Responding to Mass Casualty Incidents

Responding to MassResponding to Mass
Casualty IncidentsCasualty Incidents
Lecturer:Lecturer:
Lea P. Alayon, RN.,Ph.DLea P. Alayon, RN.,Ph.D
College of NursingCollege of Nursing
Filamer Christian UniversityFilamer Christian University

LEARNING OBJECTVES:LEARNING OBJECTVES:
-Define key terms-Define key terms
- Discuss the principles of- Discuss the principles of
emergency management.emergency management.
- Discuss the competencies of- Discuss the competencies of
nurses responding to mass casualty.nurses responding to mass casualty.

-Explain the levels of management.-Explain the levels of management.
-Cite the different levels of triage.-Cite the different levels of triage.
-Enumerate the components ofEnumerate the components of
- emergency operations plans.emergency operations plans.

--discuss the management of mass-discuss the management of mass
casualty.casualty.
--Identify the common reaction of-Identify the common reaction of
disaster survivorsdisaster survivors

Definition of terms:Definition of terms:
EmergencyEmergency
is a medical or surgical conditionis a medical or surgical condition
requiring immediate care or timelyrequiring immediate care or timely
intervention to prevent permanentintervention to prevent permanent
disability or death.disability or death.

EmergencyEmergency
Much advancement in the care canMuch advancement in the care can
be attributed to the military.be attributed to the military.
In order to manage vast numbersIn order to manage vast numbers
of injured soldiers.of injured soldiers.

Emergency nursingEmergency nursing
is the care of clients who requireis the care of clients who require
emergency intervention.emergency intervention.

Emergency management Emergency management
(or disaster management) is the(or disaster management) is the
discipline ofdiscipline of dealingdealing with andwith and avoidingavoiding
bothboth naturalnatural andand manmade disastersmanmade disasters..

Emergency management Emergency management
It involvesIt involves preparedness, responsepreparedness, response andand
recoveryrecovery in order to lessen the impactin order to lessen the impact
of disastersof disasters

DisasterDisaster is a situation or event ofis a situation or event of
greater magnitudegreater magnitude than an emergencythan an emergency
that has unforeseen, serious orthat has unforeseen, serious or
immediate threats to public health.immediate threats to public health.

DisasterDisaster
They may beThey may be naturalnatural (large fires,(large fires,
earthquakes, floods, hurricanes orearthquakes, floods, hurricanes or
tornadoes) ortornadoes) or manmade eventsmanmade events (war,(war,
terrorism, or overwhelmingterrorism, or overwhelming
contamination of the environment).contamination of the environment).

Mass casualty incidentMass casualty incident (MCI)(MCI)
situation in which the number ofsituation in which the number of
casualtiescasualties exceeds the number ofexceeds the number of
resources.resources.

DestructionDestruction (WMDs): weapons used(WMDs): weapons used
to cause widespread death andto cause widespread death and
destruction.destruction.

Biological warfareBiological warfare: use of biological: use of biological
agents, such asagents, such as anthraxanthrax, as a WMD., as a WMD.
Chemical warfareChemical warfare: use of a: use of a
chemical agent, such aschemical agent, such as chlorinechlorine, as, as
a WMD.a WMD.

DecontaminationDecontamination::
process of removing or renderingprocess of removing or rendering
harmless, contaminants that haveharmless, contaminants that have
accumulated on personnel, patients,accumulated on personnel, patients,
and equipment.and equipment.

Background :Background :
The use of WMDs dates as far backThe use of WMDs dates as far back
as the century BC for biologicalas the century BC for biological
weapons and the year 436 BC forweapons and the year 436 BC for
chemical (US army medicalchemical (US army medical
institute of infectious disease,institute of infectious disease,
1996).1996).

Background :Background :
with the geopolitical forces andwith the geopolitical forces and
interests, and the availability ofinterests, and the availability of
destructive technology has broughtdestructive technology has brought
the possibility of more terrorists’the possibility of more terrorists’
events to our doorsteps.events to our doorsteps.

Examples:Examples:
1995-Oklahoma City bombing of1995-Oklahoma City bombing of
the Murrah building;the Murrah building;
1993- New York City, World Trade1993- New York City, World Trade
CenterCenter
Sept. 11, 2001- World Trade CenterSept. 11, 2001- World Trade Center
Towers/ damage to the pentagon/Towers/ damage to the pentagon/
anthrax exposure.anthrax exposure.

Sept. 11, 2001- World Trade CenterSept. 11, 2001- World Trade Center
TowersTowers

1995-Oklahoma City bombing of1995-Oklahoma City bombing of
the Murrah building;the Murrah building;

Anthrax ExposureAnthrax Exposureanthrax exposureanthrax exposure

Terrorism has become increasinglyTerrorism has become increasingly
sophisticated, organized andsophisticated, organized and
therefore effective. Because oftherefore effective. Because of
these incidents, severalthese incidents, several
organizations on preparedness wereorganizations on preparedness were
developed to combat terroristdeveloped to combat terrorist
activity.activity.

1999- National Domestic1999- National Domestic
Preparedness OrganizationPreparedness Organization
2001- After New York attack The2001- After New York attack The
Department of Homeland SecurityDepartment of Homeland Security

TerrorismTerrorism andand warfarewarfare are twoare two
manmade reasons that health caremanmade reasons that health care
providers need to plan for massproviders need to plan for mass
casualty and their communities.casualty and their communities.

OtherOther manmade disastersmanmade disasters that canthat can
result in casualties and tax theresult in casualties and tax the
resources of health facilities:resources of health facilities:
Airplane crashes, train crashes andAirplane crashes, train crashes and
toxic substances spillages.toxic substances spillages.

Natural phenomena:Natural phenomena:
Floods, tornadoes, hurricane, fires,Floods, tornadoes, hurricane, fires,
and earthquakesand earthquakes

Principles of Emergency ManagementPrinciples of Emergency Management
In 2007, Dr. Wayne Blanchard ofIn 2007, Dr. Wayne Blanchard of
FEMA’s Emergency ManagementFEMA’s Emergency Management
Higher Education Project, at theHigher Education Project, at the
direction of Dr. Cortez Lawrence,direction of Dr. Cortez Lawrence,
Superintendent of FEMA’sSuperintendent of FEMA’s
Emergency Management Institute.Emergency Management Institute.

