大愛醫療無國界 delivery of medical care in natural disaster

大愛醫療無國界大愛醫療無國界Delivery of Medical Care in Delivery of Medical Care in

Natural DisasterNatural Disaster

大林慈濟醫院李維哲醫師Buddhist Dalin TzuChi General Hospital

Wei-che Lee MD

Basic Disaster Awareness

• Disasters follow no rules. No one can predict the complexity, time, or location of the next disaster.

• All disasters, regardless of etiology, have similar medical and public health consequences.

• Disasters differ in the degree to which these consequences occur and the degree to which they disrupt the medical and public health infrastructure of the disaster scene.


• The key principle of disaster care is To Do the Greatest Good for the Greatest Number of Patients, while the objective of conventional medical care is to do the greatest good for the individual patient.

• Mass Casualty Incident (MCI) Response.A consistent approach to disasters, based on an understanding of their common features and the response expertise they require.


• The mass-casualty-incident response has four critical medical components: Search and rescue Triage and initial stabilization Definitive medical care Evacuation

• This strategy permits teams from various countries to work together to meet disaster-related needs, despite language and cultural barriers.


• Disaster Medicine is a severe form of First Aid, in which treatment priorities need to be reassessed against those usually applied in an everyday First Aid emergency.

• Priorities are reassessed because: Significant numbers of casualties are involved Emergency services are overwhelmed Hospital facilities are compromised Damaged roads mean difficulties with transportation.

TIMA in Natural Disaster

• El Salvador, Jan 13, 2001

• 7.6-magnitude earthquake struck El Salvador at 11:34 AM, killing at least 844, injuring 4,723 and damaging or destroying 278,000 dwellings.

• El Salvador, Jan 13, 2001• Exactly one month later another quake, with a magnitude of

6.6, hit this country, killing at least 400, injuring 3,153 and destroying 45,000 homes. Still recovering from the damage wrought by Hurricane Mitch few years ago, this disaster maimed the tiny country.


• El Salvador, Jan 13, 2001• The first Tzu Chi medical team, composed of five physicians

and one nurse from the United States, provided medical service for some 2,000 residents at four places in three days.

• Tzu Chi distributed food for 35,750 victims to last one month

and helped 6,729 victims through the free clinics.


• Back to 921 Earthquake• 921 earthquake rocked the island at 1:47 am. By 3am, TzuChi

Taichung Rescue Center was established.

• TIMA members established first aids stations in 11 heavily damaged areas

• Medical teams from Tzu Chi Hospital in Hualien, consisted of 40 medical staffs, set up medical aids centers in 3 local hospitals.


• Iran Earthquake, Dec 26, 2003• 41,000 people presumed to be dead

• Tens of thousands injured

• Nearly all survivors among the original 100,000 inhabitants left homeless.

• Iran Earthquake, Dec 26, 2003


• Iran Earthquake, Dec 26, 2003

• Medical aid is not simply coming to the help of someone in pain, but should also inspire local people to bring their own compassion and kindness into play, so that even more people will contribute.

Principles of International Relief Work

• Directness: We insist on personally distributing relief supplies into the hands of victims without going through any third party.

• Priority: There are too many victims and disasters in the world, and our resources are very limited. So we are forced to offer our help and rebuild homes only for victims in the most devastated areas.

• Respect: We respect the victims' lifestyles, customs, culture and traditions. We distribute relief supplies with gratitude and without expecting to receive anything in return, so that the victims' dignity will be maintained.

Principles of International Relief Work

• Timeliness: We provide victims with what they need when they need it the most. Though our resources are limited, their hearts will be warmed.

• Conservation: We fully utilize every single dollar that people have donated.

"Three No's" principles during relief distribution:

• No politics

• No propaganda

• No religion, especially in mainland china.

Notes on International Relief Work

• Medical intelligence is an essential part of an international disaster response.

• Data on endemic and epidemic illnesses are critical, but an understanding of the cultural and social norms is of equal importance in meeting disaster-related needs.

• Trained specialists, however well-intentioned, do not by themselves constitute an effective medical team for a response to international disasters.

• Critical to a successful medical response to a mass casualty incident are important non-medical elements such as communication, safety, sanitation, and security.

