Medical support in lebanon

1. Medical Support for Disaster
Survivors (MSDS)
• Ali Menhem
• Amal Mazloum

2. 2
Objectives
• Define Medical Support in the Time of Disaster
• Identify the different types of disasters
• Discuss the Mission Areas of Emergency Management
• Provide overview of disaster plan development process
• Discuss importance of WASH.
• Vector control/pest management.
• Food security/nutrition in disasters.
• Shelter
• Triage and Medical evacuation.
• Infectious/Chronic Diseases and Disasters.
• NGOs duties.
• Team Work Communication.

3. Medical Support Definition
Medical support
Disaster
medicine
Disaster
management

4. What is the Disaster
4
• “…a situation or event which overwhelms
local capacity, necessitating a request to a
national or international level for external
assistance.” (Center for Research on the
Epidemiology of Disasters-CRED)
• “…exceptional events which suddenly kill or
injure large numbers of people.” (Red
Cross/Red Crescent
• “…an occurrence that causes damage,
ecological disruption, loss of life, deterioration
of health and health services on a scale
sufficient to warrant an extraordinary response
from outside the affected community area”
(World Health Organization-WHO)

5. Disaster Types
• Natural
• Man-made
‒ Accidental
‒ Malicious
5
Tornado
Natural Disaster
Chernobyl
Technological Disaster

6. Natural Disasters
6

7. Man-Made Disasters
• Accidental
‒ Factory Explosions
‒ Air or Sea disasters
‒ Fires
‒ Hazardous Material spills (HAZMAT)
• Malicious
‒ Terrorist Activities
‒ Civil / Regional conflicts – WAR
‒ Embargos & Sanctions
7

8. What do disasters affect?
8
• People
• Places
• Things

9. Natural Disasters in Lebanon
.

10. Man Made Disasters in Lebanon
• Structural Collapse Terrorist Activities
• Fires

11. Disaster
Impacts
Socio-
economic
effects upon
women:
↓ Protection
Behavioral
effects upon
women:
↓ Resilience
Cultural
effects upon
community:
↑ Risk
Behavioral
effects upon
potential
abusers:
↑ Risk
Infrastructural
Effects upon
community:
↓ Support
11

12. Emergency Management
Mission Areas
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PREVENTION PROTECTION
RESPONSE
RECOVERY
MITIGATION

13. Prevention/Protection
Response
Recovery
Mitigation
Post-EventEventPre-Event
Emergency Management
Mission Areas
13

14. Steps in the Disaster Planning Process
14

16. Responsibility for
Plan Development
Emergency Manager
A big job but someone has to do it.
• Coordinate plans and preparedness activities
• Conduct vulnerability assessments
• Locate resources
• Establish mutual aid agreements
• Establish warning systems
• Plan evacuation routes
31

17. • support for the emergency management program
• Develops Strategic Plan, Budget, and Status Reports
• Recruits Staff
• Liaison on Emergency Management Issues
• Enlist and train volunteers
• Educate the public
• Work with local government officials to establish
mitigation actions
The Role of the
Emergency Manager
32

18. Session Rationale
33
A Hazards analysis and Risk
assessment process helps to answer
the following questions:
• What does the community/Nation need
to prepare for?
• What resources are required in order to
be prepared?
• What actions (e.g., mitigation activities)
could be employed to lessen or eliminate
the threat or hazard?
• What impacts need to be incorporated
into recovery preparedness planning?
The results of the process form the
foundation for subsequent National
Preparedness System activities.

19. Hazard Analysis Process
34
• Every community has an obligation to understand the
risks it faces.
• Risk is commonly thought of as a product of a threat or
hazard, the vulnerability of a community or facility to a
threat or hazard, and the resulting consequences that
may impact the community or facility.
• Knowledge of these risks allows a community to make
informed decisions about how to manage risk and
develop needed capabilities.
• By considering changes to these elements, a jurisdiction
can understand how to best manage risk exposure.