He convened a working group ofHe convened a working group of
emergency managementemergency management
practitioners and academics topractitioners and academics to
considerconsider principles of emergencyprinciples of emergency
management.management.

TheThe eight principleseight principles that will be used tothat will be used to
guide the development of a doctrine ofguide the development of a doctrine of
emergency management.emergency management.

Eight Principles EmergencyEight Principles Emergency
management must be:management must be:
1. Comprehensive1. Comprehensive – emergency– emergency
managers consider and take intomanagers consider and take into
accountaccount all hazardsall hazards, all phases, all, all phases, all
stakeholders and all impactsstakeholders and all impacts
relevant to disasters.relevant to disasters.

::
Emergency management must beEmergency management must be
2. Progressive2. Progressive – emergency– emergency
managersmanagers anticipate futureanticipate future
disastersdisasters and take preventive andand take preventive and
preparatory measures to buildpreparatory measures to build
disaster-resistant and disaster-disaster-resistant and disaster-
resilient communities.resilient communities.

::
3. Risk-driven3. Risk-driven – emergency– emergency
managersmanagers use sound riskuse sound risk
managementmanagement principles (hazardprinciples (hazard
identification, risk analysis, andidentification, risk analysis, and
impact analysis) in assigningimpact analysis) in assigning
priorities and resources.priorities and resources.

::
4. Integrated4. Integrated – emergency– emergency
managers ensuremanagers ensure unityunity of effortof effort
among all levels of government andamong all levels of government and
all elements of a community.all elements of a community.

::
Principles: EmergencyPrinciples: Emergency
management must bemanagement must be
5. Collaborative5. Collaborative – emergency– emergency
managers create and sustain broadmanagers create and sustain broad
and sincereand sincere relationshipsrelationships amongamong
individuals and organizationsindividuals and organizations toto
encourage trust, advocate a teamencourage trust, advocate a team
atmosphere, build consensus, andatmosphere, build consensus, and
facilitate communication.facilitate communication.

::
6. Coordinated6. Coordinated – emergency– emergency
managersmanagers synchronizesynchronize the activitiesthe activities
of all relevant stakeholders toof all relevant stakeholders to
achieve a common purpose.achieve a common purpose.

::
7. Flexible7. Flexible – emergency managers– emergency managers
useuse creative and innovativecreative and innovative
approaches in solving disasterapproaches in solving disaster
challenges.challenges.

::
8. Professional8. Professional – emergency– emergency
managers value a science andmanagers value a science and
knowledge-based approachknowledge-based approach; based; based
on education, training, experience,on education, training, experience,
ethical practice, public stewardshipethical practice, public stewardship
and continuous improvement.and continuous improvement.

COMPETENCY OFCOMPETENCY OF
NURSES RESPONDINGNURSES RESPONDING
TO MASS CASUALTYTO MASS CASUALTY
INCIDENTSINCIDENTS

::
1. The emergency nurse must be1. The emergency nurse must be
capablecapable of rapid assessmentof rapid assessment andand
history taking and immediatehistory taking and immediate
intervention formulation andintervention formulation and
implementation utilizing theimplementation utilizing the
nursing process.nursing process.

::
2. The emergency nurse must2. The emergency nurse must planplan
and teach prevention and healthand teach prevention and health
promotionpromotion, as well as, as well as rapidlyrapidly
develop rapport with the client anddevelop rapport with the client and
family, including with thefamily, including with the
emotional needs.emotional needs.

::
3. Clinical knowledge,3. Clinical knowledge,
communication, client teaching andcommunication, client teaching and
empathy skills are essential toempathy skills are essential to
effective emergency care.effective emergency care.

The Role of Nursing in DisasterThe Role of Nursing in Disaster
Response PlansResponse Plans
The role of the nurse during aThe role of the nurse during a
disaster varies:disaster varies:

1. The nurse maybe asked to1. The nurse maybe asked to
perform outside his/her area ofperform outside his/her area of
expertise and may take onexpertise and may take on
responsibilities normally held byresponsibilities normally held by
physicians or advanced practicephysicians or advanced practice
nurses.nurses.

For example:For example:
-a critical care nurse may-a critical care nurse may intubateintubate aa
patient or even insert chest tubes.patient or even insert chest tubes.
-A wound-A wound debridement or suturingdebridement or suturing
may be performed by staff nurses.may be performed by staff nurses.
-A nurse may serve as-A nurse may serve as triage officer.triage officer.

2. The nurse may2. The nurse may provide shelterprovide shelter
care in a temporary housing areascare in a temporary housing areas
or bereavement support andor bereavement support and
assistance with identification ofassistance with identification of
deceased loved ones.deceased loved ones.

3. The nurse may participate in3. The nurse may participate in
counselingcounseling other staff membersother staff members
and in critical incidents stressand in critical incidents stress
management (CISM).management (CISM).

LEVELS OF DISASTERLEVELS OF DISASTER
Disaster is often assigned levels,Disaster is often assigned levels,
which indicate the anticipated levelwhich indicate the anticipated level
of response.of response.

LEVEL DESCRIPTION
LEVEL 1 Local emergency response personnel and
organizations can contain and effectively
manage the disaster and its aftermath.
LEVEL 11 Regional efforts and aid from surrounding
communities are sufficient to manage the
effects of the disaster.
LEVEL 111 Local and regional assets are overwhelmed;
statewide or federal assistance is required.

THE INCIDENT COMMANDTHE INCIDENT COMMAND
SYSTEM (ICS)SYSTEM (ICS)
The ICS is aThe ICS is a management toolmanagement tool forfor
organizing personnel, facilities,organizing personnel, facilities,
equipment, and communication forequipment, and communication for
any emergency situation. Theany emergency situation. The
federal government mandates thatfederal government mandates that
the ICS be used duringthe ICS be used during
emergencies.emergencies.

