest, airway obstruction, shock, and seizure.
Conditions classified as 1B would include moderate to severe respiratory distress, cardiac dysrhythmia
with adequate blood pressure, or heavy bleeding without hypotension or tachycardia.

In a five-tier system, the Nonurgent category is also subcategorized. Conditions that are nonacute, but
require the technology of the ED to diagnose or treat, are categorized as nonurgent ED (Class 3). This
would include conditions such as minor lacerations requiring sutures, or minor musculoskeletal trauma
requiring x-rays for diagnosis.

SALT TRIAGE

CDC-sponsored expert panel developed SALT Triage. It is nonproprietary and meets the model uniform
core criteria for mass casualty triage. SALT stands for Sort-Assess-Lifesaving interventions-Treatment/
transport, which describes the steps followed when performing SALT triage.
Once any lifesaving interventions are performed, the responders should evaluate the patient and
prioritize him or her for treatment and/or transport.

• Dead: those who are not breathing even after lifesaving interventions have been attempted.

• Immediate: those with difficulty breathing, uncontrolled hemorrhage, absence of peripheral pulses,
and/or inability to follow commands; who are likely to survive given the available resources.

• Expectant: those with difficulty breathing, uncontrolled hemorrhage, absence of peripheral pulses,
and/or inability to follow commands; who are unlikely to survive given the available resources.

• Delayed: those who are alert and follow commands, have palpable peripheral pulses, no signs of
respiratory distress, and all bleeding is controlled, with injuries or an illness that in the opinion of the
rescuer is more than minor.

• Minimal: those who are alert and follow commands, have palpable peripheral pulses, no signs of
respiratory distress, and all bleeding is controlled, with injuries/condition that in the opinion of the
rescuer are minor.

SIMPLE TRIAGE AND RAPID TREATMENT (START)

The five basic parameters assessed with START are:

• the ability to walk

• the presence or absence of spontaneous respirations

• the respiratory rate

• an assessment of perfusion

• the ability to obey commands.

These parameters are often referred to as respirations, perfusion, and mental status (RPM).
THE JOB OF THE TRIAGE OFFICER

The primary responsibility of the triage officer is to ensure that every victim has been found and triaged.
Triage officers and those responders assigned to perform triage do not provide immediate treatment
other than to provide lifesaving interventions such as opening airways and trying to control active
bleeding.

SAS 8

Traumatic Injury Due to Explosives and Blast Effects

Resultant bodily & structural damage following an explosion depends on:

o Type of explosive

o Medium in which the explosion occurred

o Proximity to the explosion’s epicenter

Assist the health care providers to determine what type of injuries & how many casualties to expect
following an explosion
o Total number of casualties = Number of casualties arriving in the first hour x 2

Classifications of Blast Injury

A. Primary Blast Injury

o Unique to HE

o Due to impact of over-pressurization wave with body surfaces

o Commonly involve air-filled organs & air-fluid interfaces (middle ear, lungs, GIT )

• Types of injuries

o Blast lung, TM rupture

o Abdominal hemorrhage & perforation

o Globe rupture

Tympanic Membrane Injury

o TM- structure most frequently injured by blast

• TM rupture

• Ossicle dislocation

• Disruption of oval or round window

o Sx: hearing loss, tinnitus, vertigo, bleeding from external canal, mucopurulent

otorrhea

B. Secondary Blast Injury

o Due to flying debris & bomb fragments

o Penetrating ballistic or blunt injuries

o Leading cause of death in military & civilian terrorist attacks except in cases of major building collapse

o Wounds can be grossly contaminated

C. Tertiary Blast Injuries

o Due to persons being thrown into fixed objects by wind of explosions

o Also due to structural collapse & fragmentation of building & vehicles; structural collapse may cause
extensive blunt trauma.

o Crushing injuries, fracture & traumatic amputation

o Closed & open brain injury

D. Quaternary Blast Injuries

o Explosion related injuries or illnesses not due to primary, secondary, or tertiary injuries

o Exacerbations of preexisting conditions (asthma, COPD, CAD, HTN, DM, etc.)

o Burns (chemical & thermal)

o Toxic inhalation

o Radiation exposure

o Asphyxiation (CO, cyanide)

General Considerations

• Confined space vs. open space: increase number of penetrating & primary blast injuries if closed space

• Blast wave reflected by solid surfaces: person next to a wall may sustain a greater primary blast injury

• Detonating a bomb underwater will produce more damage than air detonation because water is
incompressible.

