LECTURE NOTES IN EMERGENCY AND DISASTER NURSING

Mary C. Balintona, RN, MAN

DEFINITION OF TERMS

Disaster

Any destructive events that disrupts the normal functioning of a community.

Ecologic disruptions or emergencies of a severity and magnitude that result in deaths, injuries,
illness and property damage that cannot be effectively managed using routine procedures or
resources that require outside assistance.

Types of Disaster

1. Natural- cause by natural or environmental forces. It includes earthquakes, floods,

tornadoes, hurricanes, volcanic eruptions, etc.

2. Man Made/Human Generated

- The principal direct causes are identifiable human actions, deliberate or otherwise.
- It has three broad categories: complex emergencies, technologic emergencies,
disasters that are cause by natural hazards but occur in natural settlements.
- Complex emergencies: involve situations where populations suffer significant
casualties as a result of war, civil strife, or other political conflict.
- Technologic emergencies: large number of people, property, community
infrastructure, and economic welfare are directly and adversely affected by major
industrial accident, unplanned release of nuclear energy and fires or explosions from
hazardous substances such as fuel, chemicals, or nuclear materials.

Medical Disaster

- Is a catastrophic event that results in casualties that overwhelm the health care resources in that
community.

Disaster Planning

- Addresses the problems posed by various potential vents, ranging in scale, from mass casualty
incidents.

Types of Disaster Planning

1. Agent specific approach

Its a planning type that focuses on the preparedness on most likely threats to occur
based on their geographic location.
2. All hazards approach
Is a conceptual model for disaster preparedness that incorporates disaster management
components that are consistent across all major types of disaster events to maximize
resources, expenditures and planning efforts.
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

Crisis/crisis management
Administrative measures that identify, acquire, and plan the use of resources need to
acquire and plan the use of resources need to anticipate, prevent, and or resolve a
threat to public health and safety.
Triage
Is a process which places the right patient in the right place at the right time to receive
the right level of care.
The word triage is derived from the French word trier, which means to sort out or
choose.

DISASTER MANAGEMENT AND PLANNING

Disaster Planning
Requires the cooperative efforts of the hospital, community agencies and local government.
Cunny describes three types of advanced planning activities
i. Strategic Planning
These are planning activities that focus on preparing the organization for any type of
threat. This is commonly referred to as the all hazards approach.
ii. Contingency Planning
These are planning activities related to a site-specific threat that may occur at any
time. An example of this is in the hospital setting would be planning activities from a
facility that is in close proximity to a nuclear power plant or an airport.
iii. Forward Planning
These are planning activities pt a known imminent disaster; for example, a pending
snowstorm, hurricane or major rock concert.

Internal vs External Disaster

Internal Disaster
o Occurs when there is an event within the facility that poses a threat to disrupt the environment
of care. (e.g., related to physical plants, loss of utilities or fire).
External Disaster
o Becomes a problem for a facility when the consequences of the event that creates a demand for
services that tax or exceed the usual available resources (e.g., arrival of large number of trauma
patients of a chemical spill).

Combined Internal and External Disaster

o Classified as
i. Level 1- if the organization, agency or community is able to contain the event and respond
immediately.
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

ii. Level 2- if the disaster requires assistance from external sources, but these can be obtained
from nearby agencies.
iii. Level 3- if the disaster is of a magnitude that exceeds the capacity of the local community or
region and requires assistance form national level.

Disaster Management Programs

o is composed of five phases
i. Preparedness/Risk Assessment
o Evaluates the facilitys vulnerability or propensity for disasters. Issues to consider include
weather patterns, geographic locations, expectations related to public events and
gatherings, age, condition, and location of the facility.
ii. Mitigation
o Steps that are taken to lessen the impact of as disaster should one occur and can be
considered as prevention measures.
o Examples are installing and maintaining backup generators to mitigate the effects of
power failure or cross training staff to perform tasks to maintain services during staffing
crisis that is due to weather emergency.
iii. Recovery
o Once the incident is over, the organization and staffs need to recover. Invariably,
services have been disrupted and it takes time to return to routine.
iv. Evaluation
Often this phase of disaster planning and response receives the least attention. After
a disaster, employees of the community are anxious to return to usual operations. It
is essential that a formal evaluation be done to determine what went well and what
problems were identified.