THE INCIDENT COMMANDTHE INCIDENT COMMAND
SYSTEM (ICS)SYSTEM (ICS)
Under this structure,Under this structure, one personone person isis
designated as incident commanderdesignated as incident commander
(IC).(IC).
This person must be continuouslyThis person must be continuously
informed of all activities andinformed of all activities and
informed about any deviation frominformed about any deviation from
the established plan.the established plan.

HOSPITAL EMERGENCYHOSPITAL EMERGENCY
PREPAREDNESS PLAN SPREPAREDNESS PLAN S

Every facility is required by JointEvery facility is required by Joint
Commission on Accreditation ofCommission on Accreditation of
Healthcare organizations (JCAHO)Healthcare organizations (JCAHO)
create and to plan for emergencycreate and to plan for emergency
preparedness practice this planpreparedness practice this plan
twice a year.twice a year.

HOSPITAL EMERGENCY PREPAREDNESS PLANSHOSPITAL EMERGENCY PREPAREDNESS PLANS

Joint Commission on Accreditation ofJoint Commission on Accreditation of
Healthcare organizations (JCAHO)Healthcare organizations (JCAHO)
requires the following:requires the following:
-Create and to plan for emergency-Create and to plan for emergency
preparedness practice this plan twice apreparedness practice this plan twice a
year.year.


-Before the EOP can be developed the-Before the EOP can be developed the
planning committee of the facility firstplanning committee of the facility first
evaluates the communityevaluates the community to anticipateto anticipate
the types of natural and manmadethe types of natural and manmade
disaster that might occurdisaster that might occur


-assessment be done from local law-assessment be done from local law
enforcers, assess train, automobile andenforcers, assess train, automobile and
air traffic. Earthquakes, tornado, orair traffic. Earthquakes, tornado, or
hurricane activity. Proximity to chemicalhurricane activity. Proximity to chemical
plants, nuclear facilities or militaryplants, nuclear facilities or military
bases. Federal, judicial, financialbases. Federal, judicial, financial
buildings. Schools other places withbuildings. Schools other places with
large group of people gathered highlarge group of people gathered high
risk areas.risk areas.


-the planning committee must have a-the planning committee must have a
realistic understanding of its resources.realistic understanding of its resources.
(check adequacy of pharmaceutical(check adequacy of pharmaceutical
stockpile available to treat specificstockpile available to treat specific
chemical or biological agents)chemical or biological agents)
-the committee might outline how staff-the committee might outline how staff
would triage and assign priority towould triage and assign priority to
patients when the number of ventilatorspatients when the number of ventilators
is limitedis limited

COMPONENTS OFCOMPONENTS OF
EMERGENCY OPERATIONEMERGENCY OPERATION
PLANSPLANS

Once the initial assessment isOnce the initial assessment is
complete, the facility develops thecomplete, the facility develops the
EOP.EOP.

Essential components of the plan are as follows:Essential components of the plan are as follows:
1. An activation response1. An activation response
The EOP activation response of aThe EOP activation response of a
health care facility shouldhealth care facility should definedefine
where, how, and whenwhere, how, and when the responsethe response
is initiated.is initiated.

2. An internal/external2. An internal/external
communication plancommunication plan
Communication is critical for allCommunication is critical for all
parties involved, includingparties involved, including
communication to and from thecommunication to and from the
hospital arena.hospital arena.

3. A plan for coordinated patient3. A plan for coordinated patient
carecare
A response is planned forA response is planned for
coordinated patient care into andcoordinated patient care into and
out of the facility, includingout of the facility, including
transfers to other facilitiestransfers to other facilities. The site. The site
of the disaster can determine whereof the disaster can determine where
the greater number of patients maythe greater number of patients may
self refer.self refer.

4. Security plans4. Security plans
A security plan involving facilityA security plan involving facility
and community agencies is key toand community agencies is key to
the control of an otherwisethe control of an otherwise chaoticchaotic
situation.situation.

5. Identification of external5. Identification of external
resourcesresources
External resources are identified,External resources are identified,
includingincluding local statelocal state, and, and federalfederal
resourcesresources and information aboutand information about
how to activate these resources.how to activate these resources.

6. A plan for people management6. A plan for people management
and traffic flowand traffic flow
““People management” includePeople management” include
strategies to manage the patients,strategies to manage the patients,
the public, the media, andthe public, the media, and
personnel. Specific areas arepersonnel. Specific areas are
assigned, and a designated personassigned, and a designated person
isis delegateddelegated to manage each ofto manage each of
these areas.these areas.

7. A data management strategy7. A data management strategy
A data management plan for everyA data management plan for every
aspect of the disaster willaspect of the disaster will save timesave time
at every step. A backup system forat every step. A backup system for
charting, tracking, and staffing ischarting, tracking, and staffing is
developed if the facility has adeveloped if the facility has a
computer systemcomputer system..

8. Deactivation response8. Deactivation response
Deactivation of the response is asDeactivation of the response is as
important as activation. The personimportant as activation. The person
who decides when the facility is ablewho decides when the facility is able
to go from the disaster response backto go from the disaster response back
to daily activities is clearly identified.to daily activities is clearly identified.
Any possibleAny possible residual effects of aresidual effects of a
disaster must be considered beforedisaster must be considered before
this decision is made.this decision is made.

9. A post incident responses9. A post incident responses
Often facilities see increasedOften facilities see increased
volume s of patients up to 3 monthsvolume s of patients up to 3 months
after an incident. Post incidentafter an incident. Post incident
response must include a critiqueresponse must include a critique
and aand a debriefing for all partiesdebriefing for all parties
involved, immediately and again atinvolved, immediately and again at
a later date.a later date.

10. A plan for practice drills10. A plan for practice drills
Practice drills that includePractice drills that include
community participationcommunity participation allow forallow for
troubleshooting any issues before atroubleshooting any issues before a
real-life incident occurs.real-life incident occurs.

11. Anticipated resources11. Anticipated resources
FoodFood andand waterwater must be availablemust be available
for staff, families, and others whofor staff, families, and others who
may be at the facility for anmay be at the facility for an
extended period.extended period.

