This document summarizes key topics related to trauma and injuries caused by disasters such as earthquakes. It discusses: 1) Types of injuries that commonly occur in earthquakes including crush injuries, fractures, burns and respiratory issues. It also discusses factors that affect mortality rates. 2) Disaster injury epidemiology and models that show patterns of injuries from minor to severe. It also discusses how behaviors and building vulnerabilities influence outcomes. 3) Psychological impacts of disasters including short-term conditions like depression and anxiety as well as long-term impacts like post-traumatic stress disorder.

1. Trauma in
Disaster
David Alexander
University College London

2. Evidence

3. "Now, what I want is, facts. Teach
these boys and girls nothing but Facts.
Facts alone are wanted in life. Plant
nothing else, and root out everything
else. You can only form the minds of
reasoning animals upon Facts: nothing
else will ever be of any service to
them. This is the principle on which I
bring up my own children, and this is the
principle on which I bring up these
children. Stick to Facts, sir!"
Thomas Gradgrind in Hard Times
by Charles Dickens

4. An evidence
base for
everything

5. Robert Mallet and
evidence-based seismology

6. Evidence can be:-
• precise
• decisive
• equivocal
• ambiguous
• puzzling
• uninterpretable
(evidence of what?)
• ignored
• distorted
• used selectively.

7. Evidence is no good without
interpretation - and the ability to
interpret without misleading people.
Evidence can constrain uncertainty,
but cannot eradicate it.
All use of evidence is selective:
the criteria of choice determine
the value of the evidence.
Irregular and trending time series pose
problems for the gathering of evidence.

8. To what extent is evidence a
surrogate for experience?
Is evidence "objective data" or
mere perception of how the world is?
What is the connection
between evidence and wisdom?
How much evidence is enough?
Can we do without evidence?.

9. Analysis
• registered
• archived
• forgotten
• ignored
Vulnerability
maintained
-
• utilised
• adopted
• learned
Disaster
risk
reduced
+
Lessons
Past
events
The process of
disaster risk
reduction
(DRR)

10. Disaster injury
epidemiology

11. DISASTER
VICTIM
NOT INJURED INJURED
HEALTHY INFECTED
WORSENING
OF PATIENT'S
CONDITION
IMPROVEMENT
OF PATIENT'S
CONDITION
RECOVERS
IMPROVEMENT
OF PATIENT'S
CONDITION
DISEASES INJURIES
Public health measures
Search and rescue
Mortuary
and funeral
services
WORSENING
OF PATIENT'S
CONDITION
DEATH
Medical assistance
Medical assistance

12. Physical injury (physical trauma):-
• short-term condition
• long-term injury or disease
• fatal injury
• premature death
Psychological impairment:-
• depression
• anxiety
• post-traumatic stress
(including long-term).
Disaster injury epidemiology

13. Earthquakes
Mortality in earthquakes
• concentrated in the largest events
• concentrated in particular places

14. Instantaneous:
• crush injuries
• cranial or thorax injuries
• internal haemorrhaging
Rapid (from minutes to hours):
• asphyxia
• hypovolemic shock
• exposure
Earthquake injuries
Delayed (hours to days):
• dehydration, hypo- or hyperthermia
• crush syndrome
• infection or post-operative sepsis.

15. 0.5 1 3 12 1 2 3 45 7 10 15
Hours Days
Survival time
100
50
0
Percentageofpeopletrappedalive
undertherubbleofcollapsedbuildings
Criticalperiod
Source: Coburn and Spence (2002)

16. No damage
to buildings
Damage
to buildings
Injuries
Emergency room
injuries
Hospital
admissions
Source: Linda Bourque, UCLA

17. In the largest earthquakes
• mortality is 10-85% of
population of the epicentral area
• death/injury ratio 1:3 (hypothesized)
• casualties lessen rapidly with
distance from the epicentre.

18. Factors that affect mortality and
morbidity in earthquakes
• type, density and state of
maintenance of buildings
• number of occupants of buildings
• post-earthquake fire
• time of day (aggregate
patterns of human activity).

19. Active behaviour:
• travel to and from work
• leisure activities, etc.
• mealtimes and family activities
Passive behaviour:
• night-time sleep
• efficiency and timeliness of post-
earthquake SAR and medical assistance.

20. At the world scale, most injuries
occur in nocturnal earthquakes:
• a sleeping person is not
able to react rapidly
• vernacular housing is particularly at risk
• 50-90% of mortality is nocturnal.