Acute Injuries and Illnesses in the Aftermath of a Natural Disaster

• Open and closed fractures

• Foreign-body eye injuries

• Crush-related injury and contaminated lacerations

• Drowning

• Heart attacks and other stress- and exertion-related conditions

• Injury and exacerbation of illness related to the evacuation and transferring

• Electrocutions

• Shock

Disruption of Medical and Public Health Infrastructure

• Local clinics• Drugstores• Hemodialysis center• Psycotherapy service• Home care nursing

– IV medication– Parenteral nutrition– Ventilator– Dialysis– Oxygen

Needs Of The VictimsDuring the Immediate Phase

Whether they are injured, survivors, disaster victims, evacuees or people involved, the victims all have the

same needs:


Physical Needs• Survival

• To be looked after (somatic care and medico-psychological care)

• Shelter (tent, gymnasium, caravan, housing)

• Bedding (bed, blankets)

• Food and drink

• Hygiene (washing, toilets)

• Clothing, grants


Cognitive needs• Information (about the disaster)

• Information on aid, help and grants

• Information on legal advice


Emotional needs• Need not to feel abandoned or excluded

• Need to verbalize the experience lived through

• Need to be listened to

• Need for empathy and understanding

• Need to return to (or be accepted in) the community of the living

• Need to restore autonomy

Disaster Medical Assistant Team (DMAT)

DMAT teams normally consist of approximately 35 members –

• 4 or 5 physicians

• 10 to 12 nurses and paramedics

• 8 to 12 EMTs

• The remainder of the team made up of support personnel

There are still controversies about role of the volunteers attending in the DMATs.

• Most of the volunteers lack in medical training such as basic and advanced life support and lack clinical experiences.


• Deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site.

• In mass casualty incidents, Triaging patients Providing austere medical care Preparing patients for evacuation

• May provide primary health care and/or may serve to augment overloaded local health care staffs.


• DMAT is an independent, self-sufficient team that can be deployed within a matter of hours and can set up and continue operations at the disaster site for up to 72 hours with no additional supplies or personnel.

• The 72-hour period allows national/international support, including medical supplies, food, water and any other commodity required by the DMAT, to arrive.

Operations Plan of the Medical Disaster-response

• The model organizes surviving health care providers into teams capable of delivering medical care immediately.

• Stabilize the condition of victims in the field and then facilitate their transport.

• The plan is divided into three phases according to the time elapsed and the location of treatment: Hour 0 to 1 Solo-treatment period Hours 1 to 12 Disaster-medical-aid period Hours 12 to 72 Casualty-collection period.

Phase 1: Solo-Treatment Areas

• Immediately after an earthquake, physicians would assess their surroundings.

• If patients in critical condition were present, solo-treatment locations would be established where patients could be evaluated and their condition stabilized with resources from a medical backpack.

• Patients would be moved to a disaster-medical-aid center as soon as possible.

Medical Emergencies and First Aid

• Most field medical situations you encounter are not immediately life threatening. The few that are can generally be addressed by anyone with basic first aid skills and a rational approach.

• Maintain a calm, thoughtful manner. Panic will cause or contribute to a “shock” response in the victim and may cause others to act irrationally as well.


• When confronted by a medical emergency, your first step is to determine whether or not you can safely and effectively render assistance.

• Do not move the victim unless you have to for your safety or his or hers.

• Once you have determined that you are not endangering yourself and that the victim is in a relatively safe position, get help if you are able to do so.


WARNING• There is a definite risk to the first aid responder from the

bodily fluids of the patient. These include blood, mucus, urine, and other secretions.

• You should take the steps necessary to protect yourself before attempting to treat the patient.

• Use surgical gloves if you have them. Also, it is strongly advised that you use a cardiopulmonary resuscitation (CPR) barrier device if giving mouth to mouth.

• A facemask will also reduce the potential for rescuer infection.


Try to do the most good for the greatest number in the shortest possible time but always ensure your own safety first!

• Do not attempt CPR (heart massage) unless you have received instruction in the technique.

• Do not give a casualty any food or drink if they are badly injured, suspected of having broken bones, or are likely to require surgical treatment.


Primary Survey• Ensure your own safety first.

• Assess the hazards and remove or secure them where possible.

• Sort mobile casualties from immobile ones.

• Assess the consciousness of any silent, immobile casualties by use of voice and/or tapping collarbone.


Primary Survey • Use your voice first - "Can you hear me?".

• If casualty responds, place in a comfortable position and monitor.

• If casualty does not respond, tap their collarbone to check response to pain.