• Half of all initial casualties seek medical care over first hour

• Expect upside down triage

• Most severely injured arrive after less injured who bypass EMS & self-transport to closest hospitals

• Initial explosion attracts law enforcement & rescue personnel who will be injured by second explosion

• Open Space

o Potential for shrapnel to travel a large distance (>100m)

o Less primary blast injury

• Enclosed Space

o Increased mortality

o Increased blast pressure

o Complicated rescue

• Structural Collapse
o Increased mortality from primary blast wave as well as from tertiary and quaternary injuries

Management Elements of an Explosion

• Search & Rescue

• Triage

• Initial stabilization

• Definitive medical treatment

• Evacuation

ATLS Primary Survey (Advance Trauma Life Support)/ IDENTIFICATION AND MANAGEMENT

A. Airway and Cervical Spine

Immobilization - Assess and maintain airway patency: assess for foreign bodies and fractures

that may lead to obstruction Immobilize cervical spine with an available device

B. Breathing and Ventilation - Assess for bilateral chest wall movement; auscultate and visualize chest
wall and lung fields. Identify pneumothorax, flail chest, hemothorax, and open pneumothorax

C. Circulation - Consider hypovolemia the cause of hypotension until proven otherwise . Assess LOC,
skin color, and pulse for signs of hypovolemia and hypoxia. Identify and control external hemorrhage,
identify internal hemorrhage

D. Disability and Neurologic Deficit - Assess Glascow Coma Scale, pupil size and reactvity. A decreased
LOC may require intubation

E. Exposure and Environmental Control Expose the patient t view all body surfaces for evidence of injury.
Cover with warm blankets and use warmed intravenous fluids to maintain temperature

ATLS Secondary Survey Physical Examination

BODY SYSTEM EXAMINATION

Neurologic - Assess LOC, sensory and motor function, and pupillary response. Consult neurosurgery and
obtain a head CT if head injury is suspected

Head - Examine head and scalp for injury and fractures. Assess vision and pupils. Hemorrhage,
penetrating injury, lens dislocation and ocular entrapment may occur. Contacts should be removed

Maxilofacial. Assess for fractures and soft-tissue injury. Place a gastric tube orally in patients with
suspected or confirmed facial fractures
Cervical Spine and Neck - Maintain spine precautions

Chest- Auscultate breath and cardiac sounds. Obtain chest x-raY

Abdomen - Unexplained hypotension may be the result of an internal hemorrhage. Peritoneal lavage,
ultrasound, abdominal CT may be necessary to rule out injury

Perineum, Rectum, and Vagina - Assess for contusions, hematomas, lacerations, and bleeding. Perform a
rectal exam prior to placing a Foley catheter

Musculoskeletal - All extremities, pelvic ring, peripheral pulses, and thoracic and lumbar spine should be
assessed. X-rays should be obtained when the patient is stabilized, if necessary

Blast Injuries/ SYSTEM INJURY OR CONDITION

Auditory - TM rupture, ossicular disruption, cochlear damage, foreign body

Eye, orbit, face - Perforated globe, foreign body, fractures

Respiratory - Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, airway
epithelial damage

Digestive - Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis

Circulatory Cardiac contusion, myocardial infarction from air embolism, shock, hypotension, peripheral
vascular injury, air embolism-induced injury

CNS Injury - Concussion, closed and open brain injury, stroke, spinal cord injury

Renal - Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and
hypovolemia

Extremity Injury - Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts,
lacerations, acute arterial occlusion, air embolism-induced injury

SAS 9

BURNS

- occur when there is an injury to the tissues of the body (primarily the skin) caused by heat, chemicals,
electric current or radiation.

Classification of Burns

1. Superficial Partial-thickness - the epidermis is destroyed or injured and a portion of the dermis may be
injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister.
2. Deep Partial-thickness - involves destruction of the epi-dermis and upper layers of the dermis and
injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid.

3. Full-thickness - involves total destruction of epidermis and dermis and, in some cases, underlying
tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is
painless because nerve fibers are destroyed.

Local Physiologic Alterations

• Loss of protective barriers

• Escape of body fluids

• Lack of temperature control

• Diminished sensory receptors

Extent of Body Surface Area Injured

1. Rule of Nines

The system assigns percentages in multiples of nine to major body surfaces.