20. 35
These five steps are adaptable to the needs and
resources of any jurisdiction. The process can be
employed by a small, one-person department as
well as a larger organization with greater needs
and resources.
The 5 Step Process

21. Hazard Analysis
and Risk Assessment
36
Orientation to Group Activity

22. WASH Standard
WASH: Water Supply, Sanitation, and Hygiene Promotion
Needs of the affected population are met and users are involved
in the design, management and maintenance of the facilities
where appropriate.
Source: Bloland, CDC, Kibondo, TZ
1998
Source: Manya, Kenyan MoH, Dadaab, Kenya,
2006
37

23. Importance of WASH in Disasters
• More susceptible to morbidity/mortality
• Potential for epidemics and outbreaks of
communicable disease
• Water, sanitation and hygiene interventions
are primary means of prevention
38

24. Importance of WASH in Disasters
• More susceptible to morbidity/mortality
• Potential for epidemics and outbreaks of
communicable disease
• Water, sanitation and hygiene interventions
are primary means of prevention
39

25. Water Supply Objectives
Provide adequate quantity of safe water for drinking,
washing, bathing, and cooking
• At least15 liters/person/day (5-7 liters minimum in acute
phase)
Water should be easily accessible (distance, time)
• Maximum distance of 500 meters
• Maximum waiting time of 30 minutes
– 250 people/tap for flow of 7.5 liters/minute
– 500 people/hand pump for flow of 17 liters/minute
– 400 people/single-user open well for flow of 12.5 liters/minute
Adequate means to store water safely in home
• Sufficient water storage containers for collection and
storage
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26. Water Supply
Access is as important as quantity!
41

27. Types of Water Sources
• Surface water – lakes, streams, etc.
– Easy to access
– Contaminated, may be difficult to
treat
• Ground water - boreholes, wells
– Access more difficult
– Quality better and easier to treat
• Other sources – springs, rainwater,
bottled water, municipal tap water
• Tankered water
– Expensive
42

28. Water Quality Objectives
• Microbiological
– If NOT Chlorinated
• No fecal coliforms/100 mL
– If Chlorinated
• Turbidity less than 5 NTU
• pH < 8.5
• Free residual chlorine concentration 0.2 mg/L after 30
minutes of contact
• Chemical
– Arsenic, total dissolved solids, nitrates, etc
43

29. Water Quality: Where to Disinfect
• At source (wells, bucket chlorination, etc.)
• At storage tank or bladder or tanker truck
• At the household level
– Boil
– Disinfection tablets (Aquatabs)
– Chlorine stock solution
– Flocculant/disinfectant sachet (PuR)
– One Drop
44

30. Drainage Standard
People have an environment in which health
risks and other risks posed by water erosion
and standing water (including storm-water,
floodwater, domestic wastewater and
wastewater from medical facilities) are
minimized.
45

31. Drainage
• Most effective way to control drainage is the CHOICE
of SITE and the layout of the settlement
• Creation of small gardens to use wastewater
• On-site drainage preferable to off-site
• Where need off-site disposal, channels are
preferable to pipes
46

32. Excreta Disposal
47

33. Fecal-Oral Transmitted Organisms
• Bacteria – cholera, shigella, E. coli, salmonella,
campylobacter, etc.
• Viruses – GI viruses, Hepatitis A and E
• Parasites – giardia, cryptosporidium, amoeba
• Helminths – roundworm, hookworm,
whipworm
48

34. Excreta Disposal
• Correct design of latrines
– Pour flush vs. pit
– Squat vs. sit
– Separate stalls for females
• Lighting and other security measures
• Clean and well maintained!!
– Unhygienic latrines not used and can pose health
risk
49

35. Common Standards in Emergencies
• 20 people/latrine in stable phase (1 per family preferred)
• 50 people/latrine in acute emergency phase
• Distance from water source = 30 m
• Distance from shelter = 50 m or 1 minute walk (maximum)
• Arranged by household
• Separate toilets (men & women) available in public places
• Bottom of pit is minimum of 1.5 meters above water table
50