Phases of Disaster Management

1. Risk Assessment
The disaster manager needs to consider what type of disasters is most likely to be
encountered by the organization.
All types of events need to be considered including deliberate human-caused,
technological and natural events.
The disaster manager needs to perform also a risk assessment in the area of staffing.
Depending on the nature and extent of the disaster and the demographics of the
workforce, there may be variation in the employees ability and or willingness to
report to work.
2. Mitigation
Lessens the severity and impact of the disaster through appropriate planning and
practice. The best ways to mitigate the results of a disaster are to perform a
thorough hazard vulnerability risk assessment and be sure that your plan includes
provisions for each of the likely events.

Essential Elements for Hospital Disaster Management

1. An appropriate infrastructure to support the disaster response which includes maintaining
services for preexisting patients as well as the new arrivals.
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

2. An appropriately trained staff who are competent to perform their disaster response functional
roles and able and willing to report to work during any sort of disaster.
3. A clearly defined, executable, practiced emergency response plan.
4. A strong foundation of preexisting relationships with partnering organizations and agencies that
can be called on to provide mutual aid and support when needed.

Hospital Incident Command System (HICS)

- Is an emergency management system that is comprised of specific disaster response functional
role positions within a hierarchical organization chart.

Key Features of Incident Command and HICS

i. Predictable, responsibility oriented chain of command.
o There is one incident commander. This individual has overall responsibility for the
management of the incident and the employees know who report to them and to whom
they report.
ii. Use of common nomenclature
o All agencies utilizing ICS use the same titles and functional roles for the command staff
positions.
iii. Modular, flexible organization
o Only those portions of the system that are needed for the response are activated.
iv. Unified command structure
o This allows all agencies involved in the response to coordinate efforts by establishing a
unified set of incident objectives and strategies.
v. Incident Action Plan (IAP)
o This is a plan that is developed when multiple agencies are involved in the disaster
response.
vi. Facility Action Plan (FAP)
o A FAP describes the purpose, goals and objectives for the hospitals response.
vii. Unity of Command
o Each person reports to only one individual.
viii. Manageable span of control
o Each manager controls a defined amount of resources, which is limited to what can
realistically be managed.
ix. Use of JAS (Job Action Sheets)
o JAS define for the staff what their defined functional role is during emergency and sister
response.

TRIAGE

1. Daily Triage
Triage perform by nurse in the emergency room. It is a routine triage.
The goal is to identify the sickest patients in order to assess and provide treatment to
them first, before providing treatment to others who are less ill.
2. Incident Triage
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

Occurs when the emergency department is stressed by a large number of patients but is
still able to provide care to all victims utilizing existing agency resources.
3. Disaster Triage
Is employed when local emergency services are overwhelmed to the point that
immediate care cannot be provided everyone who needs it.
During disaster triage, patients are usually sorted into
i. Critical- are those that are life threatening but likely to be amenable to rapid
intervention that does not require an inordinate amount of resources (e.g.,
upper airway obstruction).
ii. Urgent- those conditions that are serious and if not treated in a timely manner
are likely to deteriorate to become critical (e.g., compound fracture of a long
bone).
iii. Minor- the care required can be provided in a low tech tribute setting and a
delay in treatment would unlikely constitute to a significant deterioration in the
victims condition.
iv. Catastrophic- conditions that have either a very grave prognosis or would
require an amount of resources that are so large they would divert care from
others with a much better prognosis (e.g., cardiac arrest).
4. Tactical Triage
Is similar to disaster triage, only military mission objectives rather than traditional
civilian guidelines drive the triage and transport decisions.
5. Special Conditions Triage
Is used when patients present from incidents such as radiation, biological or chemical
contamination.
6. Triage during an epidemic
Usually use during mass casualty trauma situations (e.g., bioterrorism).