2. Lund and Browder Method

A more precise method of estimating the extent of a burn is the Lund and Browder method, which
recognizes that the percent-age of TBSA of various anatomic parts, especially the head and legs, and
changes with growth. By dividing the body into very small areas and providing an estimate of the
proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA
burned. The initial evaluation is made on the patient’s arrival at the hospital and is revised on the
second and third post-burn days because the demarcation usually is not clear until then.

3. Palm Method

In patients with scattered burns, a method to estimate the per-centage of burn is the palm method. The
size of the patient’s palm is approximately 1% of TBSA

Burn Triage in Mass Casualty Incidents

Primary triage

o Local disaster triage criteria

o Occurs at the site

Secondary triage

o Occurs in the hospital or burn center ABA (American Burn Association) triage policy

o All burn patients should be transferred to a burn center within 24 hours of injury
Management of a Mass Casualty Burn Patient

 STOP the burning process

 Manage the AIRWAY, BREATHING, and CIRCULATION

 Begin FLUID RESUSCITATION

 Keep the patient WARM

 EVALUATE for other life-threatening injuries

Management of Burn MCI: Primary Survey: Stop the Burning Process

 Extinguish the flames (stop, drop and roll)

 Irrigate with cool water

 Use of ice or ice water is contraindicated

Management of Burn MCI: Primary Survey:

Airway, Breathing, Circulation

• Endotracheal intubation:

o Hoarseness

o Stridor

o Excessive use of accessory muscle

o Difficult respirations

o Decreased LOC

• 100% oxygen – smoke inhalation

• Two large-bore peripheral IV catheters

Management of Burn MCI: Primary Survey: Fluid Resuscitation

• Fluid resuscitation

o 2nd or 3rd degree burns greater than 10-20% TBSA

o Significant smoke inhalation injury

• Insertion of urine catheter

• Indications:

- Adults with burns involving more than 10% - 20% TBSA

- Children with burns involving more than 10-15% TBSA

- Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and
compromised response to burn injury

• The amount of fluid should maintain a urinary output of 30 - 50 ml/hr

Successful fluid resuscitation is evidenced by:

- Stable vital signs - Palpable peripheral pulse

- Adequate urine output - Clear sensorium

• Urinary output is the most common and most sensitive assessment parameter for cardiac output and
tissue perfusion

PARKLAND FORMULA

Example: Patient’s weight: 70 kg; % TBSA burn: 80%

1st 24 hours:

4 ml x 70 kg x 50% TBSA = 14,000ml of lactated Ringer’s

• 1st 8 hours = 7,000 ml or 875 ml/hour

• 2nd 16 hours = 7, 000 ml or 437.5 ml/hour

BROOKE ARMY FORMULA

0.5ml colloid x weight in kg x TBSA (bld, plasma, dextran)

1.5ml electrolytes X weight in kg x TBSA (normal saline)

Non electrolytes – 2000 ml (D5W)

• Day 1 = same as parkland

• Day 2 – 1⁄2 colloids, + 1⁄2 electrolytes + non electrolytes to run for 24 hours

EVANS

1ml colloid x weight in kg x TBSA (bld, plasma, dextran)

1ml electrolytes X weight in kg x TBSA (normal saline)

Non electrolytes – 2000 ml (D5W)

• Day 1 = same as parkland

• Day 2 – 1⁄2 colloids, + 1⁄2 electrolytes + non electrolytes to run for 24 hours

• Initial hourly rate:

o 0.25 mL x kg x %TBSA

• Goal: Urine output:

o Adults: 0.5 mL/kg/hr

o Children less than 30 kg: 1 mL/kg/hr

• Rule of thumb:

o Decrease the fluid rate by 10% every hour if goal is met

o Increase the fluid rate by 20% and observe the next hour, if goal is not met

Adult maintenance fluid requirement: the fluid is titrated down to maintenance rate at 24 hours from
the time of injury 30 mL/kg/day (plus an estimate of insensible loss)

