DISASTER NURSING

Introduction

“Doing the best for the most, with the least, by the fewest”

Disasters have been integral parts of the human experience since the beginning of time, causing premature death, impaired quality of life, and altered health status. The risk of a disaster is ubiquitous. On average, one disaster per week that requires international assistance occurs somewhere in the world. The recent dramatic increase in natural disasters, their intensity, the number of people affected by them, and the human and economic losses associated with these events have placed an imperative on disaster planning for emergency preparedness. Global warming, shifts in climates, sea-level rise, and societal factors may coalesce to create future calamities. Finally, war, acts of aggression, and the incidence of terrorist attacks are reminder of the potentially deadly consequences of man’s inhumanity toward man.

The word derives from French “désastre” and that from Old Italian “disastro”, which in turn comes from the Greek pejorative prefix dus = "bad" + aster = "star". The root of the word disaster ("bad star" in Greek) comes from an astrological theme in which the ancients used to refer to the destruction or deconstruction of a star as a disaster. The ancient people believed that the disaster is occurred due to the unfavourable position of the “planets” or “Act of God”. Gradually they understand the mysteries of nature.

Disaster has many forms, which can affect one family at a time, as in a house fire, or it can affect a city in case of chemical leak in Bhopal (Dec 2-3, 1984) kill 2500 and injured 150,000 or affect a state in case of Gujarat earthquake (Jan 26, 2001) affect 21 districts out of 25 districts of the state of Gujarat. 4 major urban area (Bhuj, Anjar, Bachau and Rapar) and 450 villages are almost near to totally destroyed. There were more than 20,000 death and 167,000 people were injured 600,000 people are homeless.

India has been traditionally vulnerable to natural disasters on account of its unique geo-climatic conditions. Floods, droughts, cyclones, earthquakes and landslides have been recurrent phenomena. About 60% of the landmass is prone to earthquakes of various intensities; over 40 million hectares is prone to floods; about 8% of the total area is prone to cyclones and 68% of the area is susceptible to drought.

We do not expect disaster, but they happen with living, come natural calamities, the individual and technological advances, come from expedient, socio-economic and political stagnation and war etc. disaster either man-made or natural, may be inevitable, but there are methods to prevent or manage the way, people and their communities respond to disaster. So, nurses have an important role to play during a disaster to save the lives and to provide healthcare to the victims.

DEFINITIONS

Disaster is a result of vast ecological breakdown in the relation between humans and their environment, as serious or sudden event on such scale that the stricken community needs extraordinary efforts to cope with outside help or international aid.

WHO defines Disaster as "any occurrence that causes damage, ecological disruption, loss of human life, deterioration of health and health services, on a scale sufficient to warrant an extraordinary response from outside the affected community or area."

Red Cross (1975) defines Disaster as “An occurrence such as hurricane, tornado,  storm, flood, high water, wind-driven water, tidal wave, earthquake, drought, blizzard, pestilence, famine, fire, explosion, building collapse, transportation wreck, or other situation that causes human suffering or creates human that the victims cannot alleviate without assistance.”

UNDP (2004) defines “Disaster is a serious disruption triggered by a hazard, causing human, material, economic or (and) environmental losses, which exceed the ability of those affected to cope.”

Disaster can be defined as “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.”

Disaster may also be termed as “a serious disruption of the functioning of society, causing widespread human, material or environmental losses which exceed the ability of the affected society to cope using its own resources.”

Thus, a disaster may have the following main features:-

·         Unpredictability

·         Unfamiliarity

·         Speed

·         Urgency

·         Uncertainty

·         Threat

TYPES OF DISASTER

Disasters are classified in various ways, on the basis of its origin/cause.

1. Natural disasters
2. Man-made disasters

And On the basis of speed of onset-

1. Sudden onset disasters
2. Slow onset disasters

Natural disasters

A serious disruption triggered by a natural hazard (hydro-metrological, geological or biological in origin) causing human, material, economic or environmental losses, which exceed the ability of those affected to cope. Natural hazards can be classified according to their (1) hydro meteorological, (2) geological or (3) biological origins.