12. Mass casualty planning12. Mass casualty planning
MCI planning includes such asMCI planning includes such as
mass fatality andmass fatality and morgue readinessmorgue readiness..

13. An educational plan for all the13. An educational plan for all the
aboveabove
A strong educational plan for allA strong educational plan for all
personnel regarding each step ofpersonnel regarding each step of
the plan allows forthe plan allows for improvedimproved
readinessreadiness and additional input forand additional input for
fine tuning of the EOP.fine tuning of the EOP.

MANAGEMENT OF MASSMANAGEMENT OF MASS
CASUAL CASUALTYCASUAL CASUALTY
Three general approaches toThree general approaches to
emergency care:emergency care:
1. Hospital triage (ABC’s)1. Hospital triage (ABC’s)
2. Disaster triage (Priority 1-4)2. Disaster triage (Priority 1-4)
3. Emergency medical services3. Emergency medical services

HOSPITAL TRIAGEHOSPITAL TRIAGE
TRIAGETRIAGE refers torefers to classificationclassification ofof
clients to determineclients to determine prioritypriority ofof
need and proper place of treatment.need and proper place of treatment.

HOSPITAL TRIAGEHOSPITAL TRIAGE
TRIAGETRIAGE is utilized in the ED tois utilized in the ED to
establish priorities and levels ofestablish priorities and levels of
care needed by the clients.care needed by the clients.
The nurse is responsible to sort andThe nurse is responsible to sort and
prioritize the clients as they arriveprioritize the clients as they arrive
in the ED.in the ED.

The simplest method of triagingThe simplest method of triaging
clients :clients :
Airway, Breathing, and CirculationAirway, Breathing, and Circulation
(ABC’s).(ABC’s). Patient with AirwayPatient with Airway
problems would be immediatelyproblems would be immediately
assessed and would become a topassessed and would become a top
priority of care.priority of care.

If any of the ABC’S were notIf any of the ABC’S were not
functioning, eitherfunctioning, either HeimlichHeimlich
maneuvermaneuver or cardiopulmonaryor cardiopulmonary
resuscitationresuscitation (CPR)(CPR) would bewould be
initiated.initiated.

TheThe most commonly used triagemost commonly used triage
classification areclassification are emergent, urgent,emergent, urgent,
andand nonurgentnonurgent and are recognizedand are recognized
by Emergency Nurses Associationby Emergency Nurses Association

The most common used triageThe most common used triage
CATEGORY/PRIORITY CLIENT NEEDS EXAMPLES
Emergent Immediate intervention is
required to sustain life or
limb.
Cardiac arrest, foreign
bodies in the eye, shortness
of breath, and impending
birth
Multiple trauma
Urgent Care is required within 1-
2hours to prevent
deterioration of condition.
Compound fractures, acute
abdominal pain.
Persistent vomiting and
diarrhea
Nonurgent Care maybe delayed without
risk of permanent sequelae.
Contusions
Minor sprains and fractures
SOP of general hospitals

Once the safety of the scene and ofOnce the safety of the scene and of
the client have been established,the client have been established,
assessment turns to theassessment turns to the ABC’sABC’s ––
airway, breathing, and circulation.airway, breathing, and circulation.
When these functions have beenWhen these functions have been
stabilized, the client should bestabilized, the client should be
assessed for shock.assessed for shock.

1. Emergent clients require1. Emergent clients require
immediate care in order to sustainimmediate care in order to sustain
life or limb.life or limb.
Principles of first aid, developed forPrinciples of first aid, developed for
emergency medicine, are part ofemergency medicine, are part of
the triage process and include whatthe triage process and include what
are referred to as the golden rulesare referred to as the golden rules
of emergency care.of emergency care.

Triage CategoriesTriage Categories

Category based on client’s NeedsCategory based on client’s Needs
TRIAGE CATEGORY PRIORITY COLOR TYPICAL CONDITIONS
Immediate:
Injuries are life
threatening but
survivable with
minimal
intervention.
Individuals in this
group can progress
rapidly to expectant
if treatment is
delayed.
1 Red Sucking chest wound, airway
obstruction secondary to
mechanical cause,
shock,hemothorax, tension
pneumothorax,
atotsphyxia,unstable chest and
abdominal wounds, incomplete
amputations, open fractures of
long bones and 2nd
/3rd
degree
burns of 15-40% total body
surfaces.

TRIAGE CATEGORY PRIORIT
Y
COLOR TYPICAL CONDITIONS
Delayed:
Injuries are
significant and
require medical care,
but can wait hours
without threat to life
or limb. Individuals
in this group receive
treatment only after
immediate casualties
are treated.
2 Yellow Stable abdominal wounds
without evidence of significant
hemorrhage; soft tissue injuries;
maxillofacial wounds without
airway compromise; ; vascular
injuries with adequate collateral
circulation; GUT disruption;
fractures requiring open
reduction; debridement, and
external fixation; most eye and
CNS injuries.

Minimal:
Injuries are minor
and treatment can
be delayed hours to
days. Individuals in
this group should be
moved away from
the main triage area.
3 Green Upper extremity fractures,
minor burns, sprains, small
lacerations without significant
bleeding, behavioral disorders
or psychological disturbances.

Expectant :
Injuries are extensive
and chances of
survival are unlikely
even with definitive
care. Individuals in
this group should be
separated from other
casualties, but not
abandoned. Comfort
measures should be
provided when
possible.
4 black Unresponsive patients with
penetrating head wounds, high
spinal cord injuries, wound
involving multiple anatomical
sites and organs. 2nd
and 3rd
degree burns in excess of 60%
of body surface area, seizures
or vomiting within 24 hours
after 24 hours after radiation
exposure, profound shock with
multiple injuries,

PROFESSIONAL TIPPROFESSIONAL TIP
Golden Rules of emergency careGolden Rules of emergency care
1. Establish the safety of the scene1. Establish the safety of the scene
2. Remove the client from danger.2. Remove the client from danger.
3. Establish airway, breathing, and3. Establish airway, breathing, and
circulation.circulation.