21. Pattern of injured people
• most numerous group: minor injuries
• smaller group: simple fractures
• smaller group: serious multiple injuries
• ratio of serious to slight injuries:
from 1:9 to 1:30.

22. Expected pattern of injuries
minor injuries:
bruises, lacerations, etc.
simple fractures
serious
multiple injuries
Ratio of serious to slight injuries:
from 1:9 to 1:30
dead

23. Fatal
injuries
All
injuries
Serious
injuries
low ratio
low ratio
high ratio

24. Types of injury
• crush syndrome
• clavicle fracture
• simple lacerations
• bruises and sprains
• fractures of limbs
• surgical cases.

25. Types of injury (contd.)
• orthopaedic cases
• acute myocardial infarction
(heart attack)
• neurosurgery cases
• shock
• severe burns or smoke inhalation
• paraplegia.

26. Types of injury (contd.)
• gangrene, amputation
• adult respiratory distress
syndrome (ARDS)
• psycho-physical and
psychosomatic problems
• animal bites, electrocutions, drownings
• aggravation of existing
medical conditions.

27. Ratio of deaths to buildings
collapsed- 8:100 to 16:100
Entrapment increases risk
of death 35-100 times
• respiratory difficulties caused by
pressure on thorax of fallen objects, or
by ingestion of large quantities of dust
• 2-6 hours after earthquake fewer than
half of trapped people will still be alive.

28. Medical procedures
• patient's condition must be stabilised
immediately after he or she is rescued
• advanced trauma life support (ATLS)
• life support first aid (LSFA)
• resuscitatory surgery
• field analgesia and anesthesia
• resuscitative search and rescue
• intensive therapies.

29. Disaster Risk Reduction
or disaster risk creation?

30. L'Aquila earthquake
April 2009 (308 dead)

31. Kobe 1995 earthquake deaths
by gender and age
― males ― females

32. Self-protective
behaviour
Hospital
mass-casualty
response
Urban search
and rescue
(USAR)
A practical disaster epidemiology
Focus Potential benefit to...
How, where
and why
people died;
who they were;
how they
reacted to
the disaster

33. Behaviour
Vulnerability of the
built environment
Interaction
Force majeure:
the earthquake
Perception
Knowledge, habit,
custom and training

34. ?

35. Vernacular
housing:
the main
source
of risk
This is where we need resilience...

36. Can we devise
a strategy to enhance
self-protective behaviour?

37. Poor building
quality
(low seismic
resistance)
Proximity
to epicentre
and fault
rupture
Topographic
amplification
Sedimentary
amplification
Q E
T S
Concentration
of casualties
C
C = f { E,Q,S,T }
Deaths
Injuries
Q E
T S

38. Building quality and seismic resistance:
• site factors

39. Building quality and seismic resistance:
• building type and materials
[Masonry] [Reinforced concrete]

40. • plan and elevation of building
Building quality and seismic resistance:

41. Building quality and seismic resistance:
• urban form factors
[pounding
by
adjacent
buildings]

42. Building quality and seismic resistance:
• mixed construction?
[Stone and
concrete
block]

43. Building quality and seismic resistance:
• state of maintenance

44. Building quality and seismic resistance:
• occupancy factors

45. One needs to investigate the relative
importance of these factors in
different situations
site
factors
building type
and materials
plan and
elevation
of building
urban form
factors
mixed
construction?
behavioural
factors

46. Mid-floor damage to multi-occupancy bldg:
Intertia effect
Basal acceleration
Interaction = damage
Lack of stiffness in frame

47. For example... what is the typical
pattern of seismic failure of Iranian
vernacular housing of any given type?

48. • basal acceleration
• inertial displacement
• spalling of façade
• torsion
• ejection of
infill masonry
• deformation of
structural nodes
• detachment of
internal stairways
Some possible modes of failure

49. Think of the
problem from
the point of
view of the
occupants
of a building:
occupant-
building
interaction
modes.
Boumerdes, Algeria 2003

50. A scale for damage and personal risk level
Damage level: [1] minimum damage
to walls, fitments and furniture.
Personal risk level: prudent
behaviour will minimise risks.

51. Damage level: [2] significant damage
to structures, cladding and fitments.
Personal risk level: significant
risk of injury but not of death.
A scale for damage and personal risk level

52. Damage level: [3] general damage and
collapse of architectural elements.
Personal risk level: significant risk of
injury but relatively low risk of death.
A scale for damage and personal risk level

53. Damage level: [4] serious damage
or partial collapse of building.
Personal risk level: strong risk of
injury and significant risk of death.
A scale for damage and personal risk level

54. Damage level: [5] collapse of
more than 50% of the structure.
Personal risk level: limited and mainly
unpredictable probability of survival.
A scale for damage and personal risk level

55. In the case of total collapse, little
can be done for the occupants of a
building except urban heavy rescue.
This is up to three times more likely
to be successful if the location
of trapped occupants is known
(e.g. they can attract attention).