Pediatric Maintenance Fluids: 5% dextrose

First 10 kg of body weight: 100 mL/kg over 24 hours

Second 10 kg of body weight: Add 50 mL/kg to above total

Each kg over 20 kg: Add 20 mL/kg to above total

Management of Burn MCI: Primary Survey: Other Considerations

• On-site:

o Keep the patient warm: rescue blankets or dry sheets

o Remove constrictive clothing and jewelry

• Hospital care:

o Keep the room to a minimum of 30 degrees Celsius

o Keep the patient warm: warm blankets in the hospital

o Assess pulses hourly: radial, ulnar posterior tibial, dorsalis pedis

Management of Burn MCI: Secondary Survey

• Accurate history

• Complete examination

• Close re-examination of the burn wound

• Patient Pre transport Checklist (before secondary triage to another healthcare facility)

o Primary and secondary survey are complete

o Patient is hemodynamically stable

o IV fluid resuscitation

o Patient is warm, wrapped in blankets

o ET tube, IV catheters, urine catheters, NG tube are secure and functioning

o Documentation is complete

Burn Wound Care in MCI

• Principles:

o Keep the wound clean, moist, and covered

o May keep the wound covered for transport

o When the patient arrives in the facility, cleanse with soap and warm water

o Remove any debris and loose, dead skin, and pat dry

Pain Control

• Intravenous narcotics are usually sufficient to maintain adequate pain control

• Oral and subcutaneous routes should not be used to treat burns greater than 20% TBSA

SAS 10

A major cause of global morbidity and mortality after causing or associated with large scale public health

emergencies. Ninety deaths are caused by only six diseases. percent of all infection diseases.

Emergencies

❖ Are caused by infectious conditions may occur as the primary event, or a secondary challenge
following or worsening another type of emergency.The emergence or resurgence of an infectious
disease requires the convergence of complex factors

that can be:

• genetic and biological

• physical

• ecological,

• Social

• Political

• behavioral in nature.
Infectious Diseases and Emergencies: Infectious diseases that increase in incidence and prevalence,
possibly to the point of epidemic, pandemic, or emergency, can be classified as being in one of three
groups:

■ Emerging—infections that have newly appeared in a human population and have not been previously
known, such as SARS or new strains of avian influenza

■ Reemerging or resurging—infections that have been known but demonstrate a marked increase in
incidence or geographical range, such as the enormous surge of Ebola in West Africa

■ Deliberately emerging—natural or bioengineered agents distributed by individuals as a criminal act of

bioterrorism, such as the anthrax cases in the United States in the fall of 2001

Leading Causes of Infection Disease Death according to WHO in 2017

■ Diarrheal disease

■ HIV/AIDS

■ Malaria

■ Childhood diseases, primarily measles

■ Pneumonia

■ Tuberculosis

■ Hepatitis B

EPIDEMIOLOGICAL TRIANGLE

❖ A model for explaining the organism causing the disease and the condition that allow it to reproduce
and spread.

Made up of 3 parts:

1. Agent- the microorganism that actually causes the disease

2. Host- the organism that carries the disease, a human who is susceptible to the disease

3. Environment- factors that support the transmission

FACTORS CONTRIBUTING TO THE SPREAD OF INFECTIOUS DISEASES:

• Microbial adaption and change

• Human susceptibility to infection

• Climate and weather

• Changing ecosystem

• Human demographic and and behavior

• International travel and commence

• Technology and industry

• Breakdown of public health measures

• Poverty and social inequality

• War and famine

Diseases of particular Importance to address in disaster and emergency planning and response activities
are those that are known to be:

1. Highly contagious

2. Have high mortality rate

3. To which there is no or limited human immunity coupled with either a no available treatment or
treatment to which the organism is resistant

6 Conditions of Particular Importance:

1. Cholera

2. Dengue fever

3. HIV

4. Influenza

5. Marburg hemorrhagic fever

6. Smallpox

CLINICAL PROFILE of CHOLERA

Transmission

Exposure to drinking water or food contaminated by feces of an infected individual

CLINICAL SYMPTOMS

Mild infection, little or mild gastrointestinal distress

DIAGNOSIS

Symptomatic, with definitive diagnosis based on laboratory examination of stool specimen

THERAPY
Immediate fluid and electrolyte replacement, with oral rehydration solution in large amounts

Direct person-to-person

transmission unlikely

Severe disease (~5% of

cases), profuse, watery

diarrhea, vomiting, leg

cramps. Intravenous fluid

and electrolyte

replacement may be

needed in severe cases

Intravenous

fluid and

electrolyte

replacement

may be

needed in

severe cases

Death can occur within

hours if severe disease

not treated

CLINICAL PROFILE of DENGUE FEVER

Transmission Clinical Symptoms Diagnosis Therapy

SAS 11

NATURAL DISASTERS

Types of Natural Disasters:

• Tornadoes

• Hurricanes

• Earthquakes

• Volcanoes

• Floods

• Tsunamis

• Winter storms

• Wildfires

Tornadoes

• Rotating, funnel-shaped clouds from powerful thunderstorms

• Winds up to 300 MPH capable of producing major damage

• More occur in the United States than anywhere else in the world; they occur in every state in America.