36. Sanitation in Public Areas
Institution Short term Long term
Schools 1/ 30 girls
1/ 60 boys
Same
Reception center 1/ 50 persons Same
Hospitals/clinics 1/ 20 beds or
1/ 50 outpatients
1/ 10 beds or
1/ 20 outpatients
Feeding centers 1/ 50 adults
1/ 20 children
1/ 20 adults
1/ 10 children
Markets 1/ 50 stalls 1/ 20 stalls
51

37. Emergency Sanitation: Obstacles
• How to provide sufficient numbers quickly
– Raw materials
– Manpower, organization
• How to get people to use them
– Cultural practices
– Maintenance and cleaning
• Other obstacles
– High water table or flood conditions
– Hard soil conditions
– Unstable soil
– Lack of water for pour flush latrines
52

38. Hygiene Promotion
• Targeting priority risks & behaviors
– Prioritize assistance and misconceptions addressed
• Reaching all sections of population
– Access & Awareness
– Mass media
– Different groups need different information (e.g. non-
literate, communication difficulties, no access to radio/tv)
• Interactive methods
– Opportunity to plan/monitor own improvements, make
suggestions/complaints
– Culturally appropriate
53

39. Hygiene Promotion
Basic Hygiene Items
10-20 L capacity water container - transportation 1 / Household
10-20 L capacity water container - storage 1 / Household
250 g bathing soap 1 / Person / Month
200 g laundry soap 1 / Person / Month
Materials for menstrual hygiene 1 / Person
Example of Hygiene Kit
Possible Additional Items
•Toothpaste
•Toothbrush
•Shampoo
•Lotion (infants & children)
•Disposable razor
•Underwear (women & girls)
•Hairbrush &/or comb
•Nail clippers
•Diapers & potties (depending
on household need) 54

40. Key Indicators
Water quantity Liters/ person/ day
Access to water Distance to source, time collecting water
Water quality Chlorine residual or fecal coliforms
Sanitation Number of persons/ latrine (in use)
Access to sanitation Distance to latrines, male and female latrines
Hygiene Soap distribution or availability, water storage
vessels, hygiene promotion activities
WASH Summary Indicators
55

41. Vector Control & Pest Management
56

42. Contributing Factors
• Inadequate or absent housing
• Placement of camps near water
• Overcrowding
• Poor health, malnutrition, co-infections
57

43. Pests vs. Vectors
• Pests do not transmit diseases, but are a
nuisance that can affect moral (e.g. bed bugs,
jigger fleas)
• Vectors transmit diseases that are a major
cause of sickness & death in many disaster
situations
58

44. Environmental Control Measures
• Site Selection
– 1-2 km upwind from large breeding sites (e.g. swamps or
lakes) when other clean water source can be provided
• Environmental/Chemical Control
– Proper disposal of excreta and refuse
– Drainage of standing water
– Clearing unwanted vegetation around open canals/ponds
– Spraying infected spaces
59

45. Vectorborne Diseases
Vector Disease(s)
Mosquitoes Malaria, Yellow Fever, Dengue, hemorrhagic
fever
Non-biting flies Diarrheal disease
Biting flies, bedbugs, fleas Nuisance, murine typhus, scabies, plague
Ticks Relapsing fever
Human body lice Typhus, relapsing fever
Rats, mice Leptospirosis, salmenellosis, can host fleas
60

46. Malaria
• Estimated 225 million cases of
malaria (2009)
– 781,000 deaths worldwide
– Decreases in burden in all WHO
Regions BUT…….
• Fragile gains:
– Increased # malaria cases in three
countries that previously reported
reductions
• Endemic in 99 countries
Species Disease(s) Breeding sites
Culex Filariasis Stagnant water loaded with organic matter (e.g.
latrines)
Anopheles Malaria, filariasis Relatively unpolluted surface water (e.g. puddles,
slow-flowing streams, wells)
Aedes Yellow fever, dengue Water receptacles (e.g. bottles, buckets, tires)
Image from CDC Malaria Map Application
61