·         Hydrometer logical disaster - Natural processes or phenomena of atmospheric hydrological or oceanographic nature. Phenomena / Examples - Cyclones, typhoons, hurricanes, tornados, Storms, hailstorms, snowstorms, cold spells, heat waves and droughts.

·         Geographical disaster - Natural earth processes or phenomena that include processes of endogenous origin or tectonic or exogenous origin such as mass movements, Permafrost, snow avalanches. Phenomena / Examples - Earthquake, tsunami, volcanic activity, Mass movements landslides, Surface collapse, geographical fault activities etc.

·         Biological Disaster - Processes of organic organs or those conveyed by biological vectors, including exposure to pathogenic, microorganism, toxins and bioactive substances. Phenomena / Examples - Outbreaks of epidemics Diseases, plant or animal contagion and extensive infestation etc.

Human-induced Disasters

A serious disruption triggered by a human-induced hazard causing human, material, economic or environmental losses, which exceed the ability of those affected to cope. These can be classified into – (1) Technological Disaster and (2) Environmental Degradation.

·         Technological disaster - Danger associated with technological or industrial accidents, infrastructure failures or certain human activities which may cause the loss of life or injury, property damage, social or economic disruption or environmental degradation, sometimes referred to as anthropological hazards. Examples include industrial pollution, nuclear release and radioactivity, toxic waste, dam failure, transport industrial or technological accidents (explosions fires spills).

·         Environmental Degradation - Processes induced by human behaviors and activities that damage the natural resources base on adversely alter nature processes or ecosystems. Potentials effects are varied and may contribute to the increase in vulnerability, frequency and the intensity of natural hazards. Examples include land degradation, deforestation, desertification, wild land fire, loss of biodiversity, land, water and air pollution climate change, sea level rise and ozone depletion.

Levels of Disaster

Goolsby and Kulkarni (2006) further classify disasters according to the magnitude of the disaster in relation to the ability of the agency or community to respond. Disasters are classified by the following levels:

1)      Level I: If the organization, agency, or community is able to contain the event and respond effectively utilizing its own resources.

2)      Level II: If the disaster requires assistance from external sources, but these can be obtained from nearby agencies.

3)      Level III: If the disaster is of a magnitude that exceeds the capacity of the local community or region and requires assistance from state-level or even federal assets.

Key elements of Disasters

Disasters result from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk.

Hazards

Hazards are defined as “Phenomena that pose a threat to people, structures, or economic assets and which may cause a disaster. They could be either manmade or naturally occurring in our environment.”

Hazard is a potentially damaging physical event, phenomenon or human activity that may cause the loss of life or injury, property damage, social and economic disruption or environmental degradation. (UN ISDR 2002)

Vulnerability

Vulnerability is the condition determined by physical, social, economic and environmental factors or processes, which increase the susceptibility of a community to the impact of hazards. (UN ISDR 2002)

Capacity

Capacity is the combination of all the strengths and resources available within a community, society or organization that can reduce the level of risk, or the effects of a disaster. Capacity may include physical, institutional, social or economic means as well as skilled personal or collective attributes such as 'leadership' and 'management.' Capacity may also be described as capability. (UN ISDR 2002)

Risk

Risk is the probability of harmful consequences, or expected losses (deaths, injuries, property, livelihoods, economic activity disrupted or environment damaged) resulting from interactions between natural or human-induced hazards and vulnerable conditions. (UNDP 2004)

Risk is conventionally expressed by the equation:

Risk = Hazard x Vulnerability

Some professionals use the notation:

Risk = (Hazards x Vulnerability) - Capacity

They identify capacity as an element that can drastically reduce the effects of hazards, and vulnerabilities and thus reduce risk.

For example, an earthquake hazard of the same magnitude in a sparsely populated village of Rajasthan and in the densely populated city of Delhi will cause different levels of damage to human lives, property and economic activities.

Disaster nursing- definition

Disaster nursing can be defined as “the adaptation of professional nursing knowledge, skills and attitude in recognizing and meeting the nursing, health and emotional needs of disaster victims.”

Goals of the disaster nursing

The overall goal of disaster nursing is to achieve the best possible level of health for the people and the community involved in the disaster.

Other goals of disaster nursing are the following:

1.      To meet the immediate basic survival needs of populations affected by disasters (water, food, shelter, and security).