Tornado Preparation:

• Listen to local news or Weather Radio report for emergency updates. Watch for signs of a storm, like
darkening skies, lightning flashes or increasing wind.

• If you can hear thunder, you are close enough to be in danger from lightning. If thunder roars, go
indoors! Don't wait for rain. Lightning can strike out of a clear blue sky.

• Avoid electrical equipment and corded telephones. Cordless phones, cell phones and other wireless
handheld devices are safe to use.

• Keep away from windows.

If you are driving, try to safely exit the roadway and park. Stay in the vehicle and turn on the emergency

flashers until the heavy rain ends.

• If you are outside and cannot reach a safe building, avoid high ground; water; tall, isolated trees; and
metal

objects such as fences or bleachers. Picnic shelters, dugouts and sheds are NOT safe.

Hurricanes
• Massive severe storms occurring in the tropics

• Winds greater than 75 MPH

• Clouds & winds spin around the eye

• Produce heavy rains, high winds, large waves, and spin-off tornadoes

• Hurricanes, cyclones, and typhoons are all the same weather phenomenon; we just use different
names for

these storms in different places.

• In the Atlantic and Northeast Pacific, the term “hurricane” is used.

• The same type of disturbance in the Northwest Pacific is called a “typhoon” and

• “cyclones” occur in the South Pacific and Indian Ocean.

• The ingredients for these storms include a

o pre-existing weather disturbance,

o warm tropical oceans,

o moisture, and

o relatively light winds.

• If the right conditions persist long enough, they can combine to produce the violent winds, incredible
waves,

torrential rains, and floods we associate with this phenomenon.

STRENGTH: A storm gets a name and is considered a tropical storm at 39 mph (63 kph).

It becomes a hurricane, typhoon, tropical cyclone, or cyclone at 74 mph (119 kph).

Hurricane Preparation

• Listen to a Weather Radio

• Check your disaster supplies. Replace or restock as needed.

• Bring in anything that can be picked up by the wind (bicycles, lawn furniture).

• Close your windows, doors and hurricane shutters. If you do not have hurricane shutters, close and
board up

all windows and doors with plywood.

• Turn your refrigerator and freezer to the coldest setting. Keep them closed as much as possible so that
food
will last longer if the power goes out.

• Turn off propane tank.

• Unplug small appliances.

• Fill your car’s gas tank.

• Create a hurricane evacuation plan with members of your household. Planning and practicing your
evacuation plan minimize confusion and fear during the event.

• Find out about your community’s hurricane response plan. Plan routes to local shelters, register family
members with special medical needs and make plans for your pets to be cared for.

• Obey evacuation orders. Avoid flooded roads and washed-out bridges.

Damages of Typhoons/Hurricanes

• Storm surge: increase in sea level

o low pressure central area of the storm creating suction

o storm winds piling up water

o tremendous speed of the storm

• Flash floods

Philippine Storm Warning Signals (PAGASA)

• Signal #1: winds of 30–60 km/h (20-35 mph) are expected to occur within 36 hours

• Signal #2: winds of 60–100 km/h (40-65 mph) are expected to occur within 24 hours

• Signal #3: winds of 100–185 km/h, (65-115 mph) are expected to occur within 18 hours.

• Signal #4: winds of at least 185 km/h, (115 mph) are expected to occur within 12 hours.

PSWS #1

IMPACT OF THE WINDS:

o Twigs & branches of small trees may be broken.

o Banana plants maybe tilted or downed.

o Nipa/Cogon houses may be partially unroofed.

o Light or no damage at all

o Significant damage in rice drops when it is in its flowering stage.

Precautionary Measures:
o Signal may be upgraded to the next higher level.

o Coastal waters may become bigger & higher.

o Listen to the latest severe weather bulletin. (every 6 hours)

o Business is carried out as usual except if flood occur.

o Disaster preparedness: ALERT STATUS.