• If casualty responds to tap, place in recovery position and arrange transfer to hospital.


Primary Survey • If patient does not respond, assess their breathing and

circulation.

• If breathing and pulse detected, place in recovery position, cover and arrange urgent transfer to hospital (advanced life support facility).

• Where there are many casualties, if there is no breathing or pulse, move on to others.

Phase 2: Disaster-Medical-Aid Centers

• Evenly spaced in a community, set up no more than an hour's walk from any location even if the transportation system failed.

• 3 physicians per site to provide coverage for alternating 12-hour shifts and 1 backup.

• Sites might include schools, fire stations, and hospitals.

• Adjacent open area to serve as a helicopter landing zone for patient evacuation and the resupply of equipment.

Medical-aid Centers

• The principal sites for the delivery of medical care.

• An initial triage area immediately outside the center, in accordance with the Simple Triage and Rapid Treatment system

• The walking wounded would be identified first.

• The remaining patients would then be divided into three categories: Those requiring immediate care Those for whom care might be delayed The dead or dying

Medical-aid Centers

• Patients assigned to the immediate-care and delayed-care categories would receive further evaluation and treatment.

• The dead would be sent to the morgue area and those facing imminent death segregated.

• The walking wounded might be used as volunteers to assist health care workers.

• Patients would be periodically reevaluated.

Medical-aid Centers

Phase 3: Casualty-Collection Points

• Performs two functions:

• First, it serves as a staging area for the arrival of medical supplies and personnel and the evacuation of patients.

• Second, it contains a medical area for triage and treatment.

• Once stabilized, patients would be transported either to newly established field hospitals or to functioning hospitals outside the disaster zone.

Casualty Collection Sites

Casualty collection sites for Levels 1 and 2 triage should be located close enough to a disaster site to offer quick treatment, but far enough away to be safe. Important features are:

• Proximity to the disaster site• Safety from hazards and upwind location from contaminated

environments• Protection from climactic conditions• Easy visibility for disaster victims• Convenient exit routes for air and land

evacuation

Follow-up Trauma and Medical Care

• >first 48 hours,the health services progressively overwhelmed by the need for secondary or maintenance care for the trauma victims as well as the demand resulting from the rapid emergence of normal emergencies or routine medical care.

• The health facilities may not be fully operational and staff will urgently need some rest and time to care for possible personal losses.

Long-term Medical Sequelae of Natural Disasters

• Clean-up and rebuilding-related injury

• Food- and water-borne disease

• Carbon monoxide (CO) poisoning with gasoline-powered electricity generators

• Snake and rodents bite

• Arboviral infection

Common Diseases

• The most common symptoms and diseases among displaced people are those normally to be expected in a developing country: Diarrhea Measles Nutrition Deficiencies Respiratory Infections Malaria Parasites Anemia.

• However, crowded conditions among the displaced people are likely to increase the occurrence of these diseases, in particular diarrhea.

Long-term Medical Sequelae

• Diarrhea, due to the new environment, overcrowding, and poor environmental services, usually poses the major threat to displaced people’s health in the first weeks of living in a camp.

• It remains a major health risk should there be a sudden deterioration in some aspect of the communal services, such as contamination of the water supply.

Long-term Medical Sequelae

• An important point to note is that among the diseases listed, 80- 90% of all deaths in displaced populations are caused by five killer conditions: Malnutrition Measles Acute Respiratory Infections Diarrheal Diseases Malaria.

• Most of these diseases are caused byprotozoa, bacteria, or viruses.

Notes on Caring for the Victims

• Protect the victims from further stress such as the press, curiosity seekers, gory sights and sounds, or additional unnecessary exposures to the horror of the incident.

• Mobilize the resources necessary to assist the victims such as the Red Cross or other disaster services.

• Help the victims to find missing family members and friends.

• Regroup families.


• Regroup people who come from the same areas.

• Listen carefully to the victims. They need opportunities to express themselves.

• Accurate, current and timely information is extremely important to the well being of victims.

• Reassure people that they are safe.

• Establish private quarters for the victims as soon a possible.


• Provide for medical, social, religious, psychological, shelter and other needs as they arise.

• Do not tell victims that they are “lucky” because it could have been worse. Those sorts of statements almost never console and usually anger a distressed person.

• Keep yourself calm and your voice smoothing and reassuring.