56. Seek
place of
refuge
Remain
in situ
Seek
potential
cavityRush
outside
Unexpected earthquake
Mild
impact
Severe
impact
Catastrophic
impact
Very
limited
damage
Fall of
heavy
objects
Partial
collapse
Total
collapse
Absolute immobility Frantic egress
Uninjured
Lightly
injured
Seriously
injured
Killed

57. Earthquake scenario
• magnitude range
• maximum accelerations
• recurrence intervals, etc.
Seismic
performance
of buildings
• modes of failure
• typologies of damage
Risk factors
• behaviour of building occupants
during earthquakes
• effectiveness of
search and rescue

58. Models of typical
vernacular housing
building types
Analysis of
characteristic
failure modes
Determination
of appropriate
crisis behaviour
Education and
training of
households
Culture of
protection
and resilience

59. Psychological
trauma

60. It is very rare that acute
pathological reactions and lasting
mental illness are caused by disaster.
Instead, the most common
consequences are:-
• depression
• post-traumatic stress disorder
(PTSD), including critical
incident stress (CIS).

61. Disaster is a test of the
psychological stability of the individual
• healthy behaviour means
activating internal mechanisms
that restore a sense of calm
• unhealth behaviour means the
negation of experience or
disintegration of the personality.

62. How an individual receives signs of danger:
• decoding them and reacting appropriately
• negating them and not reacting
• not understanding their significance and
not reacting in the most appropriate way:
- e.g., when the environmental signs of
disaster are neither clear nor familiar
• understanding them, but nevertheless
losing his or her equilibrium:
- the persion is overwhelmed
by fear of death and feels
abandoned or too vulnerable.

63. Risk
aversion
Risk
tolerance
Risk
denial
Risk-seeking
behaviour

64. Critical incident stress (CIS)
is a form of
post-traumatic stress disorder
which affects first responders
who work in conditions that are
difficult, dangerous or dramatic.

65. • physical (e.g. nausea, upset stomach)
• cerebral (e.g. repeated bad dream)
• behavioural (e.g. angry outbursts)
• emotional (e.g. anxiety)
• immediate or delayed.
Symptoms of PTSD and CIS

66. In emergencies loss of sense of
perspective can occur, leading to:-
Magna Mater complex: trying to solve all
the problems of the moment
Jehovah complex: believing one is
able to solve all existing problems
Tiredness can distort perception
and cause bad decision-making
Solution: take a break, rest and unwind.

67. Panic?

68. Criticisms of the concept of panic:-
• social chaos may mask
rational individual behaviour
• panic is a stereotype
and a popular myth
• running away might be the most
rational response to imminent danger
• hindsight analysis can
give the wrong perspective
• social bonds can survive major shocks.

69. Nepal

70. • reference scenario: M7.4 event of 1934
• major earthquake expected circa 2004.
Nepal earthquakes of 25 April
(M7.8) and 12 May (M7.3)

71. 1934

72. • poverty, polarisation and
general lack of governance
• almost universal absence
of disaster preparedness.
Nepal

73. • municipal disaster management
arrangements adequate for a village
of 1,000-2,000 inhabitants, not
a metropolitan area of 1.6 million
• airport far too small (cf. Haiti)
• basic preparedness virtually absent
• international community ineffective
• disaster risk reduction
measures very recent.
Kathmandu

74. • Why does disaster risk reduction have
such a low priority in national agendas?
• Why does so much international
effort achieve so few results?
• Why does the international community
focus on sophisticated aims
and ignore basic preparedness?
• What is the point of the Sendai
Framework for Disaster Risk Reduction
if it fails to reach the local level?
• Why is it so difficult to achieve
positive cultural change?.

75. Basic preparedness is a matter of
committing and organising the resources
that already exist: it is not unaffordable.
The barriers to preparedness:
• perception and interests of
powerful decision-makers
• corruption (the real cause
of earthquake disasters)
• polarisation, ideology and dogma
• lack of accountability:
"simulated ignorance".

76. david.alexander@ucl.ac.uk
emergency-planning.blogspot.com
Presentations can be downloaded from:-
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Thank you
for your
attention!