2.      To identify the potential for a secondary disaster.

3.      To appraise both risks and resources in the environment.

4.      To correct inequalities in access to health care or appropriate resources.

5.      To empower survivors to participate in and advocate for their own health and well-being.

6.      To respect cultural, lingual, and religious diversity in individuals and families and to apply this principle in all health promotion activities.

7.      To promote the highest achievable quality of life for survivors.

Principles Of Disaster Nursing

The basic principles of nursing during special (events) circumstances and disaster conditions include:

1.      Rapid assessment of the situation and of nursing care needs.

2.      Triage and initiation of life-saving measures first.

3.      The selected use of essential nursing interventions and the elimination of nonessential nursing activities.

4.      Adaptation of necessary nursing skills to disaster and other emergency situations. The nurse must use imagination and resourcefulness in dealing with a lack of supplies, equipment, and personnel.

5.      Evaluation of the environment and the mitigation or removal of any health hazards.

6.      Prevention of further injury or illness.

7.      Leadership in coordinating patient triage, care, and transport during times of crisis.

8.      The teaching, supervision, and utilization of auxiliary medical personnel and volunteers.

9.      Provision of understanding, compassion, and emotional support to all victims and their families.

HEALTH EFFECTS OF DISASTERS

The health effects of disasters may be extensive and broad in their distribution across populations. In addition to causing illness and injury, disasters disrupt access to primary care and preventive services. Depending on the nature and location of the disaster, its effects on the short- and long-term health of a population may be difficult to measure.

Disasters affect the health status of a community in the following ways: -

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

·         Disasters may destroy the local health care infrastructure, which will therefore be unable to respond to the emergency. Disruption of routine health care 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 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 range from fear, anxiety, and depression to widespread panic and terror.

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

·         Disasters may cause large population movements (refugees) creating a burden on other health care systems and communities. Displaced populations and their host communities are at increased risk for communicable diseases and the health consequences of crowded living conditions.

PHASES OF A DISASTER

There are three phases of disaster.

1. Pre-Impact Phase
2. Impact Phase
3. Post – Impact Phase

PRE-IMPACT PHASE

It is the initial phase of disaster, prior to the actual occurrence. A warning is given at the sign of the first possible danger to a community with the aid of weather networks and satellite many meteorological disasters can be predicted.

The earliest possible warning is crucial in preventing toss of life and minimizing damage. This is the period when the emergency preparedness plan is put into effect emergency centers are opened by the local civil, detention authority. Communication is a very important factor during this phase; disaster personnel will call on amateur radio operators, radio and television stations.

The role of the nurse during this warning phase is to assist in preparing shelters and emergency aid stations and establishing contact with other emergency service group.

IMPACT PHASE

The impact phase occurs when the disaster actually happens. It is a time of enduring hardship or injury end of trying to survive.

The impact phase may last for several minutes (e.g. after an earthquake, plane crash or explosion.) or for days or weeks (eg in a flood, famine or epidemic).

The impact phase continues until the threat of further destruction has passed and emergency plan is in effect. This is the time when the emergency operation center is established and put in operation. It serves as the center for communication and other government agencies of health tears care healthcare providers to staff shelters. Every shelter has a nurse as a member of disaster action team. The nurse is responsible for psychological support to victims in the shelter.

POST – IMPACT PHASE

Recovery begins during the emergency phase and ends with the return of normal community order and functioning. For persons in the impact area this phase may last a lifetime (e.g. - victims of the atomic bomb of Hiroshima). The victims of  disaster in go through four stages of emotional response.

1.      Denial - during the stage the victims may deny the magnitude of the problem or have not fully registered. The victims may appear usually unconcerned.

2.      Strong Emotional Response - in the second stage, the person is aware of the problem but regards it as overwhelming and unbearable. Common reaction during this stage is trembling, tightening of muscles, speaking with the difficulty, weeping heightened, sensitivity, restlessness sadness, anger and passivity. The victim may want to retell or relieve the disaster experience over and over.

3.      Acceptance - During the third stage, the victim begins to accept the problems caused by the disaster and makes a concentrated effect to solve them. It is important for victims to take specific action to help themselves and their families.