47. Environmental Control Measures
• Site Selection
– 1-2 km upwind from large breeding sites (e.g. swamps or
lakes) when other clean water source can be provided
• Environmental/Chemical Control
– Proper disposal of excreta and refuse
– Drainage of standing water
– Clearing unwanted vegetation around open canals/ponds
– Spraying infected spaces
62

48. Chemical Control Measures
• National & international protocols
– WHO protocols/norms should be adhered to at all
times
– Protocols for choice & application of chemicals
including protection of personnel & training
requirements
– Efficacy & safety
63

49. Indoor Residual Spraying (IRS)
Physical, Environmental, Chemical Protection
• Rapidly controls malaria
transmission:
– Need > 80% coverage
• Requires specialized spray
equipment and techniques:
– Must be maintained over
time
– Relatively expensive
• Increasing concern with
insecticide resistance
Credit: Wirtz, CDC, Lugufu, TZ, 2006
64

50. Personal Protection
All disaster-affected people have the
knowledge and the means to protect
themselves from disease and nuisance vectors
that are likely to cause a significant risk to
health or well-being
65

51. Individual Protective Measures
• Awareness among affected people
• Avoid exposure (Bed nets, repellant, etc)
• Ensure bedding/clothing are aired & washed
regularly
• All food stored in households is protected
from vectors (flies, insects, rodents)
66

52. Long Lasting Insecticidal Nets (LLINs)
• Offers individual level
protection:
– Community wide effect
if use is high enough (at
least 60%)
– Must use correctly
– Ownership ≠ use
• 2010 WHO
recommends universal
coverage :
– 1 LLIN per 2 people
Credit: Williams, CDC, Mwange Camp, Zambia, 2009 67

53. Food Security
68

54. Assessing Food & Nutrition
• Type, degree, and extent of food insecurity &
malnutrition
• Determine those most affected
• Best response
69

56. Assessing Food & Nutrition
• Type, degree, and extent of food insecurity &
malnutrition
• Determine those most affected
• Best response
71

57. Micronutrient Deficiency
Deficiency Potential Symptoms
Vitamin A deficiency Night blindness
Bitots spots
Corneal Xerosis/ulceration/keratomalacia
Corneal scars
Serum retinol
Iodine deficiency Goiter
Median urinary iodine concentration (mg/l)
Iron deficiency Anemia
Thiamine deficiency (Beriberi) Anorexia/malaise
Cardiac involvement with edema
Peripheral neuropathy
Niacin deficiency (Pellagra) Dermatitis
Digestive tract and nervous system may be involved
Anxiety/depression
Vitamin C deficiency (Scurvy) Hemorrhages
Bone lesions
72

58. Food Security
• Meet short-term needs
• Do no harm
• Reduce potentially damaging coping strategies
(e.g. overuse of natural resources, travel to
insecure areas)
• Restore longer-term food security
73

59. 74
Shelter, Settlement Management and Planning, Non-Food Items.

60. 75

61. Camps Versus
Integration in Community
• Advantages and disadvantages to both
• May be self-selection but not always
• May be mixture of camps and host
communities
76

62. Camp Setting: What are
advantages and disadvantages?
Advantages
• Services may be easier
to provide
• Easier to estimate
population/numbers
• Advocacy
• Easier to monitor health
status
Disadvantages
• Overcrowding may
increase risk of disease
• Dependency of
population
• Insecurity in camp
77

63. Integration in Community: What are advantages
and disadvantages?
Advantages
• Self sufficiency
• Access to work,
farmland
• Use of existing services
Disadvantages
• Difficult to monitor
needs
• Difficult to provide
services
• May pose difficulties to
host community
78

64. Coordination Between Camp Leaders
And Organizations is Essential
79

65. Shelter: Key Indicators
• For emergency measure, provide reinforced
plastic sheeting, rope, fixings, poles, tools
• Adequate covered living area
− 3.5 m2 per person
• Appropriate for climate
− Heat (allow ventilation/avoid dry sun; double-
skinned roof)
− Cold
− Rain
80

66. Non-Food Items: Generally
Principles
• Provision takes into account the climate, culture,
and what people have carried with them from
home
• Provision of local materials is optimal, but must
consider impact on local population and
environment
81