PROFESSIONAL TIPPROFESSIONAL TIP
(cont.)(cont.)
Golden Rules of emergency careGolden Rules of emergency care
4. Manage shock.4. Manage shock.
5. Attend to eye injuries.5. Attend to eye injuries.
6. Treat skin injuries.6. Treat skin injuries.
7. Call for help.7. Call for help.

Triage of Disaster VictimsTriage of Disaster Victims
Triage isTriage is sorting of casualtiessorting of casualties toto
determine priority of health caredetermine priority of health care
needs and the proper site forneeds and the proper site for
treatment.treatment.

Disaster Triage Systems represent aDisaster Triage Systems represent a
second approach to emergencysecond approach to emergency
care. These systems are utilized incare. These systems are utilized in
the event of community disaster,the event of community disaster,
eithereither natural or man-madenatural or man-made, such as, such as
train accident, tornado, hurricane,train accident, tornado, hurricane,
or terrorism.or terrorism.

The triage officerThe triage officer rapidly assessesrapidly assesses
those injured at the disaster scene.those injured at the disaster scene.
Victim are immediately tagged andVictim are immediately tagged and
transported or given life savingtransported or given life saving
interventions.interventions.

Given the possibility of largeGiven the possibility of large
numbers of casualties as a result ofnumbers of casualties as a result of
disasters, a different approach todisasters, a different approach to
triaging.triaging.

In-disaster
situations
Non-disaster situations
The fundamental
principle guiding
resource allocation is
to do the greatest
good for the greatest
number of people.
Health workers assign a
high priority and allocate
the most resources to
those who are most
critically ill

In disaster situations Non disaster situations
Decisions are based on the
likelihood of survival and
consumption of available
resources.
Example:
A young man with chest
injury and is in full cardiac
arrest would receive
advanced cardiopulmonary
resuscitation including
medications, chest tubes,
intravenous fluids, blood,
possibly emergency surgery
in an effort to restore life

In disaster situations Non disaster situations
Patient with high mortality
rate are given Low triage
Priority

COMMON REACTION OFCOMMON REACTION OF
DISASTER SURVIVORSDISASTER SURVIVORS
After a disaster both individuals andAfter a disaster both individuals and
communities suffer immediate andcommunities suffer immediate and
sometimes long term psychologicalsometimes long term psychological
trauma.trauma.

Common responses to disasterCommon responses to disaster
include.include.
Depression, Anxiety,Depression, Anxiety,
Somatization (fatigue, generalSomatization (fatigue, general
malaise, headache, GI disturbances,malaise, headache, GI disturbances,
skin rashes) disasterskin rashes) disaster
Post traumatic stress disorderPost traumatic stress disorder
Substance abuseSubstance abuse
Interpersonal conflictsInterpersonal conflicts
Impaired performanceImpaired performance

Factors that influence an individual’sFactors that influence an individual’s
response to include the degree andresponse to include the degree and
nature of the:nature of the:
- Exposure to the disaster.- Exposure to the disaster.
- Loss of friends and loved ones.- Loss of friends and loved ones.
- Existing coping strategies.- Existing coping strategies.
- Available resources and support, and- Available resources and support, and
- The personal meaning attached to the- The personal meaning attached to the
eventevent

Other factors that influence responseOther factors that influence response
and increase the risk of adjustmentand increase the risk of adjustment
problemsproblems
- Loss of homes and valued- Loss of homes and valued
possessions.possessions.
-Extended exposure to danger.-Extended exposure to danger.
- Exposure to danger, and- Exposure to danger, and
- Exposure to toxic contamination- Exposure to toxic contamination

Health personnel considered being atHealth personnel considered being at
higher risk for emotional sequelaehigher risk for emotional sequelae
-Those expose to dead and injured.-Those expose to dead and injured.
-Eyewitness and those endangered by-Eyewitness and those endangered by
the event.the event.
-The elderly-The elderly
-Children-Children
-Emergency first-responders-Emergency first-responders
-Medical personnel caring for victim-Medical personnel caring for victim

Nurses can assist disaster victimsNurses can assist disaster victims
by:by:
Providing activeProviding active listeninglistening andand
emotional supportemotional support..
GivingGiving informationinformation and referringand referring
patientspatients to a therapistto a therapist or socialor social
worker.worker.

by:by:
Health care workers mustHealth care workers must referrefer
individuals toindividuals to mental healthmental health carecare
servicesservices
(Early interventions minimizes(Early interventions minimizes
psychological consequencespsychological consequences))

by:by:
Nurses canNurses can discourage victimsdiscourage victims fromfrom
subjecting themselves fromsubjecting themselves from
repeated exposure to the eventrepeated exposure to the event
through media replays and newsthrough media replays and news
articles.articles.

PHASES OF EMOTIONAL RECOVERYPHASES OF EMOTIONAL RECOVERY
Disasters oftenDisasters often cause post-traumaticcause post-traumatic
stress reactionsstress reactions in people they affectin people they affect
directly.directly.

It's not uncommon for disaster victims toIt's not uncommon for disaster victims to
havehave behavioralbehavioral andand emotionaemotional issues.l issues.
Intense stress can cause feelings of fear,Intense stress can cause feelings of fear,
helplessness, anger and frustration.helplessness, anger and frustration.

In the event of a terrorist attack, peopleIn the event of a terrorist attack, people
may even feel amay even feel a desire for revenge.desire for revenge.

Reactions to disasters can be categorizedReactions to disasters can be categorized
into distinct phasesinto distinct phases..
The amount of time it takes people toThe amount of time it takes people to
work through each phase is specific towork through each phase is specific to
each personeach person

1.1. Impact PhaseImpact Phase
– During the impact phase of a disaster,During the impact phase of a disaster,
most people have amost people have a natural reactionnatural reaction toto
protect their own livesprotect their own lives and those of theirand those of their
loved ones.loved ones.

1.1. Impact PhaseImpact Phase
– These people are often left feeling as ifThese people are often left feeling as if
they could have done more to help otherthey could have done more to help other
victims.victims.

1.1. Impact Phase (cont.)Impact Phase (cont.)
Others may beOthers may be disorganizeddisorganized andand
stunned,stunned, and may wander the streets inand may wander the streets in
the immediate aftermath of thethe immediate aftermath of the
disaster.disaster.