4.      Recovery - The fourth stage represent a recovery from the crisis reaction. Victims feel that they are back to normal. A sense of well-being is restored. Victims develop the realistic memory of the experience.

DISASTER MANAGEMENT cycle

The Disaster Event

This refers to the real-time event of a hazard occurring and affecting the ‘elements at risk’. The duration of the event will depend on the type of threat, for example, ground shaking may only occur for a few seconds during an earthquake while flooding may take place over a longer period of time.

There are five basic phases to a disaster management cycle (Kim & Proctor, 2002), and each phase has specific activities associated with it.

Response

The response phase is the actual implementation of the disaster plan. The best response plans use an incident command system, are relatively simple, are routinely practiced, and are modified when improvements are needed. Response activities need to be continually monitored and adjusted to the changing situation.

Activities a hospital, healthcare system, or public health agency take immediately during, and after a disaster or emergency occurs.

Recovery

Once the incident is over, the organization and staff needs to recover. Invariably, services have been disrupted and it takes time to return to routines. Recovery is usually easier if, during the response, some of the staff have been assigned to maintain essential services while others were assigned to the disaster response.

Activities undertaken by a community and its components after an emergency or disaster to restore minimum services and move towards long-term restoration.

·         Debris Removal

·         Care and Shelter

·         Damage Assessments

·         Funding Assistance

Evaluation/Development

Often this phase of disaster planning and response receives the least attention. After a disaster, employees and the community are anxious to return to usual operations. It is essential that a formal evaluation be done to determine what went well (what really worked) and what problems were identified. A specific individual should be charged with the evaluation and follow-through activities.

Mitigation

These are steps that are taken to lessen the impact of a disaster should one occur and can be considered as prevention and risk reduction measures. Examples of mitigation activities include installing and maintaining backup generator power to mitigate the effects of a power failure or cross training staff to perform other tasks to maintain services during a staffing crisis that is due to a weather emergency.

Preparedness/Risk Assessment

Evaluate the facility’s vulnerabilities or propensity for disasters. Issues to consider include: weather patterns; geographic location; expectations related to public events and gatherings; age, condition, and location of the facility; and industries in close proximity to the hospital (e.g., nuclear power plant or chemical factory).

MANAGEMENT OF MASS CASUALTIES

Mass Casualty Management is a multi-sectorial coordination system based on daily utilized procedures, managed by skilled personnel in order to maximize the use of existing resources; provide prompt and adapted care to the victims; ensure emergency services and hospital return to routine operations as soon as possible.

Objectives

·         The application of triage and tagging procedures in the management of mass casualties

·         Understand the priorities in triage and tagging, and orders of evacuation

Disaster Triage

The word triage is derived from the French word trier, which means, “to sort out or choose.”

The Baron Dominique Jean Larrey, who was the Chief Surgeon for Napoleon, is credited with organizing the first triage system.

“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).

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 resources (Auf der Heide, 2000).

Need of the Disaster Triage

1.      Inadequate resource to meet immediate needs

2.      Infrastructure limitations

3.      Inadequate hazard preparation

4.      Limited transport capabilities

5.      Multiple agencies responding

6.      Hospital Resources Overwhelmed

Aims of triage

1.      To sort patients based on needs for immediate care

2.      To recognize futility

3.      Medical needs will outstrip the immediately available resources

4.      Additional resources will become available given enough time.

PRINCIPLES OF TRIAGE

The main principles of triage are as follows: -

1.      Every patient should receive and triaged by appropriate skilled health-care professionals.

2.      Triage is a clinic-managerial decision and must involve collaborative planning.

3.      The triage process should not cause a delay in the delivery of effective clinical care.

Advantages of Triage

1.      Helps to bring order and organization to a chaotic scene.

2.      It identifies and provides care to those who are in greatest need

3.      Helps make the difficult decisions easier

4.      Assure that resources are used in the most effective manner

5.      May take some of the emotional burden away from those doing triage

Types of triage

There are two types of triage:

1.      Simple triage

2.      Advanced triage

Simple triage

Simple triage is used in a scene of mass casualty, in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries.

This step can be started before transportation becomes available.