67. Non-Food Items: Specifically
Principles
• Sufficient clothing, blankets and bedding to
provide protection from climate and to ensure
comfort, dignity, health and well being
• Adequate items to prepare and store food, to
cook, ear and drink
• Sufficient safe, fuel-efficient stove sand fuel or
domestic energy, and artificial lighting to ensure
personal safety
82

68. Non-Food Items
83
Requires adequate storage facilities and
distribution system

69. Non-Food Items: Types
• Separate clothing for women, girls, men and boys
• Blankets and bedding
• Insecticide-treated bed nets
• Cooking and eating utensils, water-storage vessels,
cooking fuel
• Cooking fuel is particularly difficult to supply and
may include firewood, charcoal
– Stoves can provide warmth as well as cook
– Consider techniques/materials to improve fuel efficiency
• Fuel efficient stoves
84

70. Non-Food Items: Key Indicators
• 2 sets of clothes, bedding, sleeping mats, and
insecticide bed nets
• 2 family-sized cooking pots with handles, large basin,
kitchen knife, and 2 serving spoons
• Plate, spoon or other eating utensil, drinking mug
• Fuel-efficient stove (changed from firewood)
• Tools for construction, maintenance, or debris
removal
85

71. Casualty Management in the Field: Triage &
Hospital Levels of Care
Decisions may be based upon:
• Golden hour concept & Triage
• Evacuation procedures
• Hospital Treatment capabilities

72. Golden Hour Concept
• Golden Hour
– Advanced Life support as soon as possible, but not
exceeding 1 hour.
– If surgery is required, it must be carried out as
soon as possible, but not exceeding 2 hours.
87

73. What is Triage?
• Triage, derived from a French word meaning to sort,
is the first step in the hierarchy of medical support at
major incidents
‒ Triage
‒ Treatment
‒ Transport
• Goals of Triage - not only to deliver the right patient
to the right place, but also:
‒ Do the most good for the most patients…
‒ Accepting that valuable medical resources should NOT be
diverted to treating an irreversible condition
88

74. Triage (sorting casualties)
89
Urgent resuscitative interventions are required for survival. It is likely that
individuals will die within 2 hours or earlier without treatment.
Ie: Airway obstruction, shock, severe trauma.
Require early treatment, for example surgery, and patients should be evacuated
to a surgical facility within 6 hours of injury.
Ie: visceral injury, limb fractures, closed head injury, eye injury, burns.
Treatment can be deferred if there are other casualties requiring evacuation.
These patients are ambulatory and follow commands.
Ie: closed fractures, soft tissue injury, closed chest injury, maxillofacial injury
Minimal chance of survival, and if there is competition for limited medical
resources, such cases will have lower priority for evacuation and treatment.

75. Evacuation
•Two types of patient transfers:
1) Casualty evacuation: site of injury to closed medical within one hour.
May not have advanced medical training.
2) Medical evacuation: evacuation of a casualty between two medical
facilities.
•Factors: Time, ground , air, weather, Balancing demand on
medical resources (treatment capability of each hospital level
and the available evacuation assets).
90

76. UN Levels of Care: Level 1
Level 1 medical facility
• Immediate life-saving & resuscitation
• 2 medical officers, 6 paramedics, 3 support staff
• Able to treat 20 ambulatory, and hold 5 patients for 2 days.
91
UN Medical Facility:
Normally included within basic Level 1 capabilities are: routine sick call and the
management of minor sick and injured personnel, as well as casualty collection from
the point of injury/ wounding, limited triage; stabilization of casualties; preparation of
casualties for evacuation to the next Level of medical capability or the appropriate
Level of Medical Support Facility depending on the type and gravity of the injuries;
limited inpatient services; advice on disease prevention, medical risk assessment and
force protection within the Area of Responsibility. A Level 1 Medical Support Facility is
the first level of medical care where a doctor/ physician is available