1.1. Impact Phase (cont.)Impact Phase (cont.)
This reaction suggests these peopleThis reaction suggests these people
are inare in a state of shocka state of shock, and are, and are
dissociated from the event.dissociated from the event.

1.1. Impact PhaseImpact Phase (cont.)(cont.)
SeveralSeveral stress factorsstress factors can be presentcan be present
during the impact phase,during the impact phase,
including threat to life; feelings ofincluding threat to life; feelings of
helplessness; loss of loved ones, home,helplessness; loss of loved ones, home,
or possessions; dislocation from family,or possessions; dislocation from family,
home, and community; feelings ofhome, and community; feelings of
responsibility; feeling trapped; andresponsibility; feeling trapped; and
difficulty coping.difficulty coping.

2. Recoil and Rescue2. Recoil and Rescue
– In this phase, affected people recoilIn this phase, affected people recoil
from the disaster while rescuefrom the disaster while rescue
activities take place.activities take place.

2. Recoil and Rescue2. Recoil and Rescue
– Emotional reactions from survivorsEmotional reactions from survivors
tend totend to varyvary, and some reactions, and some reactions
may be delayed while the rescuemay be delayed while the rescue
phase commences.phase commences.

2. Recoil and Rescue (cont.)2. Recoil and Rescue (cont.)
– High anxiety and confusion areHigh anxiety and confusion are
commonly seen among survivors.commonly seen among survivors.
– Emotional reactions during thisEmotional reactions during this
phase canphase can include numbness, denialinclude numbness, denial
or shock, despair, anger, grief, oror shock, despair, anger, grief, or
flashbacks.flashbacks.

3. Recovery Phase3. Recovery Phase
– The recovery phase includes aThe recovery phase includes a
period ofperiod of adjustmentadjustment for thefor the
community affected by the disaster.community affected by the disaster.
– Rescue efforts are completed, andRescue efforts are completed, and
people try to start bringing theirpeople try to start bringing their
lives back to normal.lives back to normal.

3. Recovery Phase (cont.)3. Recovery Phase (cont.)
– The threat of immediate danger isThe threat of immediate danger is
over, and rebuilding within theover, and rebuilding within the
community can begin after damagecommunity can begin after damage
is cleared away and insuranceis cleared away and insurance
claims are settled.claims are settled.

– At this point, public assistanceAt this point, public assistance
begins to withdraw as mediabegins to withdraw as media
attention starts to wane.attention starts to wane.

– This is when psychologicalThis is when psychological
disturbances can begin to appear.disturbances can begin to appear.
– It's common for survivors toIt's common for survivors to
experience fatigue, depression,experience fatigue, depression,
sleep disturbances, nightmares,sleep disturbances, nightmares,
anxiety, or other prolonged healthanxiety, or other prolonged health
symptomssymptoms

– Relationships can suffer, andRelationships can suffer, and
difficulties at work can make post-difficulties at work can make post-
disaster adjustment challenging.disaster adjustment challenging.

A traumatic event disruptsA traumatic event disrupts
your life. There is no simpleyour life. There is no simple
fix to make things betterfix to make things better
right away. But there areright away. But there are
actions that can help you,actions that can help you,
your family, and youryour family, and your
community heal. Try to:community heal. Try to:

1.1.Follow a normal routine as muchFollow a normal routine as much
as possible.as possible.
2. Eat healthy meals. Be careful not2. Eat healthy meals. Be careful not
to skip meals or to overeat.to skip meals or to overeat.

3. Exercise and stay active.3. Exercise and stay active.
4. Help other people in your4. Help other people in your
community as a volunteer. Staycommunity as a volunteer. Stay
busy.busy.

5. Accept help from family, friends,5. Accept help from family, friends,
co-workers, or clergy. Talk aboutco-workers, or clergy. Talk about
your feelings with them.your feelings with them.

6. Limit your time around the sights6. Limit your time around the sights
and sounds of what happened.and sounds of what happened.
Don’t dwell on TV, radio, orDon’t dwell on TV, radio, or
newspaper reports on the tragedy.newspaper reports on the tragedy.

SPECIAL NEEDS PREPARATIONSPECIAL NEEDS PREPARATION
1. OLDER ADULTS1. OLDER ADULTS
2. THE SEVERELY MENTALLY2. THE SEVERELY MENTALLY
ILL CULTURE & ETHNICILL CULTURE & ETHNIC
SUBGROUPSSUBGROUPS
3. NURSE AND HOSPITAL3. NURSE AND HOSPITAL
PERSONNELPERSONNEL

ROLE OF RITUALSROLE OF RITUALS
IN HEALINGIN HEALING

Cultural considerationsCultural considerations
Any disaster or mass casualtyAny disaster or mass casualty
incidents can be expected to involveincidents can be expected to involve
members ofmembers of diverse religiousdiverse religious andand
ethnic groupsethnic groups or maybe targeted ator maybe targeted at
and predominantly affect a specificand predominantly affect a specific
religious and ethnic group.religious and ethnic group.

Cultural considerations (cont.)Cultural considerations (cont.)
Health care providers likewiseHealth care providers likewise
include members of allinclude members of all religiousreligious
andand ethnic backgroundsethnic backgrounds and shalland shall
bear in mind those victims maybear in mind those victims may
havehave Language difficultiesLanguage difficulties thatthat
increase fears and frustrationsincrease fears and frustrations

Specific religious practices relatedSpecific religious practices related
to medical treatment, hygiene, orto medical treatment, hygiene, or
diet.diet.

Specific times for prayerSpecific times for prayer
Rituals about handling of the deadRituals about handling of the dead
Timing of funeral servicesTiming of funeral services

1. MOURNING1. MOURNING
2. MILESTONE ANNIVERSARIES2. MILESTONE ANNIVERSARIES

EMERGENCY MANAGEMENT PHASESEMERGENCY MANAGEMENT PHASES
1.1. PreventionPrevention was recently added towas recently added to
the phases of emergencythe phases of emergency
management.management.
It focuses onIt focuses on preventing the humanpreventing the human
hazard,hazard, primarily from potentialprimarily from potential
natural disasters or terrorist (bothnatural disasters or terrorist (both
physical and biological) attacks.physical and biological) attacks.