I. In-Hospital Triage Systems

Utilize a triage system that has between three and five categories.
The three main categories are
i. Emergent- signifies a condition that requires treatment immediately within
15mins.-30mins. (e.g., cardiac arrest, airway obstruction).
ii. Urgent- utilized for serious illness or injury that must be attended to but a wait
of up to 2 hours would not add to the morbidity and mortality of the patient.
iii. Non-urgent- is any condition that can wait for more than 2 hours to be seen
without the likelihood of deterioration.

II. Disaster Triage System

Simple Triage and Rapid Treatment System (START) for adults

JumpSTART system (for triaging pediatric patients)
Start/Save (when the triage process must be over an extended period of time)

1. Simple Triage and Rapid Treatment System (START) for adults

A common algorithm that is used with adult pre-hospital triage.
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

Developed by Newport Beach California, Fire and Marine Department and Hoag
Hospital.
It is based on the persons ability to respond verbally and ambulate and their
respirations, perfusion, and mental status (RPM). The system works as follows
i. All patients who can walk (walking wounded) are categorized as Delayed (Green)
and are asked to move away from the incident area to a specific location.
ii. The next group of patients is assessed quickly (30-60 seconds per patient) by
evaluating RPM: respiration, perfusion and mental status.

2. JumpSTART
Created to meet the unique needs of assessing children less than 8 years of age.
Should be used if t5he victim looks like a child and START should be sued whenever the
victim looks like a young adult or older.
The JumpSTART Pediatric MCI Triage Tool is the first objective tool developed specifically
for the triage of children in the multicasualty/disaster setting.
The objective of JumpSTART are
i. To optimize the primary triage of injured children in the MCI setting
ii. To enhance the effectiveness of resources allocation for all MCI victims
iii. To reduce the emotional burden on triage personnel who may have to make
rapid life or death decision about injured children in chaotic circumstances.

3. START/SAVE Triage for Catastrophic Disasters

The SAVE Triage was developed to direct limited resources to the subgroup of patients
expected to benefit most from their use.
The SAVE assesses survivability of patients with various injuries and on the basis of
relationship between expected benefits and resources consumed.

Two types of area location in START Triage

i. Expectant area- would require the use of significant medical resources.
ii. Treatment area- would use few resources and would have a reasonable chance
of survival.

III. Disaster Triage for Chemical and Hazardous Material Disasters

Triage for chemical incidents will occur in several places
i. In the field
o Hot Zone- this is the area immediately adjacent to the location of the
incident.
o Warm Zone- this is the distance of at least 300 feet from the outer
perimeter of the hot zone and is upwind and uphill from the
contaminated area.
o Cold Zone- this area is adjacent (and uphill and upwind) to the warm
zone and is where decontaminated victims enter.
ii. In the hospital setting
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

o Warm Zone- this is an area that is adjacent to the hospital (usually the
emergency department), which has a source of water.
o Clean Zone- this is the treatment area inside of the emergency
department or hospital where newly arriving patients and victims are
sent after having been triaged and decontaminated.

NATURAL DISASTERS

Cyclones
Are large scale storm characterized by low pressure in the center surrounded by circular wind
motion.
Drought
Is often seen as a result of too little rain and is often synonymous with famine. Drought often
triggers a crisis in arid and semi arid areas, because rain is sparse and irregular.

Earthquake
Considered to be the most destructive and frightening of all forces of nature, is a sudden,
rapid shaking of the earth caused by the breaking and shifting of rock beneath the Earths
surface.
The Ritcher scale, used as an indication of the force of an earthquake, measures the
magnitude and intensity of energy released by the quake.

Tsunamis
Series of waves usually generated by large earthquakes under or near the ocean occur when a
body of water is rapidly displaced on a massive scale.
Submarine landslides and volcanic eruptions beneath the sea or on small islands can also be
responsible for tsunami but their effects are usually limited to smaller areas.
The following events may signal a tsunami
1. A recent submarine earthquake
2. The sea appears to be boiling, as large quantities of gas rises to the surface of the water.
3. The water is hot, smells of rotten eggs, or stings the skin.
4. There is an audible thunder or booming sound followed by a roaring or whistling sound.
5. The water may recede a great distance from the coast.
6. Red light might be visible near the horizon and, as the wave approaches, the top of the wave
may glow red.