77. UN Levels of Care: Level 2
Level 2
• Damage control surgery & Intensive care-resuscitation
• Basic imaging
• 57 personnel, 3-4 surgeries per day, and hospitalization for 10-20 for up to
7 days.
Basic Composition:
92
2 Surgeons (general and ortho); 1 Anesthetist; 1
Internist; 1 General Physician; 1 Dentist; 2 Intensive care
nurses; 19 Nurses/Paramedic; 1 Radiographer; 1
Laboratory tech
A Level 2 Medical Support Facility provides all Level 1 capabilities and, in addition,
includes capabilities for: emergency surgery, life and limb saving surgery, post
operative services and high dependency care, intensive care-resuscitation, and in–
patient services; also basic imagistic services, laboratory, pharmaceutical,
preventive medicine and dental services are provided; patient record maintenance
and tracking of evacuated patients are also minimum capabilities required for a
Level 2 Medical Support Facility

80. UN Levels of Care: Level 3
Level 3
• Multidisciplinary surgery and Medicine
• 90 personnel
• 10 operations per day,
• Hospitalize up to 50 patients for up to 30 days.
95
At this level all capabilities of a Level 1 and 2 Medical Support Facility
are provided and, in addition, capabilities for: multi-disciplinary
surgical services, specialist services and specialist diagnostic services,
increased high dependency care capacity and extended intensive care
services, specialist outpatient services, maxilo-facial surgery

81. UN Levels of Care: Level 4
Level 4
Definitive Care facility
96
Level 4 medical facilities are definitive care facilities provided outside of the
mission area to provide all levels of care, including specialist services not
otherwise available, rehabilitation and convalescence. Level 4 facilities are often
commercially contracted or contracted under a LOA with a national
government.

82. Other considerations
• Neurosurgical, Radiology support
• Blood products, and supplies.
• Weather, Roads, accessibility
• Language, cultural differences
• Number of patients already transported there.
• Availability of transport
97

83. 98
Battlefield Care
Role 1
Forward Surgical Care
Role 2
Deployed Hospitals
Role 3
Regional Evacuation
Hub
Role 4
CASEVAC
< 1 hour TACTICAL
MEDEVAC
1-24 hours
STRATEGIC AE
24-72 hours

84. Evacuation & Triage
• TRIAGE:
– IMMEDIATE: Will die within 2 hours w/o treatment.
– URGENT: Need surgery within 6 hours
– DELAYED: Don’t require immediate care, can wait.
– EXPECTANT. Deceased / incompatible with situation.
• UN LEVEL
– 1: Basic aid and stabilization. 2 Doc’s treat 20 /day.
– 2: Damage control surgery.
– 3: Hospital care.
– 4: Definitive hospital
99

85. Mass Casualty and Triage Principles Objectives
• Review mass casualty
principles
• Review triage principles
• Having a system in place
• Goals
100

86. Triage and Evacuation
101
INCIDENT
SITE
1 - Immediate
CCS
2 - Urgent
3 - Delayed
4 - Expectant
DEAD
MEDEVAC
Loading
Point
Receiving
Hospital
Receiving
Hospital
Receiving
Hospital
T4
T1
T2
Body holding
area
Temporary
morgue

87. Media Communications Role
• Help Public Understand Immediate Risks
• Move People to Take Protective Actions
• Help Prevent Casualties
• Eliminate Confusion
• Support Overall Response Efforts
• Promote Confidence in Government’s Ability
to Protect the Public
102

88. Infectious/Chronic Diseases and Disasters
• Infectious disease as public health disasters
• Infectious disease subsequent to public health
disasters
• Handling of dead bodies
• Specific infectious diseases
• Considerations with chronic diseases
103

89. NGO Duties
• Health promotion
• Manage health crises
• Community social problems
• Environment
• Economic
• Infrastructure development
• Women’s issues
• Child welfare
104

90. Team Work Communication
5 Components of Crew Resource Management include:
1) Communication
2) Decision-Making
3) Task Allocation
4) Teamwork
5) Situational Awareness
Effective team communication takes into account
barriers and biases in order to successfully accomplish
a task, safely and minimizing errors.
105

91. • List of hospitals in Lebanon