The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging.

S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly trained lay and emergency personnel in emergencies.

Triage separates the injured into four groups:

·         0 - The deceased who are beyond help

·         1 - The injured who can be helped by immediate transportation

·         2 - The injured whose transport can be delayed

·         3 - Those with minor injuries, who need help less urgently

Advanced triage

In advanced triage, doctors may decide that some seriously injured people should not receive advanced care because they are unlikely to survive.

Advanced care will be used on patients with less severe injuries. Because treatment is intentionally withheld from patients with certain injuries, advanced triage has an ethical implication.

It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive.

Principles of advanced triage is

·         “Do the greatest good for the greatest number”

·         Preservation of life takes precedence over preservation of limbs.

·         Immediate threats to life: HEMORRHAGE.

 

Advanced triage categories

Class I (emergent)                  Red                                     IMMEDIATE

– Victims with serious injuries that are life threatening but has a high probability of survival if they received immediate care. – They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. “Critical; life threatening—compromised airway, shock, hemorrhage”

Class II (urgent)                    Yellow                                   DELAYED

– Victims who are seriously injured and whose life is not immediately threatened; and can delay transport and treatment for 2 hours. – Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances). “Major illness or injury;—open fracture, chest wound”

Class III (non-urgent)        Green                                       MINIMAL

– "Walking wounded," the casualty requires medical attention when all higher priority patients have been evacuated, and may not require monitoring. – Patients/victims whose care and transport may be delayed 2 hours or more. “minor injuries; walking wounded—closed fracture, sprain, strain”

Class IV (expectant)           Black                                  EXPECTANT

They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); They should be taken to a holding area and given painkillers as required to reduce suffering. “Dead or expected to die—massive head injury, extensive full-thickness burns”

Using RPM to Classify Patients

CATEGORY (COLOR)	RPM INDICATORS
Critical (RED)	R = Respiratory rate > 30; P = Capillary refill > 2 seconds; M = Doesn’t obey commands
Urgent (YELLOW)	R < 30 P < 2 seconds M = Obeys commands
Expectant: dead or dying (BLACK)	R = not breathing

Role of nursing in disasters

“Disaster preparedness, including risk assessment and multi-disciplinary management strategies at all system levels, is critical to the delivery of effective responses to the short, medium, and long-term health needs of a disaster-stricken population.” (International Council of Nurses, 2006)

MAJOR ROLES of Nurse in disasters

1.      Determine magnitude of the event

2.      Define health needs of the affected groups

3.      Establish priorities and objectives

4.      Identify actual and potential public health problems

5.      Determine resources needed to respond to the needs identified

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

7.      Maintain a unified chain of command

8.      Communication

DISASTER TIMELINE AND NURSING ACTION/ rsponsibilities

CONCLUSION

Disaster is an emergency situation where the need of the victims mounts over the medical and nursing resources or services particularly in the developing countries like India where the resources are already short the situation becomes worst; therefore coordination of actions and various departments is an essential requisite for efficient management of mass casualties. So, in such a scenario a prudent nurse should be resourceful, making best use of the available resources like governmental, nongovernmental organisations, self-help groups, public, etc. and should act ethically with best of her knowledge, patience and judgement to minimize the effect of disaster.

Bibliography

1.      Veenema, Tener Goodwin, “Disaster Nursing and Emergency Preparedness”, Springer Publishing Company, New York, Second Edition, 2007, Page No. 1-680

2.      Ms. Dey, Balaka, Dr. Singh, R.B, “NATURAL HAZARDS AND DISASTER MANAGEMENT”, Published by central Board of Secondary Education, Delhi; First Edition, 2006, Page No. 1-45

3.      “DISASTER MANAGEMENT IN INDIA”, Published by Government of India Ministry of Home Affairs. Page No. 1-98

4.      “A COMPENDIUM ON DISASTER RISK MANAGEMENT -India's Perspective (A PRIMER FOR LEGISLATORS)”, Published by Government of India and UNDP India, 2007, page no. 1-56

5.      DISASTER,  http://www.icm.tn.gov.in/dengue/disaster.htm

6.      WHAT IS DISASTER, http://www.karimganj.nic.in/disaster.htm