2. PSWS #2

IMPACT OF THE WINDS:

o Some coconut trees are tilted or broken

o Big trees may be uprooted

o Banana plants fallen/downed.

o Nipa/cogon houses may be partially or totally unroofed.

o Some old galvanized iron roofing may be peeled off.

o Winds bring light to moderate damage

Precautionary Measures:

o Sea & coastal waters are dangerous to small sea crafts

o People travelling by sea & air are cautioned to avoid unnecessary risks.

o Outdoor activities of children should be postponed.

o Secure properties

o Disaster preparedness agencies are in action to alert their communities.

3. PSWS #3

IMPACT OF THE WINDS:

o Coconut trees destroyed.

o Banana plants downed

o Trees may be uprooted.

o Nipa & cogon houses may be destroyed

o Damage to structures of light to medium construction

o Widespread disruption of power & communication services

o Moderate to heavy damage (Agriculture and Industry)

Precautionary Measures:
o Dangerous to the community

o Sea and coastal waters will be very dangerous

o Travel is very risky by sea and air.

o Seek shelter in strong buildings, evacuate low-lying areas

o When the "eye" of the typhoon hit the community do not venture away from the safe shelter

o Classes in all levels: Suspended

o Disaster preparedness & response: agencies are in action with to actual emergency.

4. PSWS #4

IMPACT OF THE WINDS:

o Coco plantation suffer extensive damage.

o Big trees are uprooted.

o Rice/corn suffer severe losses.

o Buildings may be severely damaged.

o Power & communication services are severely disrupted.

o Damage to affected communities can be very heavy.

Precautionary Measures:

o Very destructive

o Travels & outdoor activities are cancelled.

o Evacuation should have been completed since it may be too late under this situation.

o Locality is likely to be hit directly by the eye of the typhoon.

o Winds increasing to its strongest

o Disaster coordinating councils and other disaster response agencies are now fully responding to

emergencies & in full readiness to immediately respond to possible calamity.

If you are at risk for typhoon:

• Keep trees trimmed

• Remove any debris or loose items in the yard

• Declog rain gutters & downspouts to prevent flooding

• Install permanent typhoon shutters to protect glass windows and doors

• Close all windows and doors

• Use rope/chain to secure boat to trailer to the ground or house

• Turn off water or electric utilities

Risk of Morbidity and Mortality: Hurricanes and Typhoons

• Drowning

• Electrocution

• Lacerations and punctures from flying debris

• Blunt trauma

• Gastrointestinal and respiratory diseases

What to Do After a Hurricane:

• Continue listening to a Weather Radio or the local news for the latest updates.

• Stay alert for extended rainfall and subsequent flooding even after the hurricane or tropical storm has
ended.

• If you evacuated, return home only when officials say it is safe.

• Drive only if necessary and avoid flooded roads and washed -out bridges.

• Keep away from loose or dangling power lines and report them immediately to the power company.

• Stay out of any building that has water around it.

• Inspect your home for damage. Take pictures of damage, both of the building and its contents, for
insurance

purposes.

• Use flashlights in the dark. Do NOT use candles.

• Avoid drinking or preparing food with tap water until you are sure it’s not contaminated.

• Check refrigerated food for spoilage. If in doubt, throw it out.

• Wear protective clothing and be cautious when cleaning up to avoid injury.

• Watch animals closely and keep them under your direct control.

• Use the telephone only for emergency calls.

EARTHQUAKES

• Shaking caused by movements of plates in the earth’s crust

• Occur along faults – borders between two plates

• Occur most often along the Ring of Fire

What is the Ring of Fire?

• The Pacific Ring of Fire is an area of frequent earthquakes and volcanic eruptions encircling the basin
of the

Pacific Ocean. The Ring of Fire has 452 volcanoes and is home to over 50% of the world's active and
dormant

volcanoes. Ninety percent of the world's earthquakes and 81% of the world's largest earthquakes occur
along the

Ring of Fire.

Preparing for an Earthquake:

BEFORE AN EARTHQUAKE: Have a disaster plan. Emergency preparedness can save lives.

• Choose a safe place in every room. It’s best to get under a sturdy piece of furniture like a table or a
desk where

nothing can fall on you.

• Practice DROP, COVER AND HOLD ON! Drop under something sturdy, hold on, and protect your eyes
by

pressing your face against your arm.