Preventative measures are taken onPreventative measures are taken on
both a domestic and internationalboth a domestic and international
levels.levels.
These are activities designed toThese are activities designed to provideprovide
permanent protectionpermanent protection from disasters.from disasters.

Not all disasters, particularly naturalNot all disasters, particularly natural
disasters, can be prevented, but the riskdisasters, can be prevented, but the risk
of loss of life and injury can beof loss of life and injury can be
mitigated with good evacuation plans,mitigated with good evacuation plans,
environmental planning and designenvironmental planning and design
standards.standards.

2. Preparedness2. Preparedness
Personal preparedness focuses onPersonal preparedness focuses on
preparing equipment andpreparing equipment and
procedures for use procedures for use whenwhen a disaster a disaster
occurs, i.e., planning.occurs, i.e., planning.

2. Preparedness (cont.)2. Preparedness (cont.)
Preparedness measures can take manyPreparedness measures can take many
forms including the construction offorms including the construction of
shelters, implementation of anshelters, implementation of an emergencyemergency
communication systemcommunication system,,
installation of warning devices, creation ofinstallation of warning devices, creation of
back-up life-line services (e.g., power,back-up life-line services (e.g., power,
water, sewage), and rehearsing evacuationwater, sewage), and rehearsing evacuation
plans.plans.

Two simple measures can help prepareTwo simple measures can help prepare
the individual for sitting out the event orthe individual for sitting out the event or
evacuating, as necessary.evacuating, as necessary.

For evacuation, a For evacuation, a disaster suppliesdisaster supplies
kitkit may be prepared and for sheltering may be prepared and for sheltering
purposes a stockpile of supplies may bepurposes a stockpile of supplies may be
created.created.

The preparation of a survival kitThe preparation of a survival kit
such as a "such as a "72-hour kit72-hour kit", is often", is often
advocated by authorities.advocated by authorities.

These kits may includeThese kits may include food,food,
medicine, flashlights, candles andmedicine, flashlights, candles and
money. Also, putting valuable itemsmoney. Also, putting valuable items
in safe area is also recommended.in safe area is also recommended.

3. Mitigation3. Mitigation
Personal mitigation is a key toPersonal mitigation is a key to
national preparedness.national preparedness.
Individuals and families train toIndividuals and families train to
avoid unnecessary risks.avoid unnecessary risks.

3. Mitigation (cont.)3. Mitigation (cont.)
This includes an assessment ofThis includes an assessment of
possible riskspossible risks to personal/familyto personal/family
health and to personal property.health and to personal property.

For instance, in a For instance, in a flood plainflood plain, home, home
owners might not be aware of aowners might not be aware of a
property being exposed to a hazardproperty being exposed to a hazard
until trouble strikes.until trouble strikes.

Specialists can be hired to conductSpecialists can be hired to conduct
risk identification and assessmentrisk identification and assessment
surveys.surveys.

In earthquake prone areas, peopleIn earthquake prone areas, people
might also make structural changesmight also make structural changes
such as the installation ofsuch as the installation of
an an Earthquake ValveEarthquake Valve to instantly shut to instantly shut
off the natural gas supply, off the natural gas supply, seismicseismic
retrofitsretrofits of property, and the securing of property, and the securing
of items inside a building toof items inside a building to
enhance enhance household seismic safetyhousehold seismic safety..

. The latter may include the. The latter may include the
mounting ofmounting of
furniture,furniture,refrigeratorsrefrigerators, , waterwater
heatersheaters and breakables to the walls, and breakables to the walls,
and the addition of cabinet latches.and the addition of cabinet latches.
In flood prone areas, houses can beIn flood prone areas, houses can be
built on poles/stilts.built on poles/stilts.

In areas prone to prolongedIn areas prone to prolonged
electricity electricity black-outsblack-outs installation of installation of
a a generatorgenerator would be an example ofwould be an example of
an optimal structural mitigationan optimal structural mitigation
measure. The construction of measure. The construction of stormstorm
cellarscellars and and fallout sheltersfallout shelters are further are further
examples of personal mitigativeexamples of personal mitigative
actions.actions.

Mitigation involvesMitigation involves StructuralStructural andand
Non-structuralNon-structural measures taken tomeasures taken to
limit the impact of disasters.limit the impact of disasters.

Structural mitigation are actions thatStructural mitigation are actions that
change the characteristics of achange the characteristics of a
building or its surrounding,building or its surrounding, examplesexamples
includeinclude shelters, window shutters,shelters, window shutters,
clearing forest around the houseclearing forest around the house..

Non-structural mitigation onNon-structural mitigation on
personal level mainly takes the formpersonal level mainly takes the form
ofof insurance or simply moving houseinsurance or simply moving house
to a safer area.to a safer area.

4. Recovery4. Recovery
The recovery phase starts after theThe recovery phase starts after the
immediate threat to human life hasimmediate threat to human life has
subsided.subsided.
The immediate goal of the recoveryThe immediate goal of the recovery
phase is to bring the effected areaphase is to bring the effected area
back to some degree ofback to some degree of normalcynormalcy..

4. Recovery (cont.)4. Recovery (cont.)
During reconstruction it isDuring reconstruction it is
recommended to consider therecommended to consider the
locationlocation or construction material ofor construction material of
the property.the property.

The most extreme home confinementThe most extreme home confinement
scenarios include war, scenarios include war, faminefamine and and
epidemicsepidemics and may last a year or more and may last a year or more
severe .severe .
Then recovery will take place insideThen recovery will take place inside
the home.the home.

A simple balanced diet can beA simple balanced diet can be
constructed from constructed from vitaminvitamin pills, pills, whole-whole-
mealmeal wheat, beans, wheat, beans, dried milkdried milk, corn,, corn,
and and cooking oilcooking oil. .


One should add vegetables, fruits,One should add vegetables, fruits,
spices and meats, both preparedspices and meats, both prepared
and fresh-gardened, when possible.and fresh-gardened, when possible.