ENVIRONMENTAL EMERGENCIES and DISASTERS

Environmental emergencies
Is a sudden threat to the public health or to the well being of the environment arising from the
release or potential release of oil, radioactive materials or hazardous chemicals into the land, air
or water.
These emergencies may occur from transportation accidents, events at chemical facilities or
other facilities using or manufacturing chemicals or as a result of natural or manmade disaster
events.
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

Environmental disasters
Is defined as an environmental emergency or ecologic disruption of a severity and magnitude
resulting in deaths, injuries, illness and/or property damage that cannot be effectively managed
by the application of routine procedures or resources and that result in a need for additional
assistance.
Measures that are implemented during environmental disasters:
1. The immediate removal of the hazard from the environment.
2. Decontamination of exposed individuals.
3. The restoration of services to meet the immediate physiological needs of the affected
people.
4. The prevention of further illness or injury as a result of exposure to the hazard.

Environmental Hazards
1. Chemical Spills
o Intentional or accidental leakage or spill of certain chemical substances into the
environment that can have devastating consequences on human health.
2. Oil spills
o The leakage of oil in the bodies of water surrounding a land area.

BIO-CHEMICAL WARFARE AND TERRORISM

Biochemical terrorism
o According to Bruce Hoffman, it is the deliberate creation and exploitation of fear through
violence or the threat of violence in the pursuit of political change.
o The use of chemical or biological agents as the main element of a terrorist attack or threat.

Chemical Agents
o Are those chemical compounds synthesized artificially and include the many toxic chemicals that
may be available to terrorists.
o Chemical weapons utilize the toxic nature of selected substances to cause death or injury. These
chemical warfare agents may cause injury via the respiratory route, through the skin by
ingestion.

Biological Agents
o Are those pathogens used deliberately to infect persons as well as toxins normally derived from
plants or animals. In biological warfare, infectious agents can infect through respiratory and
ingestion routes.

Chemical Terrorism

Delivery of Chemical Agents

o Is optimized by producing contaminated areas with high concentrations of a toxic compound.
Chemical compounds that are gaseous at room temperature or are extremely volatile do not
need much engineering to deliver.
o For a terrorist who is intent on causing chemical casualties, acquiring higher end agents such
as military nerve compounds might be too difficult r unnecessary.
LECTURE NOTES IN EMERGENCY AND DISASTER NURSING
Mary C. Balintona, RN, MAN

o Some of the chemical agents used are

a) Nerve agents (e.g., sarin)
b) Tissue (blood) agents (e.g., cyanide)
c) Lung irritants (e.g., chlorine gas)
d) Vesicants (i.e., blister agents such as mustard or lewsite)
e) Psychoincapacitants (e.g., BZ, LSD)
f) Pesticides

Nerve Agents
o Include the chemical tabun, sarin, soman, and VX. These toxic organophosphate compounds all
operate on the same basic principle-they inhibit acetylcholinesterase.
Tissue (Blood) Agents
o Includes cyanide in its various forms. Ultimately cyanide blocks the enzyme cytochrome oxidase,
shutting down the energy transport (ATP) system.
Lung Irritants
o Attack the respiratory system causing tightness in the airways, hypoxia, and in more severe
cases, pulmonary edema.
o Vesicants
- the so-called vesicants or blister agents such as mustard gas and lewisite, have less utility for
terrorist.
o Psychoincapacitants
- The psychotropic compounds such as the belladonna drug BZ (3-quinuclidinyl benzilate) or the
hallucinogen LSD have been considered by militaries for use in combat and for sabotage. Their
performance on the battlefield, however, has largely been considered unpredictable and
impractical.
o Pesticides
- Refers to a group of agents used to kill a number of different pests, such as weeds, insects,
ticks, rats, and so forth.

Bioterrorism
o The act of biological terrorism (bioterrorism) involves the deliberate use of microbial pathogens
or toxins. Unlike a chemical incident, the effects from bioterrorism may not be fully known until
many hours or days after the event.
o The following are the agents used in bioterrorism
- Bacterial agents
- Viral agents
- Toxins (derived from plant or animals)
- Parasites

PHILIPPINE DISASTER COORDINATING COUNCIL AND THE PHILIPPINE NATIONAL RED CROSS