• Gently touch a distressed person on the shoulder or hand if they seem receptive to such contact.


• A shocked, very silent and withdrawn person should be evacuated from the scene immediately.

• Noisy, hysterical or acting out victims are actually a secondary priority.

• Those who seem to be doing fine at the scene are the third priority for evacuation. However, it does not imply that they should be ignored. They can get worse if they are unattended.

• Children are the most vulnerable to psychological harm during a disaster. Special care should be afforded for children.

Effects on Children

• Children, in particular, in the three to ten age group, may be adversely affected by the disaster, even if not affected physically.

• It is extremely difficult for children to understand what has happened to their home and family, following the impact of a major disaster.

• Intense feelings and emotional trauma may result directly and immediately for some children, while for others it may occur at a later time.

Children in Disaster

• Most children will be confused by the sudden interruption of the normality of life. Some children may become very restless and unable to sleep, others quiet and withdrawn and not willing to discuss the experience.

• It is very important for parents and teachers to help the children work out their problems so that there will be no lasting emotional trauma.

• Proper communication with the children,encouraging them to talk and listening to their fears.

Children in Disaster

• Adults should explain as well as they can the disaster, and should let children know that their fears are normal and are shared by all.

• Efforts should be made to reduce the children's anxiety by returning to as normal a routine as possible.

• Children should be involved in the recovery efforts and should be encouraged to participate in the clean-up activities.

• Parents and teachers should assure the kids that they are not going to leave them alone.

Screening for and Managing Psychological Sequelae

• Posttraumatic stress disorder can be found in both the victims and the responders.

• The elderly and children are especially vulnerable to the sequelae of disaster-related mental trauma

• Special teams called Crisis Intervention Stress Management

Teams are often deployed to the site of a disaster.

Facilitate Rapid and Complete Physical and Emotional Recovery

• Rapid rebuilding of homes, communities

• Early resumption of school and work

• Every effort should be taken to maintain and strengthen families and support systems.

Psychological Sequelae of Disasters

Disaster characteristics that seem to have the most significant mental health impact are the following:

• Little or no warning

• Serious threat to personal safety

• Potential unknown health effects

• Uncertain duration of the event

• Human error and/or malicious intent

• Symbolism related to terrorist target


• Post-disaster responses are wide-ranging, from mild stress responses to full blown post-traumatic stress disorder (PTSD), major depression, or acute stress disorder.

• While many people may exhibit signs of psychological stress, relatively few (typically 15%–25%) of those most directly impacted will subsequently develop a diagnosable mental disorder.


Worker Stress• Disaster workers who choose to be involved in this type of

work gain great reward and satisfaction, but can also become secondary victims of stress and other psychological sequelae.

• This can adversely affect their functioning during and after an event. It can also adversely impact their personal well-being as well as their family and work relationships.

How Team Members May Be Affected by Stress

• They may experience physical symptoms associated with stress, such as headaches, upset stomach, diarrhea, poor concentration, and feelings of irritability and restlessness.

• They may become tired of the disaster and prefer not to talk about it, think about it, or even associate with coworkers during time off.

• They may become tired of continual interaction with victims and may want to isolate themselves during time off.

Signs of Stress in Workers

Physiological signs of stress • Fatigue, even after rest • Nausea • Fine motor tremors • Tics • Paresthesias • Dizziness • GI upset • Heart palpitations • Choking or smothering sensations


Emotional signs of stress:

• Anxiety

• Irritability

• Feeling overwhelmed

• Unrealistic anticipation of harm to self or others


Cognitive signs of stress such as:

• Memory loss

• Decision-making difficulties

• Anomia (the inability to name common objects or familiar people)

• Concentration problems or distractibility

• Reduced attention span

• Calculation difficulties


Behavioral signs of stress such as:

• Insomnia

• Hypervigilance

• Crying easily

• Inappropriate humor

• Ritualistic behavior

Coping Methods for Rescue Workers

• Avoid humanization of the bodies

• Do not look at the faces

• Do not learn the names of the victims

• Concentrate on the tasks at hand

• Concentrate on the benefit to society

Managing Worker Stress On-Site

• Limited exposure to traumatic stimuli • Reasonable hours • Adequate rest/sleep • Reasonable diet • Regular exercise program • Private time • Talking to somebody who understands • Monitoring signs of stress • Identifiable endpoint for involvement

大愛醫療無國界 delivery of medical care in natural disaster

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