Planners for these events usuallyPlanners for these events usually
buy buy bulkbulk foods and appropriate storage foods and appropriate storage
and preparation equipment, and eat theand preparation equipment, and eat the
food as part of normal life.food as part of normal life.

National Commission on
Children and Disasters

The The National Commission on ChildrenNational Commission on Children
and Disastersand Disasters approved its 90-page approved its 90-page
interim report to President Barack Obamainterim report to President Barack Obama
and Congress.and Congress.

The report identifies severalThe report identifies several shortcomingsshortcomings
in disaster preparedness, response andin disaster preparedness, response and
recovery and provides recommendationsrecovery and provides recommendations
designed to place children uppermost indesigned to place children uppermost in
future disaster planning efforts.future disaster planning efforts.

The recommendations includeThe recommendations include creating acreating a
national evacuee tracking and familynational evacuee tracking and family
reunification system,reunification system,
providing a safe and secure mass shelterproviding a safe and secure mass shelter
environment for children,environment for children,

The recommendations include :The recommendations include :
improving the capacity for child-careimproving the capacity for child-care
services in the immediate aftermath of aservices in the immediate aftermath of a
disaster,disaster,
and ensuring that health-care professionalsand ensuring that health-care professionals
have adequate training in "pediatric disasterhave adequate training in "pediatric disaster
medicine."medicine."

UNIQUE NEEDS OFUNIQUE NEEDS OF
CHILDREN DURINGCHILDREN DURING
DISASTERSDISASTERS

Hurricane Katrina revealed theHurricane Katrina revealed the
harm children and familiesharm children and families
experience when kids are notexperience when kids are not
accounted for in disaster planning:accounted for in disaster planning:

The storm displaced nearly 200,000The storm displaced nearly 200,000
children from the Gulf Region.children from the Gulf Region.
Following Hurricanes Katrina andFollowing Hurricanes Katrina and
Rita, it took six months for all ofRita, it took six months for all of
the 5,192 children separated fromthe 5,192 children separated from
their families to be reunited.their families to be reunited.

About 50,000 Louisiana andAbout 50,000 Louisiana and
Mississippi children missed schoolMississippi children missed school
in the 2005-2006 school year andin the 2005-2006 school year and
approximately 15,000 did not attendapproximately 15,000 did not attend
in the 2006-2007 school year.in the 2006-2007 school year.

More than a third of LouisianaMore than a third of Louisiana
children affected by the stormchildren affected by the storm
experienced clinically-diagnosedexperienced clinically-diagnosed
depression, anxiety, or anotherdepression, anxiety, or another
behavior disorder.behavior disorder.

The federal government and a vastThe federal government and a vast
majority of states are still not fullymajority of states are still not fully
prepared to protect children inprepared to protect children in
disasters, five years after Hurricanedisasters, five years after Hurricane
Katrina ravaged the Gulf Coast.Katrina ravaged the Gulf Coast.
WASHINGTON, D.C., (August 24, 2010) — New reportsWASHINGTON, D.C., (August 24, 2010) — New reports
from Save the Children and the National Commission onfrom Save the Children and the National Commission on
Children and DisastersChildren and Disasters

Among the findings are :Among the findings are :
-seriously-seriously underfundedunderfunded federalfederal
programs for school disasterprograms for school disaster
preparedness,preparedness,
--inadequateinadequate coordination amongcoordination among
federal,federal,
-state and local agencies and-state and local agencies and lack oflack of
preparednesspreparedness in our private health carein our private health care
system,system,

Too many states fail to ensure theToo many states fail to ensure the
safety of children in child caresafety of children in child care
during disastersduring disasters

Save the Children lookedSave the Children looked
at four very basic disasterat four very basic disaster
preparation requirements.preparation requirements.

1.1. A Plan for Evacuating ChildrenA Plan for Evacuating Children
in Child Care. in Child Care.
The state requires all regulated childThe state requires all regulated child
care programs to have acare programs to have a writtenwritten
plan for evacuating and movingplan for evacuating and moving
children to a safe location forchildren to a safe location for
multiple types of disasters.multiple types of disasters.

2. A Plan for Reuniting Families2. A Plan for Reuniting Families
after a Disaster. after a Disaster.
care programs to have a written policycare programs to have a written policy
to notify parents of an emergency andto notify parents of an emergency and
reunite parents with their children. reunite parents with their children.

3. A Plan for Children with3. A Plan for Children with
Disabilities and Those with AccessDisabilities and Those with Access
and Functional Needs. and Functional Needs.
care programs to have a written plancare programs to have a written plan
that accounts for any special assistancethat accounts for any special assistance
an infant, toddler, or child withan infant, toddler, or child with
physical, emotional, behavioral orphysical, emotional, behavioral or
mental health challenges may need. mental health challenges may need.

4. A Multi-Hazard Plan for K-124. A Multi-Hazard Plan for K-12
Schools.Schools.
The state requires all K-12 schools toThe state requires all K-12 schools to
have a disaster plan that accounts forhave a disaster plan that accounts for
multiple types of hazards. multiple types of hazards.

Disaster plans and preparation canDisaster plans and preparation can
reduce chaos and danger when disasterreduce chaos and danger when disaster
hits.hits.

In the Philippines, the NDRRMC, throughIn the Philippines, the NDRRMC, through
the Office of Civil Defense (OCD), took thethe Office of Civil Defense (OCD), took the
lead in the implementation of the ASEAN-lead in the implementation of the ASEAN-
US Cooperation on DM. Partner agenciesUS Cooperation on DM. Partner agencies
are the Department ofare the Department of
Local Government, (DILG-BFP), (DOH),Local Government, (DILG-BFP), (DOH),
(DSWD), (PNP), (AFP), (PRC), (MMDA),(DSWD), (PNP), (AFP), (PRC), (MMDA),
(FNTI), (SBMA), the City(FNTI), (SBMA), the City
Government of Olongapo, Davao CityGovernment of Olongapo, Davao City
Rescue 911 and Amity Public SafetyRescue 911 and Amity Public Safety
Academy (APSA).Academy (APSA).

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